RESEARCH DISCUSSION

 

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Discussion #7

Discuss your individual critical analysis of the posted article with in-text referencing to support your thoughts and ideas and with a reference list. 

Critique the posted QI article and respond to the following items:

1.      Analyze and discuss why a QI project was needed.

2.      What initial steps were assessed by the QI team? Discuss their findings, including the data.

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3.      Why was the focus of the QI project on a specific population?

4.      Analyze the QI model used for this project. Name and discuss an alternative QI model that could have been used in this project.

5.      Evaluate the findings of the QI project. Were the findings relevant? How did the RNs utilize and integrate the findings into their nursing    practice? 

6.      What is your cosmic question?

ResearchEBP

QI colorectal screening article

1Martin Y, et al. BMJ Open Quality 2019;8:e000670. doi:10.1136/bmjoq-2019-000670

Open access

Offering patients a choice for colorectal
cancer screening: a quality improvement
pilot study in a quality circle of primary
care physicians

Yonas Martin,1,2 Leo Alexander Braun,1 Marc-Andrea Janggen,1 Kali Tal,1
Nikola Biller-Andorno,3 Cyril Ducros,4 Kevin Selby,5 Reto Auer,1,5
Adrian Rohrbasser 6

To cite: Martin Y, Braun LA,
Janggen M-A, et al. Offering
patients a choice for colorectal
cancer screening: a quality
improvement pilot study in a
quality circle of primary care
physicians. BMJ Open Quality
2019;8:e000670. doi:10.1136/
bmjoq-2019-000670

► Additional material is
published online only. To view
please visit the journal online
(http:// dx. doi. org/ 10. 1136/
bmjoq- 2019- 000670).

Received 24 February 2019
Revised 15 September 2019
Accepted 21 September 2019

1Institute of Primary Health Care
(BIHAM), University of Bern,
Bern, Switzerland
2Department of General Internal
Medicine, Inselspital, Bern
University Hospital, University of
Bern, Bern, Switzerland
3Institute for Biomedical Ethics
and History of Medicine (IBME),
University of Zurich, Zurich,
Switzerland
4Foundation for Cancer
Screening of the Canton of Vaud
(FVDC), Lausanne, Switzerland
5Center for Primary Care
and Public Health (Unisanté),
University of Lausanne,
Lausanne, Switzerland
6Medbase, Wil, Switzerland

Correspondence to
Dr Yonas Martin;
yonas. martin@ biham. unibe. ch

Quality improvement report

© Author(s) (or their
employer(s)) 2019. Re-use
permitted under CC BY.
Published by BMJ.

AbstrAct
Background Guidelines recommend primary care
physicians (PCPs) offer patients a choice between
colonoscopy and faecal immunochemical test (FIT) for
colorectal cancer (CRC) screening. Patients choose almost
evenly between both tests but in Switzerland, most
are tested with colonoscopy while screening rates are
low. A quality circle (QC) of PCPs is an ideal site to train
physicians in shared decision-making (SDM) that will help
more patients decide if they want to be tested and choose
the test they prefer.
Objective Systematically assess CRC screening status of
eligible 50–75 y.o. patients and through SDM increase the
proportion of patients who have the opportunity to choose
CRC screening and the test (FIT or colonoscopy).
Methods Working through four Plan-Do-Study-Act
(PDSA) cycles in their QC, PCPs adapted tools for SDM and
surmounted organisational barriers by involving practice
assistants. Each PCP included 20, then 40 consecutive
50–75 y.o. patients, repeatedly reported CRC status as
well as the proportion of eligible patients with whom CRC
screening could be discussed and patients’ decisions.
Results 9 PCPs initially included 176, then 320 patients.
CRC screening status was routinely noted in the electronic
medical record and CRC screening was implemented
in daily routine, increasing eligible patients’ chance
to be offered screening. Over a year, screening rates
trended upwards, from 37% to 40% (p=0.46) and FIT use
increased (2%–7%, p=0.008). Initially, 7/9 PCPs had no
patient ever tested with FIT; after the intervention, only 2/8
recorded no FIT tests.
Conclusions Through data-driven PDSA cycles and
significant organisational changes, PCPs of a QC
systematically collected data on CRC screening status
and implemented SDM tools in their daily routine. This
increased patients’ chance to discuss CRC screening. The
more balanced use of FIT and colonoscopy suggests that
patients’ values and preferences were better respected.

Problem
Primary care physicians (PCPs) do not
usually offer their patients to make an
informed choice on colorectal cancer (CRC)
screening1 and patients might not have the
opportunity to decide whether they want to

be tested or how they would like to do so.
Guidelines emphasise the importance of
offering patients a choice between a struc-
tural examination like colonoscopy and a
high-sensitivity stool-based test like faecal
immunochemical test (FIT).2 3 When offered
both options, patients divide almost evenly in
their preferences.4 The large preponderance
of colonoscopy in Switzerland5 6 suggests
that PCPs in this country strongly prefer
colonoscopy over FIT regardless of patient
preferences.7 Consistent failure to offer FIT
may contribute to low CRC screening rates in
Switzerland.5 8

We designed this quality improvement
(QI) project to encourage practice teams
to implement systematic collection of CRC
screening status and communication tools
promoting shared decision-making (SDM)
in CRC screening decisions. We conducted
and tested the feasibility of data-driven
PDSA cycles in a practice team and aimed to
increase the proportion of patients eligible
for CRC screening who could express their
preference for or against testing and for FIT
versus colonoscopy.

background
In Switzerland, screening colonoscopies and
faecal occult blood tests (FOBTs) such as FIT
are nationally reimbursed by the basic health
insurance, for people aged 50–69 years. Access
to colonoscopy varies by personal insurance
plan. If patients are insured under a Health
Maintenance Organisation plan, they need
to be referred by their PCP. If insured with
a flexible plan, patients have direct access
to any specialists such as gastroenterologists
but are typically referred by their PCP or by
other involved specialists. Any specialist can
prescribe FOBT, but because PCPs are the

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http://orcid.org/0000-0001-6718-6821

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2 Martin Y, et al. BMJ Open Quality 2019;8:e000670. doi:10.1136/bmjoq-2019-000670

Open access

coordinating healthcare professionals in Switzerland,
they issue almost all the FOBT prescriptions.

