Maintaining and enhancing the quality and safety of endoscopy services should be a continuous process that measures aspects of endoscopic performance, implements changes based on these measurements, monitors the effect of these changes and evaluates these effects to achieve new standards (Figure 2).

# Statement 10. Endoscopy facilities should maintain a comprehensive quality improvement program incorporating formal, regular, scheduled review of performance reports.
Evidence grade: Low/very low Strength of recommendation: Do it, 85%; possibly do it, 9%; possibly don't do it, 3%; don't do it, 3% level of agreement with recommendation: Agree, 94% (agree strongly, 76%; agree moderately, 12%; agree slightly, 6%; disagree slightly, 6%)

# Statement 11. Endoscopy facilities should appoint a review committee to monitor and report back to management on adherence to and implementation of quality standards.
Evidence grade: Low/very low Strength of recommendation: Do it, 79%; possibly do it, 21% level of agreement with recommendation: Agree, 97% (agree strongly, 71%; agree moderately, 24%; agree slightly, 3%; disagree strongly, 3%)
In some jurisdictions, quality assurance activities are legislated and, in many jurisdictions, a quality assurance committee's proceedings are protected from disclosure if it is constituted according to applicable regional, territorial, state or national legislation and regulations (66)(67)(68)(69)(70)(71)(72)(73)(74)(75)(76)(77). Thus, endoscopy quality assurance committees must be developed within the appropriate legislative framework to oversee the performance of the endoscopy facility and all of its personnel. The potential conflicts arising from the disparate perspectives of different stakeholders can be resolved if quality in endoscopy is addressed from the perspective of the patient. In developing the GRS for evaluation of endoscopy, two patient-centred quality dimensions were devised (10): the "Clinical Quality and Safety" dimension addressed six items related to appropriateness of the procedure, information and consent, safety, patient comfort, quality and prompt communication of results, while the "Quality of Patient Experience" (customer care) dimension addressed six items related to equality, timeliness, patient choice, privacy and dignity, aftercare and the ability to provide feedback to the endoscopy service.
A quality improvement and assessment tool such as the GRS provides a framework to support evaluation of service delivery by identifying specific indicators, consistent with high-quality endoscopy that should be auditable (ie, relevant outcomes for which there are no set standards) or measurable (ie, relevant outcomes for which there is an established standard).
Quality indicators and safety indicators for endoscopy were considered sufficiently distinct that two working groups were charged with identifying measurable or auditable outcomes that would support quality improvement. After the consensus meeting, participants voted on their endorsement of each quality and safety indicator identified by the working groups (Boxes 6 and 7).

# box 6 Indicators of quality in endoscopy

# Consensus, %
Indicator related to entire endoscopy facility Quality and safety indicators should be recorded systematically; the American College of Surgeons National Surgical Quality Improvement Program ( 78) is a potential model for a safety monitoring system, although it is labour intensive and would require modification for use in endoscopy. Requiring further evaluation but not proven as perforation Adverse events should be reviewed by the facility's endoscopy quality review committee to determine the indication for the procedure and decision as to the level of attribution (eg, definitely, probably, possibly or unlikely to be due to the procedure), as recommended for good clinical practice in clinical research (79), the severity of the event and the appropriateness of the procedure. Changes should be implemented as appropriate and the impact of changes made should be reviewed within an acceptable time frame (such as three to six months).
Indicators of safety compromise may be monitored by phone call follow-up, questionnaire mail back or review of hospital admissions. At a minimum, relevant clinical events and near misses should be recorded, systematically, through a safety learning report system to identify risks, reduce the likelihood of complications, improve safety of the service and reassure patients and physicians.

