Quality Improvement (QI) Programme Proposal

Pre-Colonoscopic Preparation for Diagnosis of Colon Cancer

Oncology Department — Final Year Medical Student Submission

1. TITLE

2. BACKGROUND AND RATIONALE

The Problem

• Up to one-third of patients undergo colonoscopy with inadequate bowel preparation, leading to missed lesions, incomplete procedures, and need for repeat colonoscopy (Jung et al., Dis Colon Rectum 2022, PMID: 34459448).
• Inadequate preparation directly reduces the Adenoma Detection Rate (ADR) — the most validated quality indicator for colonoscopy and a proven surrogate for interval cancer rate (Yamada's Textbook of Gastroenterology, 7th ed.).
• Poor preparation prolongs procedure time, increases complication risk, and burdens the endoscopy unit with repeat bookings.
• Patients in an oncology setting present unique challenges: comorbidities, concurrent chemotherapy, opioid-induced constipation, anxiety, and frequent inpatient status — all independent risk factors for inadequate preparation.

Evidence for Improvement

3. AIM AND OBJECTIVES

Aim

Specific Objectives

1. Identify the current departmental baseline rate of adequate bowel preparation (Boston Bowel Preparation Scale ≥6, right colon ≥2).
2. Identify patient-level and system-level predictors of inadequate preparation in the oncology cohort.
3. Implement a structured multi-modal preparation education pathway.
4. Re-audit preparation adequacy at 3 and 6 months post-intervention.
5. Measure secondary outcomes: ADR, caecal intubation rate, procedure cancellation rate, and patient satisfaction.

4. STANDARD BEING MEASURED AGAINST

5. CURRENT SITUATION — DATA COLLECTION (CYCLE 1 AUDIT)

Data Collection Plan

• Period: Retrospective review of all diagnostic colonoscopies performed in the oncology department over the preceding 3 months.
• Tool: Standardised data extraction form capturing:
  • Patient demographics (age, sex, BMI, comorbidities, oncology diagnosis, treatment regimen)
  • Indication for colonoscopy
  • Preparation agent used and dosing protocol
  • Start time of preparation; interval between completion and procedure start
  • Boston Bowel Preparation Scale (BBPS) score — right colon (segment 1), transverse (segment 2), left colon (segment 3)
  • Endoscopist-documented preparation quality
  • Whether procedure was abandoned, repeated, or required early rescheduling
  • ADR, polyp detection rate
• Sample size target: Minimum 50 consecutive procedures to establish a reliable baseline.

Predictors of Inadequate Preparation to Screen For

• Late colonoscopy start time
• Failure to follow preparation instructions
• Inpatient status (particularly relevant in oncology)
• Procedure indication of constipation
• Opioid use / constipating medications
• Prior incomplete colonoscopy
• Obesity (BMI >25)
• Diabetes mellitus
• Cirrhosis

6. ROOT CAUSE ANALYSIS (FISHBONE / ISHIKAWA)

                         INADEQUATE BOWEL PREPARATION
                                    |
        ┌───────────────────────────┼────────────────────────────┐
        │                           │                            │
   PATIENT FACTORS          SYSTEM FACTORS              STAFF FACTORS
   ─────────────────         ────────────────             ─────────────
   • Poor literacy           • Paper-only instructions    • Inconsistent 
   • Language barriers       • No reinforcement calls       counselling by 
   • Opioid use              • Late-day scheduling          different staff
   • Inpatient status        • Insufficient prep time     • No standardised
   • Comorbidities           • Wrong prep agent choice      prep protocol
   • Non-compliance          • No risk stratification     • Lack of audit/
   • Anxiety/fear            • No BBPS documentation        feedback loop

7. INTERVENTION — THE PREP-CLEAR BUNDLE

Component 1: Risk Stratification at Booking

• All patients booked for colonoscopy complete a Pre-Colonoscopy Risk Stratification Checklist (inpatient/outpatient, opioid use, prior failed prep, comorbidities, constipation, language).
• High-risk patients identified at booking for enhanced pathway:
  • Inpatients
  • Active chemotherapy patients
  • Opioid-dependent patients
  • Prior inadequate preparation

Component 2: Individualised Preparation Protocol

• Half the preparation taken the evening before, half taken the morning of the procedure (ending 4–6 hours before colonoscopy start). This minimises the interval between preparation completion and procedure start — a key quality predictor.

Component 3: Multi-Modal Patient Education

1. Written instructions (clear, plain-English, illustrated, available in top 3 local languages) provided at booking — minimum 7 days before procedure.
2. Structured nurse-led verbal education session at booking or via telephone within 48 hours of booking.
3. Automated SMS/text reminder 3 days before: dietary restriction reminder.
4. Automated SMS reminder evening before: preparation start time, dietary advice, what to expect.
5. Nurse call-back for high-risk patients 24 hours before procedure: verify understanding, troubleshoot.
6. Video resource link (1–2 minute animated explainer on bowel preparation process) — sent via SMS.

