Taking a pragmatic approach to implement colonoscopy quality at a health system level: Ontario’s colonoscopy quality strategy

Abstract

Objectives

To describe Ontario’s colonoscopy quality strategy (OCQS), to review outcomes to date, to assess it against the Health Quality Ontario framework, and to identify areas for improvement.

Methods

We provide a descriptive analysis of the OCQS, tracing its development from the launch of the ColonCancerCheck program in 2007 through subsequent initiatives, including funding mechanisms, evidence-based standards, systematic data collection, provider-level performance reporting and feedback. The impact of the OCQS is assessed via temporal trends in colonoscopy quality indicators.

Results

The OCQS has evolved into a multipronged, system-wide strategy emphasizing evidence generation, collaboration with clinical leaders, and embedding quality improvement within regional cancer programs. Key achievements include standardized reporting, provincial and regional accountability structures, and integration of quality metrics into practice. Over time, there has been improvement in colonoscopy and screening indicators, reflecting the impact of the OCQS. Challenges include addressing endoscopists with persistent performance issues, optimizing accountability mechanisms, and sustaining engagement in a resource-constrained system.

Conclusions

Ontario’s experience demonstrates that implementing colonoscopy quality initiatives within a complex health system requires pragmatism, iterative refinement, and continuous evaluation. Lessons learned may inform other jurisdictions in designing and scaling endoscopy quality strategies.

Introduction: health care quality and colonoscopy

Colonoscopy is essential for colorectal cancer screening and diagnosis, as well as for the diagnosis and management of other gastrointestinal diseases. It is also an invasive test and may be time-consuming and unpleasant for patients. Poor quality colonoscopy can limit the effectiveness of colorectal cancer screening, as it may lead to harm, either from missed lesions or from complications of the procedure. To mitigate these risks, colorectal cancer screening programs have developed interventions to monitor and assure colonoscopy quality. However, the substantial complexity of health systems, commonly compounded by resource shortages, can make implementing colonoscopy quality programs challenging. The objective of this paper is to describe Ontario’s colonoscopy quality strategy (OCQS), to review the objective and subjective impacts that it has achieved to date, to assess it against the Health Quality Ontario framework, and to identify gaps and areas for improvement.

Based on the 6 Institute of Medicine quality domains,¹ the Health Quality Ontario framework (Figure 1) defines health care quality as safe, effective, patient-centered, efficient, timely, and equitable.² Building on this definition and the core underlying principles described, the framework outlines characteristics of high-quality health systems: They should engage patients and the public, be designed to support quality care, help professionals and caregivers thrive, ensure technology works for all, support innovation, spread knowledge, monitor performance with quality in mind, and build a quality-driven culture.

Figure 1.

Health Quality Ontario framework.

Note: Republished from Health Quality Ontario. https://www.hqontario.ca/. Accessed July 15, 2023.

Organized colorectal cancer screening in the province of Ontario, Canada, began in 2007 with the launch of a province-wide program, ColonCancerCheck (CCC). At the time, studies from large provincial administrative databases revealed a worrisome picture of colonoscopy quality in Ontario,^3–7 including important risks of missed lesions, perforation, bleeding, or death from colonoscopy. In the context of the planned increased coverage of colorectal cancer screening, these findings raised concerns that healthy and asymptomatic Ontarians undergoing screening could be exposed to unnecessary harm from colonoscopy, supporting the need for a province-wide colonoscopy quality program. Over the years, Ontario has extended its approach to colonoscopy quality from one focused on the CCC program to a multipronged approach for all colonoscopies performed in the province.

Context: screening, cancer care, and delivery of colonoscopy services in Ontario

Canada has a publicly funded universal access health care system that is administered regionally by its 10 provincial and 3 territorial health systems; there are some unifying national principles, but significant variations exist across and within these systems. The Ontario provincial health system is coordinated by the Ministry of Health (MOH) along with Ontario Health (OH), which is a Crown agency that oversees the delivery of health care, including the province’s population-based cancer screening programs, such as CCC. The screening programs are supported by regional cancer programs (RCPs), which comprise a network of hospitals, agencies, administrators and “champion” clinical leads, and which are tasked with implementing standards and programs that support cancer care within 14 geographic regions in the province.