# SECtIon 4: tRAInInG, EDuCAtIon, CoMPEtEnCy AnD PRIvIlEGES Introduction
To provide high-quality endoscopy services, endoscopy staff's skills must meet predefined standards. This requires that endoscopy facilities provide staff with the opportunities to evaluate, maintain and improve their skills on a regular basis while accommodating the disparate needs of patients, trainees, trainers and the facility. level of agreement with recommendation: Agree, 100% (agree strongly, 66%; agree moderately, 26%; agree slightly, 9%)
Endoscopy facilities should provide continuing training and competency assessment for all staff in all their areas of activities, including clinical policies, patient monitoring, administration of intravenous medications, endoscope handling and maintenance, use of accessories, emergency procedures, decontamination, patient recovery, communication skills and new technologies. The benefits of nurse training, for example, include improved polyp detection rates ( 39) and nonpharmacological management of pain and anxiety. This statement does not imply that the facility should pay for all education opportunities or support 'growth opportunities' that are not congruent with the facility's needs. It does, however, imply that all staff members have the opportunity to evaluate and maintain skills relevant to their position. level of agreement with recommendation: Agree, 97% (agree strongly, 91%; agree moderately, 6%; disagree strongly, 3%)
Competency is the minimal level of skill, knowledge and expertise derived through training and experience required to perform a task or procedure safely and proficiently, without assistance or supervision (80). Endoscopists must be competent to perform endoscopic procedures safely and to interpret and manage findings correctly. Competency for specific procedures should be assessed by objective measures with full documentation of the number and type of procedures performed. Methods for determining competency should include guidelines on the role of observers, number of cases observed and criteria assessed. Competency assessment should encompass proficiency in common therapeutic interventions, cognitive competency (ie, how to manage the patient overall) and technical competency.
Minimal levels of endoscopic competency should be defined, consistent with the OMGE/OMED guidelines on credentialing and quality assurance in digestive endoscopy (Box 8) (3). The minimum numbers of procedures recommended by many professional associations as thresholds for evaluation of competency, may be markedly lower than numbers required for documentation of proficiency (81,82). level of agreement with recommendation: Agree, 97% (agree strongly, 66%; agree moderately, 29%; agree slightly, 3%; disagree slightly, 3%)
Under the auspices of a properly constituted quality assurance committee (see statements 10 and 11) (66-77), endoscopists should review their endoscopy practice data regularly including the number and type of procedures, and standard quality and safety indicator outcomes (eg, completion rates, unplanned events, comfort scores, patient satisfaction). Practice audits (83)(84)(85)(86) to facilitate maintenance of competence should be complemented by a formal annual evaluation of endoscopy performance. Any serious unplanned event or series of events should be reviewed by the endoscopist and quality assurance committee with documentation of deficiencies, discrepancies and any consequent actions. Audits can detect poor performance/inadequate numbers and can improve outcomes such as colonoscopy completion rate (52,(87)(88)(89).
Unverified self-reporting is not encouraged as a formal performance indicator, although this does not preclude self-reflection based on structured practice audits directed at personal learning programs. Verifiable databases, generated from electronic reporting systems or web-based practice audits, have greater validity for documenting, but these do require that endoscopy facilities have tools available to monitor outcomes. Statement 18. Endoscopists should be granted privileges to perform specified procedures based on a formal evaluation of their competence consistent with appropriate current standards.

# Evidence grade: Low/very low

# Strength of recommendation: Do it, 100%
level of agreement with recommendation: Agree, 100% (agree strongly, 91%; agree moderately, 9%) Introduction A completed, comprehensive endoscopy report is an essential element of a quality endoscopy service. Traditional, narrative reporting is associated with marked variations in the documentation of positive findings, pertinent negative findings and other procedural details. Effective communication of procedural findings and successful practice audit and quality improvement processes are virtually impossible in the absence of a standardized, ideally electronic, endoscopy report format.
Statement 20. Endoscopic procedures should be reported in a standardized electronic format, including mandatory reporting fields, to provide full documentation of all necessary clinical and quality measures.

