Read the report submitted by the Kensington Health Centre to the

Benefits of Out-of-Hospital Endoscopy Procedures
Kensington Health Centre Report to the Ministry of Health and Long-Term Care
December 2013
Introduction
Colorectal cancer is responsible for approximately 608,000 deaths worldwide every year, according to the
World Health Organization.
Even though it is preventable, an estimated 23,000 Canadians will be diagnosed with the disease this
year, and about 9,200 Canadians will die from it. Ontario has among the highest rates of colorectal
cancer in the world and according to Cancer Care Ontario, it is the number two cause of cancer deaths in
men and women combined in the province.
While there are a number of things that people can do to lower their risk of developing colorectal cancer like consuming a diet high in fruits and vegetables, limiting the intake of red and processed meats, and
engaging in regular physical activity – early detection through proactive colorectal screening is the best
method for reducing deaths due to colon cancer. In fact, colorectal screening can yield reductions of up
to 83 per cent in colorectal cancer mortality.
Screening colonoscopies save lives. It makes sense to expand current health system capacity in order to
make this life-saving procedure more readily accessible outside of the acute care environment.
Kensington Screening Clinic
The Kensington Screening Clinic (KSC or the “Clinic”) is a not-for-profit, charitable entity dedicated to
improving access for patients requiring colonoscopy/gastroscopy screening and surveillance with patientfocused services and state-of-the-art facilities and equipment. Since opening in 2009, KSC has
performed close to 25,000 endoscopy procedures.
KSC is a purpose-built facility designed to optimize the patient experience with streamlined processes
that maximize efficiency and effectiveness. It has four full procedure rooms with space for all required
clinical and administrative services to meet procedural and patient flow needs, and a bright and spacious
recovery area designed for patient comfort. The procedure rooms have hospital Operating Room quality
air handling and the facility utilizes modern Automatic Scope Reprocessors. In addition, KSC is proximate
to Toronto’s adult academic hospitals in the event urgent hospital treatment is required.
KSC’s current annual volume is approximately 3,500 colonoscopy procedures per year plus 2,000
gastroscopies and combined procedures (using two rooms full time). The Clinic has the capacity to
conduct as many as 7,000 colonoscopies and 3,000 other procedures a year using all four procedure
rooms.
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December 2013
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Governance
KSC is governed by a volunteer Board of Directors and operates within an accountability framework that
ensures excellent patient care and services, promotes excellence through innovative approaches, sets
and achieves high standards for quality, and is financially responsible.
The Clinic meets all the requirements of the College of Physicians and Surgeons of Ontario (CPSO) and
in July 2012 received a 5-year “pass” following a CPSO inspection, and a letter stating that Kensington
Screening Clinic and staff are “in keeping with the Out-of-Hospital Premises Standards.”
Quality
The Clinic has an internal Quality Committee at the Board level, which meets quarterly and is Chaired by
the Medical Director. The Committee monitors quality indicators and other information pertaining to the
delivery of care and oversees the implementation of quality improvement initiatives to ensure excellence
in patient care and innovation.
KSC has adopted all of the recommendations of Cancer Care Ontario’s Guideline for Colonoscopy
Quality Assurance in Ontario, September 2013.
KSC Team
KSC has a skilled and committed medical/surgical team of 19 doctors (5 surgeons and 14
gastroenterologists ) led by Dr. Ian Bookman, (Staff Gastroenterologist, St. Joseph’s Health Centre;
Assistant Professor, Internal Medicine, University of Toronto; Regional Colorectal Screening / GI
Endoscopy Lead, Toronto Central, Cancer Care Ontario). With one exception, KSC’s endoscopists are on
active staff at St. Joseph’s Health Centre, St. Michael’s Hospital, University Health Network, Sunnybrook
Health Sciences Centre, or at one of the community hospitals in the Greater Toronto Area (GTA).
Continuation of hospital appointments is a KSC requirement for privileges at KSC. The KSC endoscopist
without hospital affiliation was on staff at the former Doctor’s Hospital, has been at KSC since opening,
has good standing and a solid reputation and as a result, has been grandfathered. If a patient of this
endoscopist were to require hospitalization, the privileges of KSC’s Medical Director would be utilized to
facilitate access.
Currently, anesthesiologists from Sunnybrook Health Sciences Centre provide services to KSC. All
doctors affiliated with KSC bill OHIP directly for their services.
The Study
In March 2013 the Clinic received one-time funding from the Ministry of Health and Long-Term Care to
study the benefits of and requirements for the delivery of out-of-hospital endoscopy procedures.
KHC Report to the MOHLTC
December 2013
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Results
The study assessed the facility against a number of quality criteria and facility standards. In total, 1,559
patients were surveyed regarding their experience over a six month period between November 1, 2012
and April 30, 2013. The average wait time for patients during the period of study was 21.9 days (mode: 14
days, median 21 days). The findings are summarized in the table below.