Component 4: Scheduling Optimisation

• Prioritise morning slots for high-risk patients (reduces the gap between preparation completion and procedure start).
• Ensure minimum 4-hour and maximum 8-hour interval between end of preparation and procedure start.
• Avoid scheduling high-risk patients as last case of afternoon list.

Component 5: Day-of-Procedure Assessment

• On arrival, nursing staff complete a structured preparation quality pre-screen:
  • Last preparation dose taken? Time?
  • Last solid food? Time?
  • Stool colour — was it clear/yellow? (self-reported)
• Patients not meeting criteria (coloured stool, preparation not completed) flagged for endoscopist review — potential rescheduling before the patient is sedated.

Component 6: Standardised Intra-Procedure Documentation

• Every colonoscopy report mandates:
  • Boston Bowel Preparation Scale (BBPS) — segmental scores (right, transverse, left)
  • Total BBPS score
  • Whether preparation was adequate/inadequate
  • Reason for any early termination
• Template embedded in endoscopy reporting software / paper pro forma.

8. IMPLEMENTATION PLAN

9. OUTCOME MEASURES

Primary Outcome

• Adequate bowel preparation rate (BBPS total ≥6 with no segment score <2) — target ≥85%

Secondary Outcomes

10. PROCESS MEASURES

• % of patients who received risk stratification at booking
• % of high-risk patients who received nurse call-back
• % of colonoscopy reports documenting BBPS score
• % of patients receiving educational materials ≥7 days before procedure
• % on split-dose preparation protocol

11. BALANCING MEASURES

• Patient complaints related to preparation burden
• Rate of electrolyte abnormalities or adverse events attributable to preparation agent
• Staff workload (nurse call-back time quantified in hours/week)
• Procedure list capacity and scheduling delays

12. ETHICAL CONSIDERATIONS

• No experimental intervention: all preparation agents are standard of care.
• Patient education materials will be culturally and linguistically appropriate.
• Informed consent for colonoscopy already mandated as part of standard care.
• Data collection and audit conducted within existing clinical governance framework — full ethical approval not required (service evaluation), but local departmental governance sign-off obtained.
• Patient identifiable data stored securely in accordance with GDPR/local data protection policy.

13. STAKEHOLDERS

14. PDSA CYCLES

• PDSA Cycle 1: Baseline audit → identify problem magnitude and root causes
• PDSA Cycle 2: Implement PREP-CLEAR bundle → assess early impact at 3 months
• PDSA Cycle 3: Refine based on Cycle 2 data → full rollout at 6 months

15. SUSTAINABILITY AND SPREAD

• BBPS documentation embedded permanently in procedure reporting template.
• Risk stratification checklist integrated into colonoscopy booking form.
• SMS platform automation removes ongoing staff burden.
• Annual re-audit built into departmental governance calendar.
• Findings to be presented at departmental grand round and submitted to regional/national QI networks (e.g., CREST, ACPGBI, BSG Quality Improvement).

16. SUMMARY TABLE

REFERENCES

1. Rex DK, Anderson JC, Butterly LF, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2024;[Practice Guideline]. PMID: 39177519
2. Jung DH, Gweon TG, Lee S, et al. Combination of Enhanced Instructions Improve Quality of Bowel Preparation. Dis Colon Rectum. 2022;65(1). PMID: 34459448
3. Solonowicz O, Stier M, Kim K, et al. Digital Navigation Improves No-Show Rates and Bowel Preparation Quality. J Clin Gastroenterol. 2022;56(2). PMID: 33471486
4. Zhong H, Hou C, Huang Z, et al. AI-driven smartphone application for bowel preparation. Scand J Gastroenterol. 2025. PMID: 39709551
5. Clinical Gastrointestinal Endoscopy, Expert Consult, 3rd ed. Chapter: Preparation for Colonoscopy; Chapter 36: Colonoscopy Quality Indicators.
6. Yamada's Textbook of Gastroenterology, 7th ed. Colonoscopy quality: adenoma detection rate and beyond.
7. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. Screening Capacity and Quality Assurance.

Word to the examiner: This QI proposal follows a structured clinical governance framework — identifying the problem with evidence, setting measurable SMART targets against published standards, designing a multi-component evidence-based intervention, and embedding re-audit within iterative PDSA cycles. It is directly relevant to the oncology context where patient complexity creates specific barriers to adequate pre-colonoscopic preparation, and where the stakes of a missed diagnosis are highest.