Patient-identified quality indicators for colonoscopy services

the 29 patient-identified indicators, 17 (58.6%) were novel. ConCluSionS: Patients identified 17 novel quality indicators, suggesting that patients and health professionals differ in their perspectives with respect to quality in colonoscopy services.

United Kingdom (UK) to support the provision of high-quality patient-centred care (12).The GRS was developed following meetings with endoscopy staff who identified 12 areas or 'items' that were considered to be important for a patient undergoing endoscopy: six items each (total 12) in the dimensions of 'Quality and Safety' and 'Customer Care'.The GRS affords endoscopy facilities the ability to evaluate the overall quality of endoscopy services on a regular sixmonth schedule and, hence, to evaluate the effects of targeted qualityimprovement interventions.However, although the GRS has been very effective in influencing endoscopy services by assuming a patient perspective, the quality items were defined by health care providers whose views may not be congruent with those of patients (21)(22)(23).This may be particularly relevant when the health care providers work in one health care system (eg, UK) and the patients are served by a different system or systems (eg, Canada).Thus, the patient feedback and surveys recommended by the GRS program should be tailored to the specific health care system.Therefore, the present study aimed to identify patient-derived quality indicators for colonoscopy services by understanding aspects of patients' experiences with and perceptions of endoscopy services; rate quality indicators for their relative importance to patients; determine the factors that influence quality indicator ratings; and compare the patient-derived indicators with the UK-GRS items.Phase 1: Focus groups Study population: Study gastroenterologists and nurses assisted with patient recruitment by determining interest in study participation.In Montreal and Hamilton, the research assistant was given patient names and telephone numbers; she would call, explain the study and invite individuals to participate in one focus group session.In Calgary, patients were recruited following the routine colonoscopy information session.Eligible individuals were ≥18 years of age and fluent in English or French, and had undergone or were scheduled to undergo a colonoscopy, with or without previous experience with colonoscopy (recent or remote).Data collection methods: Based on expert opinion, a blueprint (Appendix A) that considered an individual's pathway through the system was developed to determine what may be important to an individual undergoing a colonoscopy.Subsequently, a standardized focus group guide, which also drew areas of inquiry from the published literature, was developed.At the focus group discussions, trained facilitators introduced topics and guided the discussion by directing participants to discuss aspects of the colonoscopy procedure or service that they considered to be important to the quality of patient care according to each phase of the procedure (ie, before, during and after colonoscopy).The 60 min to 90 min discussions were audiotaped and transcribed verbatim.Facilitators took brief field notes during the discussions and recorded comprehensive field notes within 24 h of the discussions to capture impressions and main themes.Indicators that were identified in one group were repeated and tested for their relevance in subse-quent focus groups.Written informed consent was obtained from participants before the focus group discussions began.Data analysis: Audiotapes were analyzed using the constant comparative approach developed by Glaser and Strauss (24).A constant comparative thematic content analysis guided the data analysis.The focus group facilitator and at least one study investigator independently read all transcripts, and identified emerging and recurrent themes and indicators.Similar themes identified across focus groups were compared and additional codes for newly emerging topics were created.Team consensus (investigators: MS, CD; qualitative researchers: JS, KL) was used to develop the major themes and focus group-derived indicators, reduce data into these categories and select the exemplar quotations illustrating each indicator.Data collection methods: Individuals were approached at discharge from the colonoscopy recovery area by the research assistant who explained the study and distributed an envelope with the study materials (invitation letter, consent form, anonymous self-administered questionnaire, postage-paid envelope) to interested patients.The questionnaire comprised two sections: an indicator rating section and an open-ended statements section.The indicator rating section included the 20 focus group-derived indicators.Respondents were asked to rate each indicator according to level of importance (low, medium or high).The open-ended statements section contained three questions that asked individuals to list up to three aspects of their colonoscopy experience that they considered to be most important according to phase: before, during, after the colonoscopy.Survey participants could either choose from the 20 focus group-derived indicators or they could record additional items that were relevant to their personal experiences.Data were also collected on age, sex, perceived personal CRC risk (low, moderate, high) and overall colonoscopy experience (satisfactory, unsatisfactory).All study questionnaires were developed in English and forward and back translated into French.Data analysis: Descriptive statistics characterized the study population overall as well as according to site.Frequencies for each highly rated quality indicator (defined as high versus medium/low importance) were generated and the χ 2 test was used to determine differences according to site.Responses to the open-ended questions were classified into existing focus group-derived indicator categories or new categories were created (ie, survey-derived indicators).Team consensus (MS, TE) was used to ensure reproducibility of the classifications.Frequencies were generated overall and according to site for the responses to the open-ended statements that were endorsed by ≥10 survey respondents.Multiple logistic regression was used to determine the factors that influenced focus group-derived indicator ratings.Separate models were generated for each indicator, controlling for age (continuous), sex (female/male), site (Montreal/Calgary) and perceived CRC risk status (low/moderate or high).ORs and 95% CIs were calculated using SAS version 9.2 (SAS, USA).