1559 Patients/Procedures
Assessment:
Quality Criteria &
Facility Standards
Findings
Total Yes
%
Total
No
No
Response
%
%
Number of Patients
treated by
Endoscopist
affiliated with
Hospital
1419
91%
140*
9%
0
0
Automatic
Endoscopic
Reprocessor used
for Cleaning
1559
100%
-
-
-
-
Patient was ASA 1,2
or 3
1559
100%
-
-
0
0
457
ASA1
641
ASA2
321
ASA3
Procedure Reached
the Cecum
1558
99.9%
1**
-
0
-
Follow-up plans
Communicated in
Endoscopist’s report
1556
99.8%
3
.2%
0
-
Efficiency of Design
and Flow for Patient
1559
100%
-
-
-
-
Staffing Levels
Exceed Hospital
Requirements***
1559
100%
-
-
-
-
Report Sent
Electronically to
Referring Physician
1559
100%
-
-
-
-
* Of the 140 patients treated by endoscopist without hospital affiliation, 37 ASA1, 59 ASA2 and 44 ASA3
**No Cecum present
*** 1 endoscopist, 1 anesthetist and 1 procedure nurse are in the procedure room (compared to norm in
hospital of 1 endoscopist and 1 RN in procedure room)
KHC Report to the MOHLTC
December 2013
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Patient Satisfaction Just over 34 percent (535 of 1,559) of patients responded to the survey.
1559 Patients Surveyed/535 Respondents
Patient
Satisfaction
Findings
Yes
%
No
%
No Answer
%
With
Procedure
522
97.6%
12
2.2%
1
-
With Facility
528
98.7%
6
1.1%
1
-
With Care
526
98.3%
9
1.7%
0
-
With Access
514
96%
19
3.5%
2
0.4%
Best Practices
A number of best practices emerged with respect to the delivery of out-of-hospital endoscopy services as
a result of this review, all of which are part of policies and procedures in place at KSC.
Patient Safety
First and foremost, out-of-hospital facilities should have a system in place to monitor patient safety,
including adverse events and quality assurance for infection control.
Appropriateness of patient
morbidity for an out-patient setting should be pre-screened, such as ASA class. KSC is of the view that
out-patient facilities should be limited to ASA 1 and ASA 2 patients for the most part, with ASA 3 patients
reviewed on a case-by-case basis in terms of level of appropriateness. Procedures are not done at KSC
on ASA 4 patients and KSC does not consider it appropriate for ASA 4 to be done in an out-of-hospital
setting.
Quality Assurance
Out-of-hospital clinics should have a quality assurance committee that meets regularly to review
processes and performance and implements changes where warranted. To drive professional excellence,
we recommend that endoscopists receive a quarterly report card on their performance that compares
them with their peers in the facility. The facility can then address the performance issues of outliers and
implement a plan for follow-up reassessment to measure the impact of change.
Technical aspects of the quality of endoscopic procedures should also be measured, including cecal
intubation rates, bowel preparation, polyp detection and whenever possible, adenoma detection rates.
In addition, appropriateness in level and number of staff, both nursing and reprocessing technicians
should be reviewed at regular intervals, and the use of automatic endoscopic reprocessors should be
mandatory.
KHC Report to the MOHLTC
December 2013
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Medical Staff
All medical staff of an out-of-hospital facility should have and maintain hospital privileges and be on their
hospital roster for the provision of in-patient and emergency services.
Sedation
KSC staff anesthesiologists pre-screen all potential endoscopy patients through a mandatory preoperative questionnaire and are solely responsible for ASA designation. The questionnaire is provided to
the patient at the time of booking, and must be completed and returned to KSC a minimum of 48 hours
before their appointment. The anesthesiologist reviews the patient’s medical and surgical history and
indicates whether the patient is acceptable, unacceptable, or if further information is required (he/she
may, for example, request clinic notes from the patient’s cardiologist, or a more recent ECG).
For sedation, there must be a separate staff member in the procedure room devoted to administering the
drugs and monitoring the patient’s airway and vital signs. Deeper sedation such as propofol must be
administered by an anesthesiologist that is Board certified and in good standing with the College. Lighter
sedation, such as midazolam or fentanyl, can be administered either by an anesthesiologist or a
registered nurse with ACLS training. In addition to the staff member providing sedation, there must
always be at minimum one procedural nurse in the room along with the endoscopist. The staff devoted to
administering and monitoring sedation must stay with the patient throughout the procedure and during
transfer to the recovery room, and must not leave the patient until handover has been completed with the
recovery room registered nurse.
Access and Flow
In support of a positive patient experience, patient flow design and efficiency should be monitored,
including booking, admitting, intra-procedure and post-procedure monitoring. Patterns of regular delay
could then be identified and, assessed for cause, and addressed for change when appropriate. Regular
chart audits should be conducted to ensure completeness, including adequate documentation of the
consent process. Patient comfort and safety should be included as monitoring parameters.
Wait Times and Results
Wait times should be triaged according to the indication for endoscopy and monitored for acceptability as
per guidelines published by the Canadian Association of Gastroenterology and other medical authorities.