The CCC program sends correspondence to the entire eligible population (all persons who are 50-74 years of age and due for screening), inviting recipients to visit their primary care practitioner to be screened. Those who are at average risk are offered the fecal immunochemical test (FIT) (sigmoidoscopy is an acceptable alternative), while those at increased risk due to a history of colorectal cancer in one or more first degree relative(s) are offered a colonoscopy (of note, eligibility criteria for the CCC program have recently changed⁸). The CCC program contracts a central laboratory to perform FIT testing. Results are reported to the primary care practitioner and to the participant.f note, eligibility criteri

The primary care practitioner is responsible for referring participants with an abnormal FIT to an endoscopist (generally a gastroenterologist or surgeon) to perform a colonoscopy. Given the additional complexity of these colonoscopies, they are primarily carried out in hospitals, with a minority being conducted in out-of-hospital premises (OHPs). In some hospitals or health regions, individuals requiring a colonoscopy because of an abnormal FIT may be referred to a central referral intake program, which will triage and possibly navigate them to a colonoscopy. Endoscopists are paid on a fee-for-service basis through the Ontario Health Insurance Plan (OHIP). Hospitals are funded by the MOH to cover the overhead costs of colonoscopy, including, for example, nursing salaries, equipment, medication, and reprocessing of the colonoscopes. OHPs do not receive provincial funds; instead, they rely on contributions from the endoscopists who practice in these clinics to pay for overhead costs.⁹

Evolution of Ontario’s OCQS

Programs, funding, and clinical leadership

The OCQS is the product of several interrelated programs and initiatives that have, since the launch of the CCC program, functioned concurrently or sequentially to promote and monitor colonoscopy quality in Ontario (Figure 2). Evidence-based clinical guidelines for colonoscopy quality were first published just before the launch or the screening program and have periodically been updated (see “Evidence”). At program launch, hospitals began to receive additional annual funding for screening-related colonoscopies (ie, abnormal fecal test and family history indication) on a volume basis and hospitals have in turn been required to collect and report wait time and quality data on all colonoscopies performed, regardless of indication (see “Data Collection and Reporting”). Colonoscopy wait times are included in the RCP performance reports, creating accountability between hospitals, their respective RCPs, and the CCC program.

Figure 2.

Description of the timeline, programs, data collection, funding, reporting, and evidence products in the Ontario’s colonoscopy quality strategy.

In 2014, OH (through its former agency, Cancer Care Ontario) and the College of Physicians and Surgeons of Ontario (CPSO) jointly created the Colonoscopy Quality Management (QMP) Partnership to enhance the consistency of the quality of care provided across facilities and to increase accountability and transparency. The Colonoscopy QMP had 4 main components: (1) evidence-based provincial standards and guidelines, which applied to all providers and facilities delivering colonoscopies; (2) quality reporting at the provincial, regional, facility and endoscopist levels supported by (3) a 3-tier clinical leadership structure comprising the provincial lead, regional leads and facility leads, and (4) resources, tools, and opportunities to support quality improvement. The vision of the QMP was to promote quality with positive reinforcement through the provision of guidance and performance reporting. No punitive strategies were used, and the performance reports were not tied to provider credentialing or privileges. Through the QMP, the pillars of colonoscopy quality initiated by the CCC program were strengthened through annual facility surveys, colonoscopy quality reporting (see “Data Collection and Reporting”), and quality improvement tools.

In response to the desire to maintain access to high-quality health care for all in the face of fiscal challenges, the Government of Ontario undertook health system funding reform in 2010. Through the Quality-Based Procedures (QBPs) initiative, the MOH began to directly fund specific services and procedures by volume and complexity level, outside of the hospital global budget system. The goal was to promote standardization of care and funding, particularly for services rendered to patients requiring similar levels of care. The gastrointestinal endoscopy QBP (GI Endo QBP), which provides volume-based funding to include colonoscopies for all indications (as well as all other gastrointestinal endoscopic procedures), was launched in 2014 and is administered by OH and the CCC program. Over time, colonoscopy funding was adjusted to better align with the CCC program needs and policies, for example, by adjusting QBP reimbursement for the number and size of polyps removed and the use of funding levers to disincentivize average risk colonoscopy and promote access to colonoscopy in FIT-positive individuals.