CRC kills 1600 people each year and is the third most
common cause of death from cancer in Switzerland. If
screening with either colonoscopy or FIT begins at age
50, the absolute risk of dying from CRC at age 80 can
be halved.9 Colonoscopy is accurate but invasive, requires
unpleasant preparations that begin the day before, and
carries a small risk of serious adverse effects. FIT is conve-
nient, and the patient can take the sample at home. It
can detect CRC as well as colonoscopy but may not iden-
tify as many polyps.10 Since these screening options have
various benefits and harms with similar expected efficacy,
this makes the choice of CRC screening methods a ‘pref-
erence sensitive’ situation in which physicians should
accept their patient’s judgement about which test is better
for them.11

SDM is an approach where clinicians and patients share
the best available evidence when faced with the task of
making decisions, and where patients are supported to
consider options, to achieve informed preferences.11–13 If
SDM was adopted by most Swiss PCPs to discuss CRC with
their patients, it could increase the rate of patients getting
the choice to be screened and reduce the discrepancy
between patient’s preferences and prescribed methods
for CRC screening. SDM is based on the assumption that
the PCP is the person most trusted by the patients to
help them consider and decide on a treatment path that
accords with their values and needs.12 14 15

Changing PCPs’ routine so that most will offer patients
the opportunity to be tested for CRC and the choice
between screening tests poses a serious challenge, and
the best place to address it may be in a quality circle
(QC). QCs are groups of 6–12 healthcare professionals
who meet regularly to reflect on their practice and realise
multifaceted, step-based interventions for QI.16 17 80%
of PCPs in Switzerland regularly attend QCs18 . QCs
can use data-driven Plan-Do-Study-Act (PDSA) cycles to
implement changes in their practices, especially if PCPs
actively collect reliable data that inform their efforts.19 20
QC participants create new concepts by combining practi-
tioner-based and evidence-based medical knowledge and
test these new concepts to implement them into everyday
practice.21 22

Practice assistants (PAs) can be deployed to help
PCPs overcome organisational barriers to implementing
systematic SDM for CRC screening. PAs are health profes-
sionals who carry out clinical and administrative tasks in
PCP practices; they are common in Germany, the Nether-
lands, the USA and Switzerland.23 24 PAs might be able to
take over some work of SDM, lowering the burden that it
imposes on PCPs.25 26

measuremenT
To assist comprehension, please see online supplemen-
tary appendix 1. In collaboration with the PCPs of the
QC, we developed and adjusted our data collection

