Guidelines for consultants / independent endoscopists

Index

• Introduction
• Colonoscopists for Screening Colonoscopy
  • Special requirements for those participating in the NHS Bowel Cancer Screening Programme
• Consultant Endoscopy Trainers
  • Introduction
  • Training Trainees, and assessment of trainee competence
    • Training
    • Educational Supervision
    • Courses for trainees
  • Trainer skills
    • Introduction
    • Trainer Evaluation Tool
    • Peer Evaluation of Trainer’s skills
    • Trainee Evaluation of Trainer’s skills
• Colonoscopists
  • Demonstrating colonoscopic competence and professional development
• Endoscopists in general
  • Demonstrating endoscopic competence and professional development
• Appendix
  • Derivation of Trainer Evaluation Tool

Introduction

1. When the JAG was first formed, its remit was entirely concerned with standards of teaching, training, and curricula for trainees in endoscopy in the UK. With the advent of the NHS Bowel Cancer Screening Programme http://www.cancerscreening.nhs.uk/bowel/index.html, the NHS felt it important to ensure that any colonoscopy undertaken on a screened population was performed to the highest standards possible. The BCSP sought the collaboration of JAG, interested endoscopists, and the National Endoscopy Training Programme with its National and Regional Training Centres, to help devise a high level assessment of colonoscopy skills and performance. All screening colonoscopists must meet the agreed criteria and be accredited as such, the accreditation being endorsed by and issued from the JAG.
2. Unsurprisingly, there was significant concern about the form of the first version of the assessment, and this has undergone thorough and significant revision. In conjunction with international experts in clinical assessment from the USA and the Netherlands, further validation is on-going. The BCSP and JAG are confident that the process is rigorous and fair, and are continuing to refine it.
3. This small development does however signify a step change for the role and remit of the JAG, and has moved it into helping set standards and issue accreditation for the consultant and other permanent professional grade staff.
4. The DOPS form used in the assessment for accreditation, and developed after extensive consultation with the multi-professional endoscopy community, has been slightly adapted for use in assessing competence in trainees, both for formative and for summative purposes.
5. The JAG feel that the DOPS tool can be used formatively for independent practitioners, including consultants, and that the voluntary intermittent use of DOPS is an excellent way to maintain and improve endoscopic skills. The JAG is aware that in 2009 professional bodies will not simply applaud but require evidence of quality of practice. Evidence of satisfactory performance data and endoscopic continuing professional development may support individual endoscopists and units in the event of unavoidable complications.

Colonoscopists for Screening Colonoscopy

6. As the National BCSP rolls out over 2007 – 2009, around 90 screening centres will start up, each with 2 – 3 screening colonoscopists. Because of appropriate concerns following the national audit of colonoscopic practice (Bowles et al, Gut 2004), the standards set for these colonoscopists are extremely high, with their scrutinised performance data being supplemented by a rigorous assessment. This is briefly outlined below – for full details see the BCSP guidance NHS BCSP Version 2 November 2006 Accreditation of screening colonoscopists

Extract from BCSP document

Consultant Endoscopy Trainers

Introduction

7. Formal JAG endoscopy courses, in line with best practice, are important for trainees learning endoscopy. Nevertheless, the vast majority of training is carried out, hands on, back at the base endoscopy units throughout the UK. Therefore, the key individual in endoscopy training in the UK is the independent endoscopist trainer. The training leads and centres have important and complementary roles in setting standards, developing training, and modelling and disseminating best practice, as well as delivering high quality courses.

Training trainees, and assessment of trainee competence

8. Recent audits of endoscopic practice across the UK have demonstrated the need for improved training. The relevant professional bodies and the NHS feel that it is imperative that practitioners are not only thoroughly trained and competent, but are demonstrably shown to be so. The JAG, with the backing of its’ constituent bodies, the support of the NHS National Endoscopy Programme and consonant with the mandatory principles of training and assessment laid out by PMETB and the GMC, is now applying formal assessment for all endoscopic procedures for trainees.
9. The mainstay of teaching & training in endoscopy should be supervised practice by competent and trained trainers. Within rough guidance of numbers of procedures undertaken by trainees, and when performance criteria are met, trainers should be intermittently evaluating a trainee to determine if they are ready to undergo formal assessment of competence by DOPS – see below.