The clinical leadership of the CCC, QBP, and QMP, along with a group of designated clinical champions (“regional leads”) from each one of Ontario’s 14 RCPs, worked in close collaboration to ensure a shared vision and synergy between the programs. The responsibilities of the regional leads include promoting CRC screening and endoscopy quality, engaging facilities and endoscopists through the creation of communities of practice, providing education, and supporting quality improvement and program implementation throughout the region. Regional leads also coach endoscopists who fail to meet quality standards or appear to have a greater than expected number of complications, using an evidence-based facilitated feedback¹⁰ approach (see “Integrated Reporting”).

In 2019, the QMP was dissolved¹¹ because of a change in mandate and vision at the CPSO and the OCQS continued under the leadership of the CCC program at OH.

Evidence

An evidence-based approach to delivering high-quality colonoscopy in Ontario is a foundational principle of the OCQS. Prior to the launch of the CCC program, a number of landmark studies in colonoscopy quality,^3–7 along with Ontario’s first evidence-based colonoscopy quality standards,¹² were published.

This emphasis on an evidence-based approach continues and underpins the evolution of the OCQS. The colonoscopy quality standards were updated and aligned with the standards endorsed by the QMP^13,14 in 2014¹⁵ and a subsequent update is currently in progress.¹⁶ To support provider reporting, a pragmatic province-wide randomized controlled trial (RCT) comparing the receipt of these reports versus no intervention¹⁷ was conducted in 2015. Findings from this work have been instrumental in the design and implementation of provider-level reporting in the province (see “Data Collection and Reporting”).

The evidence generated by the OCQS has also been adopted by other jurisdictions, for example, a landmark systematic review on the risk of colorectal neoplasia in individuals with low risk adenomas at baseline^18,19 and foundational work on anesthesiologist-assisted colonoscopy.^20,21 The CCC and QMP have embedded domain-area and methodological expertise through their clinical, quality improvement, and scientific leadership. This structure facilitates mission-aligned research, such as the externally funded RCT of the colonoscopy provider level reports¹⁷ described above. Although these studies and others are complex from logistical, privacy and legal perspectives, they contribute to Ontario’s cancer “learning health system” by providing invaluable, context-specific data that are critical to designing and running its programs and strengthening its quality strategies, including the OCQS.

Data collection and reporting

Indicators for quality reporting were developed based on various data sources held at OH, including colonoscopy data (eg, indication, quality of bowel preparation) submitted by all hospitals performing colonoscopy in the province, provider claims data, hospital admission datasets, and the Ontario Cancer Registry.

Methodologies for data elements and quality indicators were developed and validated to support the OCQS^22,23 and are reported annually at the provincial, regional, facility, and provider levels. Regional reports are disseminated to the 14 RCPs while approximately 160 facilities across the province, including hospitals and OHPs, receive facility-level reports. Comparisons to other regions and across facilities within each region are included. RCPs review the reports and comment on factors associated with performance at the regional and facility level and opportunities for improvement through quarterly conversations with provincial leadership. These quarterly discussions occur at the regional level and are distinct from the individual endoscopist feedback process.

A provider-level report is sent annually to all endoscopists in the province (1026 endoscopists in 2024). This report was designed with the help of a behavioral scientist and a data visualization expert to motivate and help endoscopists improve their performance by incorporating social comparators and visual cues. Initial quality indicators included colonoscopy volume, polypectomy rate, cecal intubation rate, perforation rate, post-polypectomy bleeding rate, post-colonoscopy colorectal cancer rate, colorectal cancer detection rate, bowel preparation, and colonoscopies with recent normal findings (a measure of appropriateness). The reports have evolved over the years, with improvements in methodology. For example, polyp detection rate was the only measurable indicator of colonoscopy detection at first; however, a methodology to measure and report adenoma detection rate was since developed, using natural language processing to analyze pathology reports.¹⁵ To ensure privacy, endoscopists must access their quality reports through a secure online platform. Provider-level reports are confidential and are not publicly reported. While initially, only 28% of endoscopists accessed their reports, an important increase in report uptake occurred during the COVID-19 pandemic with the subsequent expanded use of secure electronic platforms. In 2023, 42% of endoscopists accessed their reports. Optimizing provider participation in the reporting process remains a focus for future work.