form, which allows PCPs to systematically and consecu-
tively collect data on 50–75 y.o. patients seen for more
than 5 min in a non-urgent face-to-face consultation.5 6 To
check consecutive enrolment, PCPs reported the number
of weeks it took them to collect all the data. PCPs reported
the patient’s age (birth year only), sex and previous CRC
testing. We categorised previous CRC testing status as no
previous testing, colonoscopy within the last 10 years,
colonoscopy more than 10 years ago, FOBT within the
past 2 years, FOBT more than 2 years ago, other tests
and unknown. We collected data on any prior FOBT
because FIT was introduced only 4 years ago in Switzer-
land; it was likely some patients were screened with other
types of FOBT like the guaiac-based test. If patients had
been tested within recommended intervals, PCPs did not
need to collect more data. If patients had not been tested
before or within recommended intervals, PCPs reported
if patients had contraindications to CRC screening (life
expectancy <5 years, current severe condition or other); if the patient had a contraindication, the PCP could stop collecting data. For eligible patients, PCPs reported whether they had discussed CRC. If they did not discuss it, they reported the reason: it was not appropriate to discuss screening during this visit; they had already discussed screening with the patient; or the patient had been seen during data collection or for another medical reason. If they discussed screening, PCPs reported the presence of potential symptoms of CRC (bloody stools, abdominal pain, weight loss, change in the bowel habits, others) and risk factors for CRC (personal history of CRC or polyps, family history of CRC or polyps, personal history of Crohn disease or ulcerative colitis or other). If the patient refused screening, the PCP noted the reason: no reason for refusal; patient does not feel concerned; patient fears side effects or complications; financial barriers; or other. Then, the PCP recorded the patient’s choice and the test they planned to take (no screening, colonoscopy, FOBT or other). In the second data collection, we added ‘decision postponed’ to the choices to give patients the chance to think about it before making a decision. PCPs took their first measurement in March 2017 and included 20 consecutive patients. They took their second measure- ment in May 2018 and included 40 consecutive patients. design The long-lasting QC in Wil has been created 21 years ago and currently includes nine PCPs working in the same primary care office. One psychiatrist and one derma- tologist working in the same office do not participate to the QC. The group consists of five senior and four younger physicians, five men and four women. They are employed by a large network providing primary health- care. The patient population is mixed, rural and urban, as the practices serve a small city, surrounding villages and rural areas. Between January 2017 and May 2017, two clinician-researchers from the research team of the Institute of Primary Healthcare of Bern met with the QC’s https://dx.doi.org/10.1136/bmjoq-2019-000670 https://dx.doi.org/10.1136/bmjoq-2019-000670 3Martin Y, et al. BMJ Open Quality 2019;8:e000670. doi:10.1136/bmjoq-2019-000670 Open access Figure 1 Study timeline. participants in four QC meetings. PAs from the primary care office participated in the second part of the QI project lasting until September 2018. We describe these meetings in detail in the Strategy section and a timeline (see figure 1) offers an overview of the QI project. One PCP who moved to a different region did not participate to the second data collection. sTraTegy The research team helped the QC conduct overlapping PDSA cycles. Pdsa cycle 1 (January 2017–march 2017) This first PDSA cycle focused on updating existing inter- vention material consisting in communication tools promoting SDM15 to suit QC’s specifications and values. In Switzerland, all citizens have healthcare coverage by law, but flexible deductibles are applied and can be as high as 2500 Swiss franc (≈US$2500). The material presented at the first meeting had been developed for Canton Vaud’s organised CRC screening programme, which waives the deductible of the screening tests and the medical consul- tation when a test is performed within the programme. Our study was conducted in Canton St Gallen, which has no organised screening programme and where costs of both tests are reimbursed, but deductible is not waived. The QC examined the communication tools which consisted in (1) a two-page structured evidence summary on CRC screening and information about colonoscopy and FIT, (2) a patient decision aid (20-page booklet) on CRC and (3) a four-page abridged version of the booklet to help PCPs discuss CRC screening with patients (‘Deci- sion Board’).27 28 The QC also looked at a data collection form developed for this study by the research team.5 6 The PCPs studied and discussed the documents and suggested adaptations to better meet their specific needs. The research team updated the materials and data collection process accordingly. Pdsa cycle 2 (January 2017–June 2017) This second cycle was the core of the QI project. At the first QC meeting, the research team worked with QC partic- ipants to identify and analyse current problems in CRC screening. The group acknowledged current literature on CRC and screening methods. PCPs accepted that screening rates were generally low and that PCPs' preferences for screening method is likely to have a disproportionate influence on the ratio of colonoscopy to FOBT. Partici- pants then set out to change behaviour and use SDM to give their patients an opportunity to discuss CRC screening options. The group used the adapted material in role plays to improve their communication skills. The QC addressed organisational barriers by adjusting their electronic medical record (EMR) and coding patients’ CRC status as well as the performed test. In the next QC meeting, the group agreed that a data collection was necessary to quantitatively assess the current situation using the developed data collection form. The group decided that each PCP should collect data from 20 patients within a 4-week period, and they did this in March 2017. Then, the research group analysed the data and presented them to the PCPs at a fourth QC meeting. The PCPs said they had changed their behaviour and that it took less time to discuss screening with their patient than they had expected. They decided to further implement SDM and suggested they include PAs in the process because these showed interest during the first data collection and their involvement could increase the chance for patients to be screened for CRC. 4 Martin Y, et al. BMJ Open Quality 2019;8:e000670. doi:10.1136/bmjoq-2019-000670 Open access Pdsa cycle 3 (march 2017–may 2018) In the third PDSA cycle, PCPs decided to involve PAs and delegate them CRC screening discussions with patients at average risk. PCPs