Training

1. Any practitioner who is to undertake gastrointestinal endoscopy should receive formal training in the principles and practice of safe endoscopy.
2. In the best interests of patients, and to most efficiently teach trainee endoscopists, training should not be provided for practitioners who are not going to have a regular sessional commitment to endoscopy in their permanent posts.
3. Training in endoscopy should only take place in JAG approved units.
4. Endoscopy training should be provided as part of a multi-disciplinary gastroenterology service. Joint working (e.g. ward rounds, meetings) is desirable, and endoscopy units should hold regular multi-disciplinary meetings in which trainees should participate. General practitioners, nurses and other non-medical endoscopists who undertake training in gastrointestinal endoscopy must do so in units approved by the JAG and should register with the JAG.
5. Training should consist of protected, personalized, in-service teaching, and attendance at JAG initiated courses or equivalent JAG approved courses (now called JAG compliant courses).  Trainees are expected to attend the unit endoscopy users group.
6. Trained practitioners in gastrointestinal endoscopy are expected to maintain their knowledge and skills through a commitment to continuing medical education and professional development in endoscopy.
7. Training should include formal instruction in:
   • The indications for, as well as the contraindications to, each type of endoscopic procedure.
   • Obtaining informed consent from patients.
   • The technique of conscious sedation, and the avoidance and management of sedation-related complications.
   • The skills of endoscopy
   • The causes, recognition and management of endoscopy-related complications, and in how these complications can be avoided.
   • Communicating endoscopic findings and their implications to patients, relatives and carers.
   • Communicating bad news, including discussing complications of endoscopy
   • Providing a high standard of written reports and communications with other professionals.
8. All forms of therapeutic endoscopy should be taught only after adequate skills for diagnostic procedures have been acquired.  Procedures should be carried out only under supervision until competence is achieved, and has been formally assessed as such by the JAG process.
9. Trainees should have wider knowledge of issues related to endoscopy, including current surveillance protocols for gastrointestinal diseases, the implications of findings at endoscopy, the range of treatment options, or have access to such information.

Educational supervision

10. Trainees are required to participate in regular and frequent appraisal as well as supervised training. They should regularly seek formative assessments that contribute to their portfolio of evidence. They should respond positively to training, evaluation, feedback and assessment, to assist them in their preparation for accreditation and for lifelong learning. They must accept recommendations from trainers on their readiness for formal summative assessment and potential accreditation, or the need for further focussed training.   Use of the specific DOPS assessment forms is strongly recommended to provide a portfolio of assessed cases.

15. Trainees must ensure they have adequate on-site supervision at all times, for procedures that they have not yet gained a certificate of competence in, as defined in the curriculum.
16. Trainees may not undertake independent endoscopy unless formally assessed as competent by two independent assessors.

Courses for trainees

17. All trainees must attend a Basic Skills (Foundation course) in Endoscopy, initiated by or compliant with JAG standards (JAG compliant course). Courses should include such topics as patient care, maintenance, cleaning and disinfection of endoscopes and equipment, electrical hazards and the recognition and management of the complications of endoscopy. The principles and safe practice of conscious sedation should be formally covered.  
18. For those trainees undertaking therapeutic procedures, attendance at an approved advanced therapeutic endoscopy course is recommended. Courses should include stricture dilatation, PEG and prosthetic tube placement, polypectomy, treatment of GI bleeding and palliative techniques. 

Trainer skills

Introduction

The DOPS process above should help trainers develop their trainee’s skills, and help trainees themselves focus on key aspects of endoscopy. Trainers however need skills to help themselves develop also.

Trainer Evaluation Tool

With this in mind, the Endoscopy Education Steering Group (under the National Endoscopy Training Programme) brought considerable thought to this issue throughout 2006, with two outcomes. Firstly, they have given advice to the JAG on what a trainee may reasonably expect from a good trainer (See table of attributes). Secondly, from this they have devised a trainer evaluation tool, which can be used to help evaluate and improve training skills. The tool has two versions:

1. For use by peers, reviewing other trainers
2. For trainees to complete, to evaluate their trainers  

The former is slightly more extensive, as the group felt that trainees are less well positioned to evaluate certain aspects of trainer performance. The aim is to improve training for all trainees, by raising the profile of trainer evaluation, by improving awareness of the components of good training, and by enabling specific feedback to trainers, to direct their development and endoscopic CPD. A piece of academic work is underway to underpin the characteristics and evaluation of a high quality trainer, and further developments will follow.

These tools can be used in the following ways:

Colonoscopists

There are currently no mandatory criteria that consultant and other colonoscopists must meet to practice colonoscopy, or indeed any endoscopic procedure. There is however a professional obligation to practice to acceptable standards, notwithstanding any ethical and moral obligations to patients and the public. There are also recently proposed standards for endoscopic practice being put forward via the National Endoscopy Training Programme (NETP). The JAG is fully supportive of these standards. Finally, re-validation will commence in 2009, where positive proof of competence is required.

The JAG offers the quality framework and standards that are encapsulated by the processes above, to consultants and other independent endoscopists for their own voluntary use. It suggests that endoscopists might use the framework to demonstrate competence, and for their own endoscopic professional development. The JAG believes that this will not only benefit patients by improving practice, but also protect endoscopists in the (almost inevitable) event of a known complication of endoscopy. Some consultants are already voluntarily using the framework and the DOPS in such a manner.

It is suggested that individuals may wish to have a colleague observe and give formative feedback on their endoscopic performance from time to time, using the DOPS framework. These forms could then contribute to the appraisal folder as evidence of performance and endoscopic professional development, supplementing other performance data.

Endoscopists in general

See colonoscopists above – as the JAG and endoscopy community across the UK refine the Upper GI Endoscopy DOPS, Therapeutic Endoscopy and ERCP, and begin to develop and refine DOPS for other procedures, the JAG believes that endoscopists may wish to begin to use them.

It is intended to refine the current DOPS forms, and to develop DOPS for EUS and paediatric endoscopy in 2008.

Appendix

Assessment of endoscopy skills training

Derivation 

Attributes: A trainee might reasonably expect a trainer who:

Table 2. Domain Map

Mapping the original domains we identified onto the trainer evaluation tool shows that the tools cover all the domains identified.