Recognizing that performing colonoscopy is a highly complex task and that endoscopist audit and feedback alone is unlikely to result in substantial quality improvement,²⁴ a subset (∼6%) of endoscopists with potential quality issues are identified for a facilitated feedback discussion each year. Regional leads carry out the discussions one-on-one using facilitated feedback based on the R2C2 model, an evidence-based approach to delivering feedback to physicians about their performance.¹⁰ These conversations move through 4 stages: relationship building, exploring reactions, exploring content, and coaching (which includes developing an achievable learning plan). Regional leads are trained to perform facilitated feedback and share resources (written materials, video, and skills enhancement courses) to help endoscopists formulate and complete their learning plans. The facilitator and the endoscopist may choose to arrange a follow-up meeting. Endoscopists may be selected to undergo repeated facilitated feedback sessions (with the same or an alternate regional lead) if they are flagged again for low performance after a sufficient period of observation has occurred since the previous facilitated feedback session.

From inception, the OCQS has emphasized a non-punitive approach, as this is known to be a critical characteristic of successful physician audit and feedback.²⁴ Ontario’s approach is distinct from jurisdictions such as the United Kingdom where endoscopist performance is tied to the types of cases (eg, colonoscopies in the UK Bowel Cancer Screening Programme) they are permitted to perform.²⁵ In Ontario, where there are endoscopists who have persistent performance issues despite receiving the above interventions, the regional lead is instructed to escalate to provincial leadership, where bespoke strategies for each individual are developed by regional and provincial leads together (eg, direct observation, one-on-one support). These rare situations are challenging because the success of this process relies on the willingness of the individual endoscopist to engage and on their ability to improve with support.

Measurement of colonoscopy quality in Ontario over time

The OCQS comprises structures and processes to foster a culture of quality in the performance of colonoscopy in Ontario. Table 1 reports key quality indicators at the provincial level (definitions provided in Table S1), suggesting that colonoscopy quality, both at the endoscopist level, as measured by indicators such as adenoma detection rate, bowel prep quality, and rates of adverse events (post-colonoscopy colorectal cancers, perforations and bleeding) and at the system level, as measured by follow-up after an abnormal fecal test (wait times and proportions of persons having follow-up), is improving over time. It is important to recognize that over this same period, there has been a significant cultural shift toward colonoscopy quality improvement and that in Ontario (as has been seen elsewhere) endoscopists have embraced this quality agenda. While it is impossible to determine the exact contribution of the OCQS on the observed improvement in colonoscopy quality in Ontario, its role in promoting enhanced practice and more structured reporting frameworks has been influential. OCQS has provided important leadership and guidance, served as a trusted source of evidence and standards, and supported performance improvement through its reports and feedback mechanisms.

Table 1.

Colonoscopy quality indicators in Ontario from 2012 to 2023.

	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021	2022	2023
Population (ages 18+)			10 914 430	11 001 116	11 149 214	11 338 914	11 570 907	11 801 171	11 978 332	12 134 923	12 323 508	12 502 415
Colonoscopy volumes			316 506	464 348	469 505	463 703	472 223	479 831	348 901	449 099	488 420	546 482
80th percentile wait time from abnormal fecal test to colonoscopy, daysa,b			83	86	82	78	80	72	75	53	61	56
Follow-up colonoscopy within 8 weeks of an abnormal fecal test, %a  ,  b		46.3	59.2	56.1	60.3	63.2	61.8	67.8	68.1	83.3	76.8	80.8
Follow-up colonoscopy within 6 months of an abnormal fecal test, %		77.5	77.1	78.3	79.8	80.2	80.2	85.1	85.9	85.9	89.9
Post colonoscopy colorectal cancers, %	9.9	10.1	9.2	10.1	9.6	8.7	8.8	8.7	7.2
Perforations per 1000 colonoscopies			0.42	0.40	0.37	0.36	0.29	0.30	0.29	0.28	0.25	0.29
Post-polypectomy bleeding, %			0.32	0.31	0.29	0.30	0.28	0.26	0.28	0.23	0.21	0.16
Polyp detection rate in males, %			39.8	48.6	51.2	53.6	54.8	55.8	58.3	59.4	60.2	60.8
Adenoma detection rate, %							33.1	33.6	36.4	37.4	37.5	37.8
Cecal intubation rate, %			97.8	98.0	98.2	98.3	98.4	98.6	98.6	98.6	98.7	98.7
Colonoscopies with poor preparation, %b			3.5	3.3	3.0	3.1	2.7	2.5	2.6	2.4	2.4	2.4
Endoscopists performing >200 colonoscopies/year, %				95.0	95.3	94.7	95.0	94.9	89.9	93.8	94.8	95.7

^aAmong those who had a colonoscopy within 6 months of an abnormal fecal test.