decided to integrate CRC screening into the basic preventive care services the practice regu- larly provide for patients aged over 50 y.o. In this practice, PAs regularly collect patients’ smoking status and system- atically measure their body mass index (BMI), heart rate and blood pressure (BP). The PCPs conducted an internal pilot trial and involved two PAs in SDM about CRC screening options. During a session, the QC facili- tator taught the PAs how to use the adapted SDM tools (the booklet intended to patients and the decision board to support discussions on screening). The PAs then prac- tised by role playing. The PCPs implemented a rigorous process that identified high-risk patients; each morning before the consultations, PAs and PCPs briefly discussed the scheduled patients to assess to determine which of the 50–75 y.o. ones were at increased risk for CRC (personal history, familial history or symptoms suggestive for CRC) and if those conditions precluded screening (eg, pres- ence of malignancies or psychiatric diseases). The PCPs discussed screening options with high-risk patients, and the PAs discussed screening with all other eligible patients, if time allowed. If the PA identified CRC risk factors or symptoms during the discussion, the PCPs took over. If a patient opted for FIT, the PA supplied the necessary mate- rial and information. If a patient opted for colonoscopy, the PCP performed a few medical tests and organised the referral to the gastroenterologist. After their discussion with eligible patients, PAs coded patient decisions: not willing/contraindication to screening; FIT; colonoscopy; or postponed decision. The new process was tested with two PAs for 2 weeks and then PCPs’ and PAs’ suggestions were integrated; for instance, they simplified the refer- rals to gastroenterologists. The two PAs found this new process feasible and acceptable. They shared their expe- riences with the whole PA team during a meeting led by the QC facilitator. Finally, all PCPs met with the two PAs to finalise details before the strategy was routinely imple- mented. Pdsa cycle 4 (June 2017–september 2018) The fourth PDSA cycle evaluated PAs participation in the SDM process. All PCPs and all PAs were invited to a new QC meeting where the majority agreed that the whole team should implement the new process developed in PDSA cycle 3. The PCPs shared evidence and knowledge about CRC and screening with the PAs. They taught them the use of the information booklets and decision boards for SDM through role play. The QC facilitator along with the two PAs involved in the previous cycle presented the morning triage process, where eligible patients were identified. They also introduced electronic reporting of patients’ CRC status as follows: contraindications; chosen screening method; refusal or (in the second data collection round) postponed decision. The QC facili- tator and the two PAs established routines to provide patients who chose FIT with information and sampling kits. Patients who chose colonoscopy had blood drawn to exclude a higher bleeding risk and were referred to the closest hospital. The PAs implemented the new process in their routine between January 2018 and April 2018. They discussed CRC screening with patients who were not at high risk whenever possible and used the EMR to report on patients’ CRC status, BMI, heart rate, BP and smoking status. Once this process was embedded in the PAs’ routine (April 2018), PAs and PCPs decided to conduct the second data collection. For this second data collection, the collection form was filled by PAs for non-high-risk patients, and by PCPs for the other ones. The research team met with all PAs at a supplementary meeting and explained how to use the data collection form. resulTs Pdsa cycle 1 PCPs suggested adapting the intervention documents, notably concerning information on reimbursement of screening tests in their canton, since St Gallen does not have an organised screening programme. They also changed the order of items on the data collection form so it better matched the order in which topics were raised by PCPs when they discussed CRC screening with their patients. Pdsa cycle 2 PCPs implemented SDM in discussions about CRC screening options and continued to improve their communication techniques. They developed and imple- mented an electronic coding algorithm ([0;1;2]: refusal/ contraindication; colonoscopy <10 years; FIT<2 years) that allowed them to reliably report CRC status. During the first data collection, the nine QC participants reported data on 20 consecutive patients (176 patients; one PCP only collected data on 16 patients). At baseline, screening rate was 37% (65/176) and almost all patients who were already up-to-date (colonoscopy ≤10 years or FOBT ≤2 years) had been screened with colonoscopy (colonoscopy 58/65; FOBT 3/65; other 4/65; see figure 2—Panel A). Of the nine PCPs, seven had no patients ever tested with FOBT (results not shown). PCPs could discuss screening options with most of the previously untested patients (55%–100%) who had not been excluded for contrain- dications (figure 2—Panel B). After discussion, a quarter of patients refused screening. 63% opted for FIT and 12% opted for colonoscopy (figure 2—Panel C). PCPs found they were able to discuss CRC screening with most eligible patients and it was much less time-consuming to diagnose patients’ preferences than they had expected. But because of some very high discussion rates (100%), the group agreed at a further QC meeting that PCPs could not be expected to discuss CRC screening with all eligible patient they saw. 5Martin Y, et al. BMJ Open Quality 2019;8:e000670. doi:10.1136/bmjoq-2019-000670 Open access Figure 2 Panel A: CRC status at baseline in 2017 (n=176), Panel B: discussion rates for each PCP in 2017 (n=106), Panel C: decisions after discussion in 2017 (n=85). CRC, colorectal cancer; FOBT, faecal occult blood test; PCP, primary care physician. Figure 3 Panel A: CRC status at baseline in 2018 (n=320), Panel B: discussion rates conducted by PAs and PCPs for each PCP in 2018 (n=171), Panel C: decisions after discussion in 2018 (n=111). CRC, colorectal cancer; FOBT, faecal occult blood test; PAs, practice assistants, PCP, primary care physician. Pdsa cycle 3 Two PAs learnt to prepare the consultation agenda with PCPs so they could identify patients who were not at high risk, and then used the intervention material to facilitate SDM with these patients. They adapted them to suit their preferences and added the item ‘postponed decision’ to the data collection to capture this common choice. PAs learnt how to use the EMR to report a patient’s CRC status [(0;1;2;3): refusal/contraindication; colonoscopy <10 years; FIT <2 years; decision postponed). Finally, they learnt how to systematically assess CRC screening status and then discuss CRC screening with non-high-risk patients using SDM material. Pdsa cycle 4 The team (24 PAs and 8 PCPs) participated in data