Quality Assurance of Gastrointestinal Endoscopy Unit - A Single Center Study

Sarantuya Ts; Amarjargal B; Tungalag B; Khishgee D; Amarmend T; Delgertsog T; Amarjargal E; Sarantuya G; Gan-Orshikh L; Enkhjargal B; Sarantsatsral D; Burentungalag A; Nandintsetseg B; Tserendolgor Ts; Sattgul Sh; Javzanpagma E; Suvdantsetseg B; Khashchuluun O; Ouynkhishig N; Munkhtuya E; Uranchimeg M; Oyuntungalag L; Myadagmaa B; Bat-Erdene I; Batgombo N; Saranbaatar A

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Quality Assurance of Gastrointestinal Endoscopy Unit - A Single Center Study

VernacularTitle:Хоол боловсруулах эрхтний дурангийн тасгийн тусламж үйлчилгээний чанарын үнэлгээ – нэг төвт судалгаа
Author: Sarantuya Ts ¹ ; Amarjargal B ¹ ; Tungalag B ¹ ; Khishgee D ¹ ; Amarmend T ¹ ; Delgertsog T ¹ ; Amarjargal E ¹ ; Sarantuya G ² ; Gan-Orshikh L ¹ ; Enkhjargal B ¹ ; Sarantsatsral D ¹ ; Burentungalag A ¹ ; Nandintsetseg B ¹ ; Tserendolgor Ts ¹ ; Sattgul Sh ¹ ; Javzanpagma E ¹ ; Suvdantsetseg B ¹ ; Khashchuluun O ¹ ; Ouynkhishig N ¹ ; Munkhtuya E ³ ; Uranchimeg M ⁴ ; Oyuntungalag L ⁴ ; Myadagmaa B ⁴ ; Bat-Erdene I ⁴ ; Batgombo N ⁴ ; Saranbaatar A ¹
Author Information

1. Department of Gastroenterology and Endoscopy, Intermed hospital
2. Department of Gastroenterology, School of Medicine, MNUMS
3. Laboratoty Department, Intermed hospital
4. Quality and Safety Department, Intermed hospital
Publication Type:Journal Article
Keywords: Procedural sedation; Quality indicators; Quality benchmark level; Peer review
From: Mongolian Journal of Health Sciences 2025;86(2):165-170
CountryMongolia
Language:Mongolian
Abstract: Background:Accreditation of healthcare institutions serves as a fundamental mechanism for ensuring patient safety and validating the quality of medical services provided to the population. At Intermed Hospital, a quality measurement system for healthcare services has been established since 2015, encompassing 126 quality indicators at both institutional and departmental levels. This system facilitates continuous quality improvement efforts. In this context, quality indicators specific to the endoscopy department play a pivotal role in objectively assessing the quality of endoscopic services.
Aim:To assess the quality indicators in gastrointestinal endoscopy unit.
Materials and Methods:A retrospective single-center study was conducted by collecting data from the Intermed hospital’s electronic information systems which included HIS and PACS and Quality and Safety Department’s Database and the results were processed using the SPSS software. Ethical approval was granted by the Intermed hospital’s Scientific research committee. The quality of endoscopic services in the Intermed hospital was assessed based on: a) the average values of four quality indicators measured monthly; b) sample survey data from five categories of quality indicators.
Results :Between 2016 and 2024, the quality indicators of the endoscopy unit measured as the level of early warning score evaluations for patients was 95.97%±3.33, the level of cases where peripheral blood oxygen saturation decreased during sedation was 1.54%±3.78, the level of cases where patients experienced paradoxiical response during sedation was 5.82%±1.75, surveillance culturing level for validation of endoscopy reprocessing was 11.6%. The endoscopic documentation quality by peer review showed 95.7-100%, the colonoscopy quality indicators were followings as adenoma detection rate: 24.5% Cecal intubation rate: 99.1%, 95.2%, Colonoscope withdrawal average time: 13.28±10.62 minutes, Bowel preparation quality (Boston Scale): 89.3% 95.7%), patient discharge from the recovery room, Average discharge time post-procedure: With propofol alone: 30.92 minutes; With propofol and fentanyl combined: 31.52 minutes, The intermediate risk was 0.28% by the TROOPS evaluation during procedural sedation.
Conclusion:The quality benchmark levels for these endoscopic units, as determined by a single-center study, can be effectively implemented by benchmark endoscopy centers to enhance their quality and safety operations.
Full text:2025052913515424243165-170.pdf