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Canadian Journal of Gastroenterology
Volume 26, Issue 1, Pages 17-31
Special Article

Canadian Association of Gastroenterology Consensus Guidelines on Safety and Quality Indicators in Endoscopy

David Armstrong,1 Alan Barkun,2 Ron Bridges,3 Rose Carter,4 Chris de Gara,5 Catherine Dubé,3 Robert Enns,6 Roger Hollingworth,7 Donald MacIntosh,8 Mark Borgaonkar,9 Sylviane Forget,10 Grigorios Leontiadis,1 Jonathan Meddings,11 Peter Cotton,12 Ernst J Kuipers,13 Roland Valori,14 and on behalf of the Canadian Association of Gastroenterology Safety and Quality Indicators in Endoscopy Consensus Group

1Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
2Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
3Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
4Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
5Division of General Surgery, University of Alberta, Edmonton, Alberta, Canada
6University of British Columbia, St Paul’s Hospital, Vancouver, British Columbia, Canada
7The Credit Valley Hospital, Mississauga, Ontario, Canada
8Division of Gastroenterology, Dalhousie University, Halifax, Nova Scotia, Canada
9Faculty of Medicine, Memorial University, St John’s, Newfoundland and Labrador, Canada
10Division of Gastroenterology & Nutrition, McGill University, Montreal, Quebec, Canada
11Department of Medicine, University of Calgary, Calgary, Alberta, Canada
12Department of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
13Department of Gastroenterology & Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
14Gloucestershire Royal Hospital, Gloucestershire, UK

Received 2 October 2011; Accepted 4 October 2011

Copyright © 2012 Canadian Association of Gastroenterology. This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (, which permits reuse, distribution, and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes.


Several organizations worldwide have developed procedure-based guidelines and/or position statements regarding various aspects of quality and safety indicators, and credentialing for endoscopy. Although important, they do not specifically address patient needs or provide a framework for their adoption in the context of endoscopy services. The consensus guidelines reported in this article, however, aimed to identify processes and indicators relevant to the provision of high-quality endoscopy services that will support ongoing quality improvement across many jurisdictions, specifically in the areas of ethics, facility standards and policies, quality assurance, training and education, reporting standards and patient perceptions.

BACKGROUND: Increasing use of gastrointestinal endoscopy, particularly for colorectal cancer screening, and increasing emphasis on health care quality, highlight the need for clearly defined, evidence-based processes to support quality improvement in endoscopy.

OBJECTIVE: To identify processes and indicators of quality and safety relevant to high-quality endoscopy service delivery.

METHODS: A multidisciplinary group of 35 voting participants developed recommendation statements and performance indicators. Systematic literature searches generated 50 initial statements that were revised iteratively following a modified Delphi approach using a web-based evaluation and voting tool. Statement development and evidence evaluation followed the AGREE (Appraisal of Guidelines, REsearch and Evaluation) and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) guidelines. At the consensus conference, participants voted anonymously on all statements using a 6-point scale. Subsequent web-based voting evaluated recommendations for specific, individual quality indicators, safety indicators and mandatory endoscopy reporting fields. Consensus was defined a priori as agreement by 80% of participants.

RESULTS: Consensus was reached on 23 recommendation statements addressing the following: ethics (statement 1: agreement 100%), facility standards and policies (statements 2 to 9: 90% to 100%), qual: 97% to 100%) and patient perceptions ( statements 22 and 23: 100%). Additionally, 18 quality indicators (agreement 83% to 100%), 20 safety indicators (agreement 77% to 100%) and 23 recommended endoscopy-reporting elements (agreement 91% to 100%) were identified.

DISCUSSION: The consensus process identified a clear need for high-quality clinical and outcomes research to support quality improvement in the delivery of endoscopy services.

CONCLUSIONS: The guidelines support quality improvement in endoscopy by providing explicit recommendations on systematic monitoring, assessment and modification of endoscopy service delivery to yield benefits for all patients affected by the practice of gastrointestinal endoscopy.