collec- tion and reported data on 40 consecutive patients for each PCP (320 patients). We show our main results in figure 3 (panels A, B and C). Baseline screening rate increased from 37% to 40% but the increase was not statistically significant (p=0.46). The proportion of patients screened with FIT increased more than threefold (from 2% to 6 Martin Y, et al. BMJ Open Quality 2019;8:e000670. doi:10.1136/bmjoq-2019-000670 Open access 7%, p=0.008). The number of PCPs who had no patients tested with FOBT at baseline dropped to 2 of 8 (it was 7/9 in 2017, results not shown). All but one PCP were able to discuss CRC screening with most of their eligible patients (42%–84%). Of patients with whom screening was discussed, 20% decided to postpone their decision and 80% made one (30% refused screening, 38% opted for FIT and 12% for colonoscopy). Further results ► PAs added CRC status to routine collection of BMI, BP, and smoking status in EMR. ► PCPs developed routines for colonoscopy referrals that included sampling the patient’s blood, supplying detailed information about the test and giving the patient the necessary instructions for using laxative and dietary instructions. lessons and limitations When PCPs get the chance to choose what they want to address and can adapt the study material to do so, they actively get involved in the conception of a QI project. They are even able to overcome structural and organisa- tional barriers such as patients’ triage for discussions on CRC screening, time restrains, delivery of quality infor- mation and patient referrals. Baseline screening rates tended to be higher over time (37% vs 40%) and the proportion of patients screened with FOBT increased more than threefold (from 2% to 7%, p=0.008). The number of PCPs who had no patients tested with FOBT dropped from 7/9 in 2017 to 2 of 8 in 2018. These results suggest that PCPs massively changed their prescription patterns for CRC screening while patients could better choose the option which best fitted their preferences. When PCPs could discuss CRC screening, the vast majority of their patients took an active decision for CRC screening (for or against screening, and with which test). These results suggest the importance and relevance of offering patients a choice. When offered a choice, the proportion of patients who choose either colonoscopy or FOBT does not seem to match the proportion of colo- noscopy screenings (89%) found in a recent Swiss study,5 which suggests that PCP preferences overdetermine the choice of test. We found that during first data collection (PDSA cycle 2), some of the PCPs discussed screening with 100% of their eligible patients. They figured out, after discussing this point at a further QC meeting, that it was not prac- tically feasible to do so in a real-life practice. This rate markedly decreased in the second data collection corre- sponding to what seems to be routinely feasible and reasonable. Consistent with the literature,29–31 participating PCPs found out that they needed to make substantial organ- isational changes and involve PAs to implement SDM and facilitate discussions on CRC screening. PAs could significantly reduce PCP workloads25 26 by identifying and discussing CRC screening with non-high-risk patients, as well as reporting CRC status in the EMR. The higher screening rates and substantial increase in the number of patients, who had been tested with FOBT after the second data collection, suggest that imple- menting SDM increased the number of patients who were able to choose which test best suited their preferences and values. We are following up this pilot study with two randomised controlled trials in primary care practices32 33 aimed at generating more evidence that training PCPs in SDM can decrease the variation in CRC test choice between PCPs and increase the variation in screening methods,15 and that this will ultimately raise screening rates. Our study has some limitations. Since we did not perform a chart-based validation of the data collected, we could not determine the accuracy of PCP self-reports and cannot rule out the possibility of selection bias in choice of participants by PCPs who might not always have followed the rule to include patients consecutively. During the first data collection some PCPs thought the goal was to discuss CRC screening with all eligible patients, which might have influenced and increased prescription rates (after discus- sion) of the first results. In the second data collection, discussion rates decreased showing how PCPs and PAs integrated the notion that it was not feasible to discuss screening with all patients. Furthermore, our ability to compare the results of the first and second data collec- tion is limited because PCPs alone collected the data in the first round, and PCPs and PAs both collected the data in the second round. Another point needs to be voiced as a limitation; although PCPs changed their practices after the intervention, screening rates at baseline need years to actually represent current prescription practices. The short observation time could explain the only moderate increase in screening rates at baseline between data collections. Finally, although the overall baseline testing rates and test proportions we found seem consistent with the literature,5 8 34 generalisation to practices in Switzer- land is difficult due to the local context and the limited number of patients assessed in this pilot study. Our study was strengthened by the use of a data collec- tion form created by PCPs, who made sure it was clear and easy to integrate into their daily routine. Developing the implementation in a QI group allowed us to closely collaborate with PCPs, and allowed the PCPs to work together to make necessary modifications to the interven- tion materials and the data collection form. This certainly enhanced an important sense of ownership among the participants regarding the study and its material. Further- more, the study design offered PCPs to set convenient times for meetings, to improve data collection efficiency and PAs involvement as well as to implement changes to the EMR. Piloting the intervention as part of a pragmatic real-life study allowed us to test its suitability for imple- mentation in primary care practices based on collection and analysis of reliable data collected through data-based QC with PDSA cycles. This participatory research study enabled durable changes by increasing acceptance of the 7Martin Y, et al. BMJ Open Quality 2019;8:e000670. doi:10.1136/bmjoq-2019-000670 Open access intervention by its participants. Furthermore, systematic report of CRC status in the EMR next to BMI, heart rate, BP and smoking status enables simple identification of patients not up-to-date with CRC screening on the long run and helps to ensure sustainability of this project. PCPs are in a unique position to collect valuable data on discussion and refusal rates, which cannot be gath- ered by other health care