Study design and sites
The patient-derived indicators were qualitatively compared with the UK-GRS items.Two team members (MS, SB) compiled a list of all patient-derived indicators, merging similar focus group-and surveyderived indicators where appropriate, and compared them with the GRS statements to determine whether the patient-derived indicators had previously been addressed (yes/no).Indicators not addressed in the UK-GRS were considered to be novel indicators.

reSultS
Phase 1: Focus groups Sixty-six patients participated in 12 focus group discussions consisting of four to eight participants.The median age was 61 years (range 22 to 82 years), 50% were male and more than one-half (66%) had undergone a colonoscopy.Three quality themes were identified: communication, comfort and service environment.Service environment addressed eight aspects of the physical structure of the facility and the delivery of good customer service, including concerns about the following: • the cosmetic aspects of the: ○ wait area; ○ changing area; ○ recovery area; • the presence of nurses during the colonoscopy; • the flexibility to choose the: ○ bowel preparation; ○ endoscopist; ○ sex of the health care team members in the endoscopy suite; and ○ date of the colonoscopy appointment.These 20 focus group-derived items comprised the indicator rating section of the survey questionnaire that was distributed in phase 2 of the study.Exemplars from the three themes are presented in Table 1.Characteristics of the survey respondents are summarized in Table 2.
Table 3 presents the proportions of survey participants who rated the 20 focus group-derived indicators as highly important.More than 80% of participants rated four communication items (clear instructions, detailed information, knowing what to expect, obtaining results in a timely manner) and five comfort items (dignity, treated with respect, staff attitude, treat me as an individual, pain control) as highly important.In comparison, fewer participants rated service environment indicators as highly important, although three (recovery area, presence of nurses during procedure and bowel preparation options) were rated highly important by more than 55% of participants.
Site differences were noted in the focus group-derived indicator ratings (Table 3).Compared with Montreal, greater proportions of respondents in Calgary rated communication indicators including "clear instructions", "detailed information" and "ability to provide feedback" and comfort indicators "dignity" and "treated with respect" of higher importance; in comparison, greater proportions of patients in Montreal rated "relationship with physician" and the "ability to choose the doctor I want" higher.Table 4 shows that communication indicator ratings were influenced by older age, female sex and site, whereas comfort indicator ratings were influenced primarily by female sex.No systematic differences were found for service environment indicator ratings."A number to call for follow-up with some kind of counselling especially when you have complications, I would have liked some kind of follow-up or feedback from the staff" Comfort "Pain element is very important; prefer the least amount of pain possible during the procedure" "The doctor, the team and the way they speak to you needs to feel comfortable while protecting your dignity because it's a pretty embarrassing procedure" "You're anxious and it's the doctor and the team that makes the difference" "Privacy is really the main issue, when you have that type of a procedure done and you have a lot of gas, it's very embarrassing and the recovery room is an open room, we need curtains" Service environment "It's important to know if it's an experienced surgeon or a student who's going to be doing it, that would affect my decision" "At busier places I don't always feel safe, there could be an error, mix up or something" "It's important to stay connected to the same specialist when I have the same procedure repeated" "There's usually a lot of people in the waiting area, I end up waiting in the hallway" "The recovery room is an open room with no curtains and the staff is just in the middle talking, I just want some privacy to recover" "The only thing I don't like about the changing room is when you have to hang your personal stuff with other people's stuff, almost like sharing lockers"  Nine open-ended statements were endorsed by ≥10 survey respondents.Table 5 presents the proportions of survey respondents who endorsed the nine statements.Table 6 presents the 29 (20 from the focus groups and nine from the survey open-ended statements) patient-derived indicators, of which 17 (58.6%)were novel; according to theme, these included 13 service environment, four communication and one comfort.