# Evidence grade: Low/very low
Strength of recommendation: Do it, 82%; possibly do it, 15%; don't do it, 3% level of agreement with recommendation: Agree, 97% (agree strongly, 76%; agree moderately, 15%; agree slightly, 6%; disagree strongly, 3%)
Deficits in endoscopy reporting include marked variability in the definitions of inflammation in ulcerative colitis (91), as well as marked differences in the completion of different report elements such as lesion identification and removal (84% of reports), sedation procedure (75%), demographic data (69%), procedure interpretation (58%), patient history (57%) and procedure quality (40%) (92).
Electronic reporting offers a data collection method that can be more complete and cost-effective -but no more time-consumingthan handwritten reports or free-text dictated reports (93). Although electronic reporting is initially more expensive than handwritten or dictated reporting (94), the overall costs become comparable after five years, and cost-benefit outcomes are better after three years, in part, because automatic electronic transmission of reports reduces costs, administrative workload and communication delays.
Standardization of electronic reports, including mandatory reporting elements (Box 9) and accepted grading systems (Box 10), permits standardization of the data capture and long-term storage (at least 10 years) needed for audit and quality improvement processes. While electronic data (eg, digital transcripts of dictated reports) are preferable to handwritten reports, they are inferior to a full, structured electronic report.
Acknowledgement of the patient's perspective on all aspects of endoscopy service delivery and responsiveness to their concerns necessitates a collaborative relationship between the clinician and the patient to address the quality of the patient's experience and the appropriateness, accuracy and safety of the procedure. Patients' perspectives on quality endoscopy care were reviewed at the consensus conference based on the results of focus groups held in French and English Canada for adults who had undergone or were scheduled to undergo a colonoscopy. Focus group participants' discussions of the total colonoscopy experience, defined as all factors and events occurring before, during and after the day of the procedure, yielded several major quality themes, including communication: quantity and quality; comfort: physical and psychological; and attitude and demeanor: physician and endoscopy unit staff. Endoscopist expertise, procedural safety and physical amenities were also important. Many patients expressed little concern about quality indicators (106)(107)(108), reporting that they trusted the accuracy and safety of the test on the presumption that tests were closely monitored and regulated to ensure adherence to standards.
Preprocedural educational interventions, such as provision of additional information, as an educational video (16,109), booklet (110), face-to-face discussion (111) or behavioural intervention (112) can support patients' need to understand the procedure and improve their satisfaction and appointment keeping. Interventions may have a limited effect, due to high preprocedural satisfaction levels (113), but they can, nonetheless, improve patients' knowledge about the procedure.
In theory, patients should be more likely to comply with follow-up examinations if they experienced high levels of satisfaction with their previous endoscopic procedure; to date however, this hypothesis remains unproven. level of agreement with recommendation: Agree, 100% (agree strongly, 82%; agree moderately, 15%; agree slightly, 3%)
The increasing and appropriate emphasis on patient-centred care requires that patients provide feedback on their experience to inform endoscopy facilities' decisions on balancing cost and volumes, access and wait times, discomfort and completion rates, and resources and procedural times. Patient feedback should be sought, at least annually (10), using one or more methods including satisfaction surveys, focus groups and invited comments. Patient feedback is essential for assessing many aspects of endoscopy service delivery, such as the quality of the informed consent process (114), and offers measurable improvements in patient experience (115). Regular, structured measurement of patient satisfaction ensures that patients' perspectives are evaluated alongside more traditional indicators such as appropriateness, accuracy and safety.
Gastrointestinal endoscopy is a complex diagnostic and therapeutic undertaking that demands a high level of skill and knowledge on the part of the operator (2,5). However, high-quality endoscopy requires more than a skilled operator -the delivery of high-quality endoscopy services, in a cost-effective manner consistent with the broader needs of a health care system, requires a formal quality improvement framework that addresses all aspects of endoscopy service delivery from the patient's initial contact with a health care provider (eg, the identification of family history of colon cancer in an asymptomatic individual) through to documentation of long-term outcomes (eg, freedom from colon cancer over decades). Recognition of the patient as the focus of the endoscopy process provides a structure for integrating the efforts of the many diverse disciplines whose contribution is needed to ensure a high-quality service.
The fundamental principle underlying high-quality health care is the need for an iterative feedback loop centred on the patient's needs. The feedback loop requires identification of the patient's needs, measurement of the extent to which these needs are met, intervention to ensure that unmet needs are addressed and reassessment of the patient's needs after intervention. The GRS ( 10) is a quality improvement tool that enables the adoption of iterative quality improvement processes in endoscopy, supported by the identification of quality and safety indicators relevant to specific aspects of service delivery.
Whenever possible, health care recommendations are based on the highest quality evidence available. Outcomes of this consensus conference confirm that there is a paucity of high-grade evidence relevant to endoscopy service delivery. However, among a large multidisciplinary group of health care professionals, there was a high level of agreement on key features that should be addressed to improve endoscopy quality. The fact that the supporting evidence was generally graded as 'low' or 'very low' does not indicate that the recommendations, themselves, are weak; it indicates, rather, the need for concerted, widespread efforts to document the short-and long-term effects of adopting new quality improvement processes in endoscopy.
The consensus process, presented in the current report, provides the framework for a quality improvement structure in endoscopy based on explicit recommendations that will support systematic monitoring, assessment and modifications in endoscopy service delivery; this framework is intended to yield benefits for all patients whose care may be affected by the practice of gastrointestinal endoscopy.
The authors thank Sandra Daniels, Palma Colacino and Paul Sinclair from the CAG for organizing the meeting, Dr Catherine Hill and Dr Anja Becher from Oxford PharmaGenesis LtdTM for writing assistance, and Dr Khurram Khan for his work in grading the evidence.
Statement 19. Endoscopists' privileges should be subject to formal, regular, scheduled review to ensure that renewal is based on documented competence to perform specified procedures consistent with appropriate current standards.