professionals, stakeholders, or insurance companies. Since QC participants could decide which aspects of quality of care are most important and how to improve them, our study presented an exceptional opportunity to measure what they are effectively doing to reach their goal. conclusion In this pilot QI project, characterised by data-driven PDSA cycles, a QC of PCPs routinely implemented systematic data collection on CRC screening status and communication tools promoting SDM in CRC screening decisions. Combining a multilevel training intervention with significant organisational changes such as involving PAs, the QC of PCPs successfully increased the chance for eligible patients to be offered to be screened for CRC and to choose between CRC screening options. The use of FIT increased more than threefold, which indicates that a higher proportion of patients might have been able to choose the test that best matched their preferences and values. Acknowledgements The authors would like to acknowledge all practice assistants and all primary care physicians who participated in this study. Contributors YM helped conducting the study and wrote the manuscript, LAB helped conducting the study and revised the manuscript, MA-J helped conducting the study and revised the manuscript, KT helped concepting the manuscript and edited it, NB-A gave her ethical expertise and revised the manuscript, CD gave his expertise on CRC screening and revised the manuscript, KS gave his expertise on CRC screening and revised the manuscript, RA designed and helped conducting the study, and revised the manuscript, AR helped conducting the study, supervised the writing and can be designed as guarantor. Funding This work was supported by the funds from the Swiss National Scientific Foundations National Research Plan 74 NFP74. 407440_167519. The funders had no role in the design or conduct of the study, in the collection, management, analysis or interpretation of data, nor in the preparation, review or approval of the manuscript. Competing interests CD is medical director of the organised CRC screening program of Canton of Vaud in Switzerland. This program is implemented in close collaboration with primary care physicians and offers colonoscopy and FIT to all citizens aged 50 to 69 years. KS reports grants from Swiss Cancer Foundation, outside the submitted work. He is part of the steering committee for the CRC screening program for the Canton of Vaud mentioned above. He is also a primary care physician. RA reports grants from Swiss National Science Fundation, during the conduct of the study, and works part-time as a primary care physician where he actively offers choice of CRC testing options to patients. He is active in the implementation of the CRC screening program of Canton of Vaud in Switzerland mentioned above. AR is a primary care physician and facilitator of the quality circle at the healthcare centre where the study took place. Member of the board for quality improvement of Medbase, a network of health care centres providing primary healthcare in Switzerland. Patient consent for publication Not required. Provenance and peer review Not commissioned; externally peer reviewed. Open access This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https:// creativecommons. org/ licenses/ by/ 4. 0/. ORCID iD Adrian Rohrbasser http:// orcid. org/ 0000- 0001- 6718- 6821 references 1. McQueen A, Bartholomew LK, Greisinger AJ, et al. 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This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License. Offering patients a choice for colorectal cancer screening: a quality improvement pilot study in a quality circle of primary care physicians Abstract Problem Background Measurement Design Strategy PDSA cycle 1 (January 2017–March 2017) PDSA cycle 2 (January 2017–June 2017) PDSA cycle 3 (March 2017–May 2018) PDSA cycle 4 (June 2017–September 2018) Results PDSA cycle 1 PDSA cycle 2 PDSA cycle 3 PDSA cycle 4 Further results Lessons and limitations Conclusion References Thou_Shalt_Not_Fall!_Decreasing_QI article July-August 2013 • Vol. 22/No. 4246 Kimberly Foisy, MSN, RN, CMSRN, is Clinical Educator/Administrative Nursing Supervisor, Orthopedic-Neurological Medical/Surgical Unit, North Shore Medical Center (NSMC), Salem Hospital, an affiliate of Partners Healthcare System Inc.; and Assistant Professor, Massachusetts College of Pharmacy and Health Sciences, School of Nursing, Boston, MA. Acknowledgment: The author gratefully acknowledges Kathy Clune, MSN, RN, Nurse Manager, Phippen 6 and 7; and Taryn Bailey, MSN, RN-BC, Executive Director, Professional Practice and Patient Education Services, for their advice and guidance in the development of this article. Thou Shalt Not Fall! Decreasing Falls In the Postoperative Orthopedic Patient with a Femoral Nerve Block N orth Shore Medical Center (NSMC), Salem Hospital, an affiliate of Partners Health - care System Inc., is a 250-bed acute care teaching hospital located in Salem, MA, near Boston. The hospital serves a diverse patient population with 12,000 inpatient admissions per year. The hospital’s 32-bed orthope- dic-neurologic inpatient unit, which is split between the 6th and 7th floors of the Phippen Building, has an average daily census of 30 patients. Unit leadership includes a nurse manager, clinical educator, unit coordinator, and one day-shift charge nurse assigned to both floors. Average daily staffing consists of three nurses, two nursing assistants, and a service associate for each 16- bed unit; staff can be assigned to either floor. Improvement Needs Decreasing patient falls is a patient safety priority for direct-care nurses. Many regulatory and govern- mental agencies, such as the Centers for Medicare & Medicaid Services (CMS), have set standards and pay- ment incentives to reduce or elimi- nate falls in the health care setting. For example, CMS (2011) no longer reimburses for hospitalization if a patient has an injury as a result of an inpatient fall. Some health care providers suggest falls cannot be avoided (Muraskin, Conrad, Zheng, Morey, & Enneking, 2007). However, staff members for the involved units at NSMC were determined to count- er this view by taking action to address a recent increase in patient falls on the unit. Phippen 6 and 7 house postoper- ative orthopedic and neurological surgical patients. Each floor has 16 private beds. A group of multidisci- plinary professionals and unlicensed staff from the two units convened to form a team under the Transitioning Care at the Bedside (TCAB) model (Rutherford, Moen, & Taylor, 2009). The team set a goal to eliminate falls on the unit and started analyzing falls data to determine the rate and cause of falls that were occurring. Data revealed as many as three falls per month associated with femoral nerve blocks (FNBs), with two patients sustaining injury from January to July 2009. The unit had a fall rate of 5.2 per 1,000 patient days, compared with a fall rate of 3.43 per 