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.
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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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
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BY. Published by BMJ. 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
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