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to referring provider

      It is the responsibility of the endoscopist to inform the referring provider of the results of the procedure. If pathology is sent or further imaging is ordered, a clear plan outlining responsibility to follow these results must be provided in correspondence to the patient and referring provider.

Table 3.4 Postprocedure quality indicators.

Discharge criteria	Documentation that the patient has achieved predetermined criteria prior to discharge
Patient instructions	Written instructions including resumption of diet, activities (driving), and medications (including anticoagulation)
Pathology follow‐up	The plan for follow‐up of any pathology results is specified
Procedure report	A complete procedure report is prepared (see text for required elements)
Complications	The unit has a policy for monitoring complications
Patient satisfaction	Patients are periodically surveyed as to their level of satisfaction with their endoscopic experience
Communication	Documentation of communication with referring provider(s)

      Recognition of complications

      Complications may be recognized immediately during the procedure or after the procedure has been completed. Some complications may be delayed in onset by several hours (e.g., post‐ERCP pancreatitis) or may not occur until weeks later (e.g., post‐polypectomy hemorrhage). It is the responsibility of the endoscopist and endoscopy unit to identify complications and institute proper therapy in a timely manner. Complications should be recorded and each unit should have a procedure for doing so. For some procedures, the expected frequency of complications is high enough that this may be used as a quality endpoint in and of itself (e.g., post‐ERCP pancreatitis). However, most procedures' complications are rare and therefore their occurrence, or lack of occurrence, is an unreliable marker of an individual's competency. Instead, complications should be used as a tool toward quality improvement. Complications should be regularly reviewed, such as quarterly, in a nonconfrontational forum that focuses on the educational aspects with the goal of improving the quality of care. It should be noted that quality improvement meetings, such as morbidity and mortality conferences, are protected from legal discovery should a lawsuit arise.

      Patient satisfaction

      All endoscopy units should periodically consider surveying their patients for feedback regarding preprocedure (prep instructions, day of instructions), intraprocedure (endoscopy unit), and postprocedure (follow‐up calls and reporting) experiences. The benefit of this interval review is that it provides information specific to the individual practice as seen from their client base. In these modern times, patient reviews on the Internet are a common practice and capturing this feedback for internal improvement may be helpful in improving the quality of care as seen from the patient's perspective.

      Medicolegal issues

Gastroenterologists have an ethical and legal obligation to provide the highest quality of care to their patients. Use of quality markers during the pre‐, intra‐, and post‐procedural period are important to optimizing patient outcome, minimizing patient dissatisfaction, and may be useful for avoiding malpractice litigation. There are limited data on malpractice trends in gastroenterology. In a 2018 JAMA study, gastroenterology ranked 18th among paid malpractice claims [16]. One physician insurance carrier, the Physician Insurers Association of America (PIAA), showed that gastroenterology ranked 21st among 28 medical subspecialties in terms of frequency sued and accounted for 2% of claims. Interestingly, in the majority of the suits (60%), the basis of claims involved cognitive decision‐making rather than therapeutic misadventures [17, 18]. In a separate ASGE survey, 42% of gastroenterologists that had been sued reported that informed consent was an issue [19]. Thus, medical malpractice actions can be brought on because of failure to obtain informed consent (regardless of outcome) as well as civil wrong or harm brought on by medical negligence.

      Elements of malpractice

      In the setting of medical negligence or “civil wrong,” four basic legal elements must be proven in a malpractice suit [4, 10]:

      1 The physician had a duty to the patient (patient–physician relationship).

      2 The physician breached the duty by violating the standard of care.

      3 The breach resulted in injury.

      4 The injury is compensable.

      The standard of care is often determined through expert testimony, published data, and accepted practice guidelines, with the most important of these being expert testimony. It is important to note that this standard of care is what is customary among the majority of competent gastroenterologists and not what a few noted experts in the field would do in specific circumstances [10].

      The best defense against malpractice suits is good medical practice. Perform procedures that are within the accepted indications and avoid risky cases when possible. Use the process of informed consent to educate the patient on the inherent risks and limitations of the procedure, thus transferring some of the responsibility to a well‐informed patient. Employ good documentation of adverse events, decision‐making, and patient communication. In the setting of complications, be vigilant in communicating honestly with the patient and their family and provide timely and appropriate management.

      Training in quality assurance and improvement

      It is important that trainers teach their trainees both the importance of quality and also methods of quality assurance and improvement. The apprenticeship model of postgraduate medical training means that the mentors must have the proper mindset and the institutions the proper support. Faculty must be good role models for their trainees in their adherence to best clinical practice. The institutions should establish QA and QI programs that include trainee participation. These are skills that trainees can then take with them into their own practices.

      Specific curricula in quality assurance and improvement for trainees are unusual. Most institutions have lectures on obtaining informed consent and medicolegal responsibilities. It is also common to have morbidity and mortality conferences where complications and adverse events may be discussed with the goal of improving quality and patient outcomes. Most other aspects are learned through the apprenticeship of the training program: preprocedure patient assessment, proper indication, proper procedure performance, procedure reports, communication with referring providers, etc.

      Specific curricula in QA and QI would include didactic lectures on quality assurance and improvement topics, drawing from the rapidly expanding literature. They should focus on the quality improvement cycle: measuring quality indicators to identify areas of underperformance, instituting an improvement plan, and then remeasurement to document improvement. Trainees could immediately begin to incorporate relevant quality indicators into their own training (e.g., cecal intubation). Measuring these indicators during training could be used to track performance improvement and ultimately to document attainment of procedural competency.

Conclusion

      Quality measures are important in optimizing patient care and minimizing error, patient harm, and legal recourse. Trainees should familiarize themselves with the key quality measures required in the preprocedural, intraprocedural, and postprocedural time periods. Proper documentation, communication,

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