If wait times are not acceptable, then system change should be considered, such as the development of a
pooled endoscopy list or central booking system.
Results should be communicated in a timely manner both to the patient and the referring physician and
should be documented and monitored. This can best be accomplished by use of an electronic endoscopy
reporting system and/or an electronic medical record. Use of an electronic system also allows for
standardized reporting templates with mandatory fields, such as follow-up plans.
KHC Report to the MOHLTC
December 2013
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Patient Feedback
Finally, as a best practice, patients should have the opportunity to provide feedback in an anonymous
format. The handling of patient complaints should be addressed in a standardized fashion both to enable
patient input as well as to ensure fairness in the workplace.
Benefits of Out-of-Hospital Endoscopy Procedures
The Kensington Screening Clinic has demonstrated that the delivery of out of hospital endoscopy
procedures clearly supports the Ministry of Health and Long-Term Care’s Action Plan for Health Care,
and Cancer Care Ontario’s efforts to increase awareness of and participation in its cancer screening
program.
Keeping Ontario Healthy: The provision of out-of-hospital endoscopy procedures means that more
Ontarians will have timely access to screening for colorectal cancer. KSC supports the efforts of the
Ontario government and Cancer Care Ontario to improve the early detection of cancer. KSC can and is
willing to participate in an expanded screening program for colorectal cancer. The Clinic has the capacity
to screen more Ontarians and we are committed to working with primary care physicians to ensure all
patients have the follow up needed to get treatment and stay healthy. In this way, out-of-hospital facilities
like KSC have much to contribute through surveillance to reduce reoccurrences, keeping Ontarians
healthy.
Faster access to stronger health care: With its specialized focus and streamlined processes KSC can
contribute to reducing the wait for cancer screening and ensuring family practitioners have their patients’
results quickly – and KSC can do so while achieving an excellent level of patient satisfaction.
Right care, right time, right place: Since opening as a purpose-built facility, the Kensington Screening
Clinic has been helping to manage wait times for low-risk procedures and reduce last minute in-hospital
cancellations while at the same time freeing up hospital resources for patients assessed as ASA 4 or
most urgently in need of a hospital setting.
Conclusion
Through this study KSC has demonstrated that there are clear benefits to the health care system of
ensuring and funding access to endoscopy procedures outside of hospital. Several best practice
measures can be suggested from our review and parameters that should be implemented and monitored
in all out-of-hospital endoscopy units.
In support of the delivery of high quality care that is focused on patient safety, all out-of-hospital facilities
should have a system in place to monitor patient safety, including adverse events and quality assurance
of infection control. The use of automatic endoscopic reprocessors should be mandatory. The majority of
patients treated in facilities like KSC should be ASA 1 and ASA 2, with ASA 3 patients reviewed on a
KHC Report to the MOHLTC
December 2013
Page 7 of 7
case-by-case basis in terms of level of appropriateness. We recommend that ASA 4 patients be treated
in hospital.
Best practice includes the establishment of a quality assurance committee responsible for driving
excellence in patient care, technical elements of endoscopy procedures and facility operations. As
mentioned above, technical aspects of the quality of endoscopic procedures should be measured and
endoscopists should receive a quarterly report card on their performance that compares them with their
peers and sets out a plan to address performance issues if/where necessary.
Patient flow design and efficiency should be monitored in a comprehensive manner – and patient comfort
and safety should be included as a regular monitoring parameter. In addition, it is recommended that an
electronic endoscopy reporting system and/or an electronic medical record be employed to ensure the
timely communication of results to both the physician and referring physician.
Given the importance of screening in reducing the number of deaths due to colon cancer, KSC believes
that wait times should be triaged according to the indication for endoscopy, and monitored for
acceptability. If this approach fails to keep wait times at an acceptable level then system changes, such
as the development of a pooled endoscopy list or central booking system, would be warranted.
KSC is dedicated to improving access to treatment for patients requiring cancer screening and
surveillance, and to bringing about improvement in the quality of life for its patients.
We looks forward to working with Cancer Care Ontario as it continues to rollout its integrated cancer
screening strategy and to working with the Ministry, TC LHIN and CCO in the planned shift of low-risk
colonoscopy procedures to not-for-profit community-based specialty clinics like KSC. As the population
ages so too will the demand for screening. Expanding the use of out-of-hospital premises like KSC will
increase capacity for low-risk procedures, while at the same time, free up capacity in hospitals for patients
with more urgent needs.
KSC delivers seamless, high quality, efficient and cost-effective services in a comfortable state-of-the-art
environment that is sensitive to patients’ needs.
In time – and with MOHLTC, LHIN and CCO support - KSC will be able to expand its capacity and
contribute more broadly by not only improving the patient experience with better access to high-quality
clinical care and services, but also by increasing efficiency through productivity and delivering better
value for money.
We thank the Ministry of Health and Long-Term Care for the opportunity to participate in this initiative.

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