1,000 patient days for the facility. Further data analysis showed 5 of 30 falls reported during that time occurred in patients with a femoral nerve block in place following knee arthroplasty. A process flow analysis revealed the nursing practice protocol recent- ly had been replaced by a standard computerized nursing order set that did not include assessment parame- ters for the patient or a plan of care. Furthermore, the signs at the head of the patients’ beds stating “Fall Risk Femoral-Nerve Block” were being removed as soon as the FNB was dis- continued. A learning needs assess- ment demonstrated nursing assis- tants did not have adequate knowl- edge of the definition, purpose, and precautions needed in caring for a patient with a current or recently discontinued femoral nerve block. In addition, patients and families were not aware of the safety risks needed during and after the use of a contin- uous femoral nerve block. Literature Review Two searches of the CINAHL data- base were performed to identify best practices (June 2009; May 2011) for literature of the preceding 6 years. The terms searched included femoral nerve block, falls, and orthopedic sur- gery. The search revealed no pub- lished nursing literature that demon- strated a decrease in falls in persons with femoral nerve blocks after an Advanced PracticeAdvanced Practice Kimberly Foisy A Transforming Care at the Bedside model was used to decrease falls in the femoral nerve block (FNB) patient population on a 32- bed orthopedic/neurologic unit in a community hospital setting. A multifaceted, strategic practice and educational bundle was implemented, resulting in a 75% decrease in falls among patients with FNB. July-August 2013 • Vol. 22/No. 4 247 educational intervention was imple- mented to nursing staff. Results of two medical studies are described in the following paragraphs. Sharman, Iorio, Specht, Davies- Lepie, and Healy (2010) reported patients with a FNB have a shorter length of stay. According to these authors, patients ambulate earlier as a result of the comfort maintained with the block. A large percentage of postoperative falls among this group of patients have quadriceps weak- ness as a contributing factor. Continuous FNB provides effec- tive pain management as an anal- gesic adjunct to other modalities for orthopedic patients. A FNB reduces the required doses of general anes- thetic agents and hence their side effects, including nausea, vomiting, drowsiness, and respiratory depres- sion. The FNB also confers superior pain management, decreases opioid requirements, and enables earlier ambulation and hospital discharge (Atkinson, 2008). The use of FNB with general anesthesia also places the patient at a higher risk for falls. A continuous FNB is used as an anesthetic. A catheter is placed just below the skin surface, next to the femoral nerve. The catheter coats the nerve with anesthetic, blocking transmission of neuronal messages and creating a feeling of localized numbness for the patient (Kasibhatia & Russon, 2009). This block allows the patient to achieve more effective pain management. The block does not alleviate the pain on the posteri- or portion of the knee. An adjunct therapy, such as patient-controlled analgesia, often is prescribed for this reason. Because the block causes a weakness of the quadriceps muscle, the patient needs assistance with every transfer (Atkinson, 2008). One of the cases analyzed by the team involved a patient who was ambulating with a nursing assistant. The continuous femoral nerve block had been discontinued 2 hours earli- er. The patient’s knee buckled, and he proceeded to fall to the floor. The nursing assistant hit the door and sustained a minor back injury. The patient’s knee wound opened as a result of the fall, requiring minor suturing. Fortunately, the patient’s length of stay did not increase as a result of this fall. Continuous Quality Improvement Model After reviewing the data, the team developed a multifaceted plan to educate unit staff on the safety and care of patients with femoral nerve block, as well as standardize the process for patient care following femoral nerve block. The Nerve Block Bundle included developing and implementing a: 1. Patient and family education sheet to engage patients in their care (see Figure 1). 2. Revised nursing protocol to standardize the process for care. 3. Nursing education plan. 4. Fall prevention signage specific to this population (see Figures 2 & 3). 5. Tip sheet for unlicensed assistive personnel (UAP) to reinforce the care and safety needs of the patient with a FNB (see Figure 4). The education plan and bundle were presented at the NSMC Nursing Professional Practice Council, ac - cepted into practice, and imple- mented August-October 2009. Patient/Family Education Sheet Patient and family education are vital in preventing falls (Agency for Healthcare Research and Quality, 2010). The patient/family education sheet (see Figure 1) includes informa- tion related to pain management, duration of the femoral nerve block, sensation of the lower extremity, and safety guidelines to reinforce the patient’s need to call for assistance to get out of bed. Nursing Protocol Sharma and co-authors (2010) rec- ommended hospitals develop proto- cols addressing decreased quadriceps function as a result of a continuous FNB. Prolonged nerve blockade can last up to 30 hours after termination of the continuous femoral nerve block (Atkinson, 2008). This study recommended the implementation of a postoperative evaluation that included proprioceptive function. FIGURE 1. Femoral Nerve Block Patient Information Sheet • The femoral nerve block is a regional anesthetic technique used in con- junction with general anesthesia for pain relief. • It is an effective block that provides both safe and excellent surgical anesthesia and postoperative pain control. • Your leg will feel numb, but you can still move your leg • You will have little or no pain in the front of your leg or knee. However, you will probably have some discomfort behind your knee. That is expected. • Remember to discuss your pain plan with each nurse. • REMEMBER: Ring your call bell for assistance. • You MUST NOT get out of the bed or chair, or off the commode without assistance. • Your therapist and/or nurse will instruct you on the safest ways to move. • The numbness and weakness from the block usually lasts 8-20 hours and occasionally more than 24 hours once it is removed from your groin. • As the block begins to wear off, you should start your pain medicine that was prescribed by the surgeon. REMEMBER: Ask the nurse for your pain medication. The nurse will be offering you pain medication, but you need to ask as well. Thou Shalt Not Fall! Decreasing Falls in the Postoperative Orthopedic Patient with a Femoral Nerve Block July-August 2013 • Vol. 22/No. 4248 Based upon this evidence, a nurs- ing protocol was written to include the following: 1. Assess the sensory, motor, and vascular condition of the extremity every 4 hours during and after removal of the femoral nerve block until the patient obtains full sensation and motor function returns. 