# Evidence grade: Low/very low
Strength of recommendation: Do it, 94%; possibly do it, 3%; possibly don't do it, 3% level of agreement with recommendation: Agree, 97% (agree strongly, 89%; agree moderately, 9%; disagree slightly, 3%)
Health care institutions are legally responsible for ensuring that individuals who perform procedures are competent (3). Endoscopy privileges are granted or renewed by health care institutions, including hospitals and out-of-hospital endoscopy facilities, to competent individuals based on regional and national guidelines and regulations.
Policies guiding the granting of endoscopic privileges should be applied uniformly for all endoscopists; privileges should be granted separately for each endoscopic procedure, based on competence determined according to current standards (5)(6)(7)(8). Each institution should specify appropriate standards, monitor adherence to standards and update standards, as needed.
When applying for privileges, the applicant and training program director must provide details of training undertaken for each endoscopic procedure requested. Each application should be reviewed by a clinician who is knowledgeable about the relevant procedure; procedural competence should be documented from direct observation of the applicant's performance at the privileging institution or by the training program director.
Endoscopic privileges should be granted for a finite period to permit regular re-evaluation of the applicant's performance and competency; procedural volumes should also be evaluated because, for example, colonoscopic complications have been associated with procedures performed by lower-volume endoscopists (90). Renewal of privileges should be based on defined policies for addressing poor performance. level of agreement with recommendation: Agree, 100% (agree strongly, 91%; agree moderately, 6%; agree slightly, 3%)

# SECtIon 5: EnDoSCoPy REPoRtInG StAnDARDS
An important aspect of clinicians' competency relates to the timely provision of a completed procedure report. Receipt of a procedure report improves patients' adherence to follow-up appointments and therapies (66). Optimally, the endoscopy report should be available on the day of the endoscopy, either as a modified, patient-centred version or as the formal report, supplemented by a patient-centred summary.
When relevant, pathology results should accompany the final endoscopy report but this can be a technical challenge because it requires linkage of separate databases. Patient concerns regarding their test results should be addressed in a timely manner although the nature and timeliness of the response may, legitimately, vary among institutions, depending on local needs and resources.