^bHospital data only.

Discussion: lessons learned, challenges, and future goals for colonoscopy quality in Ontario

The OCQS must continue to evolve to further improve colonoscopy quality. Table 2 uses the operational domains of the Health Quality Ontario quality framework (Figure 1) to identify ongoing barriers to improving colonoscopy quality to provide a roadmap to guide the OCQS in the coming years.

Table 2.

High-level summary of key challenges for improving colonoscopy quality in Ontario using the HQO framework.

HQO framework	Challenges
Engage patients and the public	OCQS reporting does not currently include patient feedback on colonoscopy satisfaction or experience
Redesign the system to ­support quality	Existing accountability structures and processes are suboptimal to manage endoscopists who have persistent quality issues Lack of centralized colonoscopy intake and booking systems to ensure efficient and appropriate colonoscopy use About 1/3 of colonoscopies are performed in OHP facilities, where there is limited oversight Endoscopist behavior is driven to some extent by the fee-for-service schedule which is negotiated by the Ministry of Health and Ontario Medical Association with limited input from OH and OCQS No specific credentialing/oversight of endoscopists who perform abnormal FIT colonoscopies No specific CCC program accreditation for facilities performing abnormal FIT colonoscopies
Help professionals and caregivers thrive	There is limited capacity for additional support: only a small percentage of endoscopists receive peer coaching via facilitated feedback
Ensure technology works for all	Lack of single endoscopy EMR or coordination across EMRs limits the types of colonoscopy quality data collected (eg, pathology data) and the ability to easily share data to ensure appropriateness (ie, post polypectomy surveillance) and to manage complex cases (eg, large polyps requiring expert endoscopic resection) Rapidly evolving colonoscopy technology and variation in adequacy of equipment across facilities Endoscopists must access colonoscopy quality reports via virtual portal, which adds barriers to review
Support innovation and spread knowledge	Constrained resource environment, lack of nimbleness
Monitor performance with quality in mind	Key strength of the OCQS, however, there are limited tools to implement change (eg, few QBP initiatives tied funding to quality despite initial intentions)
Build a quality-driven culture	Colonoscopy is practiced by a large number of endoscopists across a large number of facilities, often with limited oversight Lack of centralized management of the resource (such that endoscopists feel ownership over “their” endoscopy lists)

Abbreviations: CCC, ColonCancerCheck; HQO, Health Quality Ontario; OCQS, Ontario’s colonoscopy quality strategy; OH, Ontario Health.

The work to improve colonoscopy quality continues to evolve; however, this account of the Ontario experience to date may benefit other jurisdictions. The lessons learned include the importance of getting started with what is possible given a jurisdiction’s current context and resources. Once started, it is important to engage in evaluation, monitoring and reflection to refine, improve, and continue to build over time as opportunities present themselves. Optimizing provider participation in the reporting process remains a focus for future work. In Ontario, as in other jurisdictions, improvements in colonoscopy have been well documented and programs such the OCQS are important drivers of this change.

Author contributions

Catherine Dubé (Conceptualization [lead], Methodology [equal], Formal analysis [equal], Writing—original draft [lead], Writing—review & editing [equal]), Akua Kyei (Writing—original draft (supporting), Writing—review & editing [equal]), Andrea Hatvani (Writing—review & editing [equal]), Meghan Walker (Formal analysis [equal], Writing—review & editing [equal]), Julia Gao (Formal analysis [equal], Writing—review & editing [equal]), Jane Ahn (Formal analysis [equal], Writing—review & editing [equal]), David Morgan (Methodology [equal], Writing—review & editing [equal]), Nancy N. Baxter (Methodology [equal], Writing—review & editing [equal]), Linda Rabeneck (Conceptualization [lead], Methodology [equal], Formal analysis [equal], Writing—review & editing [equal]), and Jill Tinmouth (Conceptualization [lead], Funding acquisition [lead], Methodology [equal], Formal analysis [equal], Writing—original draft [lead], Writing—review & editing [equal])

Supplementary material

Supplementary material is available at Journal of the Canadian Association of Gastroenterology online.

Funding

This study was supported by the investigator’s own funds.

Conflicts of interest

Conflict of interest disclosure forms (ICMJE) have been collected for all co-authors and can be accessed as supplementary material.

Data availability

Data collected as part of the work outlined in this manuscript may be available upon reasonable request to the authors.