DiSCuSSion
We used focus groups and survey methodologies to identify and rate patient-derived colonoscopy quality indicators.We determined the factors that influenced indicator ratings and identified novel indicators by comparing our indicators with those used in the UK-GRS.In total, 29 patient-derived colonoscopy quality indicators were identified, of which 17 were novel.Survey findings supported the focus group findings in that 65% of the focus group-derived indicators were rated highly important by at least 55% of survey respondents.More than 80% of participants rated four communication items (clear instructions, detailed information, knowing what to expect and obtaining results in a timely manner) and five comfort items (dignity, treated with respect, staff attitude, treat me as an individual and pain control) as highly important.Communication and comfort indicator ratings differed according to patient age, sex and site, but there were no systematic differences in service environment indicator ratings.
Site differences in quality indicator ratings may result from the diversity in the two models of colonoscopy service delivery in Calgary and Montreal.In Calgary, Forzani-MacPhail Colon Cancer Screening Centre exclusively provides CRC screening-related colonoscopy services (25) and offers a comprehensive preprocedural patient education program, whereas in Montreal, the MUHC provides full endoscopy services, including those for patients (both ambulatory and hospitalized) with symptoms and/or abnormal test results.Site differences underscore the individuality of endoscopy units and the need for routine patient surveys because the needs and perceptions of patients may vary according to the model of care delivery, sex, age group and indication for the procedure.
In considering quality indicators, patients focused more on what happened leading up to the colonoscopy than on the possible complications of colonoscopy.Items such as obtaining results, knowing what to expect, having clear instructions, good pain control and being treated with dignity were rated of greater importance compared with knowing what to do if complications were experienced.Two systematic reviews reported similar findings: items including the bowel preparation; feelings of anxiety, embarrassment, vulnerability, anticipation of pain; and fear of finding cancer were the main barriers to undergoing screening colonoscopy (26,27).Findings from both our focus group discussions and the survey revealed that patients were not con- Physician and/or staff reduced anxiety 14 ( After the procedure Contact number for more information/questions, with response 42 ( Recovery area: Allowed to rest/comfortable recovery 40 ( cerned with safety, presumably because safety was assumed to be monitored by regulatory bodies.As one focus group participant indicated: I'm sure they have a safety department that checks the equipment is up to date and clean.And the doctors must have to show they are keeping their skills up to date; this does not worry me.It's a major hospital; they have to have standards or they would be in trouble. Some of our patient-derived indicators were present in the GRS, while those that were not present were categorized under the three themes of communication, comfort and service environment.Although the GRS includes 'choice' as a quality determinant, it relates solely to scheduling the colonoscopy, whereas the present study revealed that patients also want choice in other areas of the service such as the bowel preparation.In fairness to the developers of the GRS, colonoscopy quality indicators were addressed from the service delivery perspective.Our findings provide partial validation for the GRS as a measure of patient-defined quality and suggest that endoscopy staff and patients value some of the same aspects of colonoscopy services because 12 of the 29 (41.4%)indicators overlapped.In a comprehensive quality assurance program (28) that also serves to encourage patient compliance (29,30), and positive word-of mouth recommendation (31), we also need to assess and improve the outcomes that are valued by patients (6,9), to assure patients of a safe and satisfactory experience that will not deter them from undergoing appropriate investigation.
Study strengths include the use of both qualitative and quantitative methodologies to identify and rate patient-derived colonoscopy quality indicators.The use of the open-ended survey questions not only permitted validation of the focus group-derived indicators, but also enabled identification of additional indicators not discussed during the focus groups, which will broaden the content of the subsequent questionnaire.Our study also had limitations.First, the survey was prone to selection bias because respondents may have differed from nonrespondents on important variables.Second, focus group moderators differed by city and discrepancies in the conduct of the focus group discussions may have led to information bias.However, this potential was reduced by having the focus group moderator and a coinvestigator review the focus group transcripts and by using team consensus to develop the major themes and patterns.Similarly, categorization of the open-ended statements could have produced different results, although three research staff participated to ensure reproducibility of the classifications.
Given the public health implications of provincial CRC screening programs and the vital role played by and safety profile of colonoscopy, assessment of colonoscopy services quality from the patient perspective is a critical component of endoscopy in general and, more broadly, for digestive health care and health care as a whole.Our future plans are to develop a psychometrically sound, patient-centred colonoscopy/ endoscopy services quality evaluation and improvement tool based on the patient-derived indicators that are applicable to the Canadian health care system and to integrate this tool into the CAG Quality Program in Endoscopy.aCknoWleDGMentS: This research was supported by an unre- stricted grant from the Canadian Digestive Health Foundation.Maida J Sewitch PhD, is a Checheur Boursier Junior 2 of the Fonds de recherche du Québec -Santé.The authors thank qualitative researchers Kristina Longtin and Javad Shahidi, and research staff Shasha Gong and Talia Erdan.