2. Maintain fall precautions for the duration of the patient stay, regardless of assessment of FIGURE 2. Fem Block Stop Signage STOP Do Not Get Out of Bed Call for Help FIGURE 3. Fall Prevention Signage Fem-Block High Risk for Falls! Patient: Room: Date/Time Stopped: return of motor function and sensory function. 3. Maintain fall risk signage for the duration of the patient stay. 4. Place signage at the head and foot of the bed to reinforce mes- saging for the patient, family, and staff (see Figures 2 & 3). Fall Risk Signage Patients typically have the FNB removed on postoperative day 2 in the early morning. Patients generally are discharged on postoperative day 4 either to home or a rehabilitation facility. To im prove patient safety, the team decided signage would remain for the entire length of stay. UAP Education/Tip Sheet Based on findings from the litera- ture, a one-page educational sheet was developed for all UAP (see Figure 4). The tips were developed by the FIGURE 4. Safety in Caring for the Patient with a Femoral Nerve Block A femoral nerve block is a peripherally inserted catheter that delivers a numbing medicine to cover the femoral nerve. A TKR patient usually has the catheter in place for 48 hours. Structures Seen on Ultrasound in Left Femoral Space (viewed from foot) The catheter is placed just below the skin surface, next to the femoral nerve. The catheter coats the nerve with numbing medicine; this allows for blocking of the painful sensations from the hip down the patient’s leg. The medicine will numb the patient’s leg. The thigh muscle, or quadriceps, will be very weak. The leg will be warm, and may be slightly warmer than the non-affected leg. The patient will always need two assists when getting out of bed with this catheter in place and for a certain period of time after removal. Maintain the patient on The Falling Star Program. After removal of the femoral nerve block, the same safety precautions will remain until the patient has regained complete sensation in the leg. You need to check with the nurse before moving the patient to determine if the patient has feeling back in his/her leg and identify if the patient can be transferred with one assist. Source: Reprinted with permission from Vander Beek, J. (2005). Advanced Practice July-August 2013 • Vol. 22/No. 4 249 Atkinson, H.D. (2008). Postoperative fall after the use of the 3-in-1 femoral nerve block for knee surgery: A report of four cases. Journal of Orthopaedic Surgery, 16(3), 381-384. Centers for Medicare and Medicaid Services (CMS). (2011). Medicare fact sheet: Proposals for improving quality of care during inpatient stays in acute care hospi- tals in the fiscal year 2011 notice of pro- posed rulemaking. Retrieved from http:// www.cms.gov/Medicare/Medicare-Fee- for-Service-Payment/AcuteInpatientPPS/ downloads/FSQ09_IPLTCH11_NPRM04 1910 Kasibhatia, R.D., & Russon, K. (2009). Femoral nerve blocks. Journal of Perioperative Practice, 19(2), 65-69. Muraskin, S.I., Conrad, B., Zheng, N., Morey, T.E., & Enneking, M.D. (2007). Falls associated with lower-extremity-nerve blocks: A pilot investigation of mecha- nisms. Regional Anesthesia and Pain Medicine, 32(1), 67-72. Rutherford, P., Moen R., & Taylor, J. (2009). TCAB: The “how” and the “what.” American Journal of Nursing, 109(11), 5- 17. Sharma, S., Iorio, R., Specht, L.M., Davies- Lepie, S., & Healy, W.L. (2010). Compli - cations of femoral nerve block for total knee arthroplasty. Clinical Ortho paedics and Related Research, 468(1), 135-140. Vander Beek, J. (2005). Finding the femoral nerve. Retrieved from http://www.neurax iom.com/html/finding_the_femoral.php ADDITIONAL READINGS Schulz-Stubner, S., Henszel, A., & Hata, J.S. (2005). A new rule for femoral nerve blocks. Regional Anesthesia and Pain Medicine, 30(5), 473-477. Turjanica, M.A. (2007). Postoperative continu- ous peripheral nerve blockade in the lower extremity total joint arthroplasty population. MEDSURG Nursing, 16(3), 151-154. FIGURE 5. Falls Associated with Femoral Nerve Blocks per Month (January 2009 – September 2010) TCAB team in collaboration with physical therapists. This education guide was reviewed with and sup- plied to all UAPs, and has been incorporated into new hire orienta- tion for employees on these units. The educational process consisted of either 1:1 education or group ses- sions. The educator continued to contact UAPs individually to vali- date understanding of the informa- tion provided. Nursing Implications In the calendar year 2009, Phippen 6 and 7 had a reported falls rate of 5.2 per 1,000 patient days. Following implementation of the FNB educa- tion plan and bundle, the unit fall rate decreased to 2.9 per 1,000 patient days, with a facility reported rate of 3.52 per 1,000 patient days (see Figure 5). The bundle was effective in decreasing falls among patients with FNB, also contributing to the im - proved overall fall rate. The team has been able to sustain the gains, in large part because of the interdisciplinary and multifaceted approach to analyzing the issue, pro- viding education, and implementing necessary practice changes. The sig- nage has continued to have a posi- tive influence on the fall prevention project as it serves as a helpful visual reminder for staff, patients, and fam- ilies. Education, audits, and re mind - ers to keep signs in place are ongo- ing. Staff members now utilize the two-person assist method with all affected patients during the duration of the FNB as well as after the block is removed, until sensation and motor function have returned as determined by the nurse. Patients are more aware of the need for assis- tance now due to the signage and education sheet. Patients and fami- lies have identified the value of the information. All newly hired staff members review the bundle during the orientation period. Fall data also continue to be evaluated. Conclusion The TCAB approach engaged unit leaders, clinicians, and patients to improve the quality and safety of patient care on two orthopedic- neurologic units. There was only one recorded fall in patients with FNB after implementation of the FNB bundle, from September 2009 to December 2010. It is amazing what a little bit of knowledge and education can accomplish! REFERENCES Agency for Healthcare Research and Quality. (2010). The falls management program: A quality improvement initiative for nurs- ing facilities. Retrieved from http://www. ahrq.gov/research/ltc/fallspx/fallspxman ual.htm Jan 2009 Mar 2009 May 2009 July 2009 Sept 2009 Nov 2009 Jan 2010 Mar 2010 May 2010 July 2010 Sept 2010 N u m b e r o f F a lls 2.5 2 1.5 1 0.5 0 Date Thou Shalt Not Fall! Decreasing Falls in the Postoperative Orthopedic Patient with a Femoral Nerve Block Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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