DiSCloSureS:
The authors have no financial disclosures or conflicts of interest to declare.
A two-phase study that incorporated qualitative and quantitative data collection and analysis was undertaken at the McGill University Health Centre (MUHC) in Montreal, Quebec, the Forzani-MacPhail Colon Cancer Screening Centre in Calgary, Alberta, and McMaster University Medical Centre in Hamilton, Ontario (2009 to 2011).The endoscopy facilities at the academic institutions in Montreal and Hamilton provide adult endoscopy services for symptomatic and screening-related indications, while the facility in Calgary is dedicated to colorectal cancer (CRC) screening.Phase 1 consisted of patient focus groups and phase 2 consisted of a cross-sectional study.Ethics approval was granted by the Psychiatry/Psychology Research Ethics Board at the MUHC, the Research Ethics Board at Hamilton Health Sciences, McMaster University and the Conjoint Health Research Ethics Board at the University of Calgary, Calgary, Alberta.

Phase 2 :
Patient survey Study population: Eligible individuals were ≥18 years of age, fluent in English or French, and had undergone colonoscopy.
Communication encompassed the following seven subthemes: • clear instructions; • knowing what to expect; • patient-physician interactions; • timely test results; • contact numbers for information on the procedure; • access to psychological support following a diagnosis; and • a mechanism to provide feedback about the service.Comfort addressed five physical and psychological concerns including the following: • being treated with dignity and respect; • adequate pain control; • adequate sedation; • treated as an individual; and • privacy.

Information on possible side effects of colonoscopy and what to do 21 5 )
(eg, telephone call from the clinic the next day) 13Data presented as n (%)

Table 1 exemplars of focus group-derived indicators according to theme Theme exemplar
Communication"Find out what could go wrong with the procedure and information like why are they doing it and what are they going to do" "The relation between the staff of the hospital, doctors and nurses, and the patients is the most important factor of quality" "When they give you the results, you're not fully awake and you can't grasp anything.I have to be fully recovered and if I have a question I don't want to feel pressed for time"