Reviewer’s report
Title: 
A Patient-Centered Framework for Health Systems Engineering in
Gastroenterology: Improving Inpatient Colonoscopy Bowel Preparation
Version: 
0 
Date: 
25 Sep 2020
Reviewer's report:
This submission is a study to examine the approach to developing an
intervention to improve inpatient colonoscopy bowel preparation (ICBP) at a
large academic medical center. The primary outcomes were to increase ICBP
and decrease length of stay (LOS). The paper addresses a common challenge for
inpatient GI and hospital services. 
The paper is organized and easy to read. 
Background: 
Lines 14-16 discuss reasons for possible aborted procedure such as poor bowel
preparation and this is captured in the fishbone diagram. The authors did not
acknowledge the change in clinical status or development of other acute medical
issues which can also cancel or delay exams. There is a comment about this on
page 7 later in the manuscript. 
In lines 26-34, there is thorough review of papers which discuss factors for a
poor bowel preparation. Most of these are outpatient procedures and stating this
would help to highlight the need/gap for this work. 
Page 5, line 13: HSE principles: this is not a commonly understood term and has
many meanings. Please explain. Do the authors mean continuous process
improvement/quality improvement? 
Line 17-20: Please add the population of focus, being as specific as possible to
the aim statement. Line 21, mentions intervention—please state which
intervention you are referring to in order to improve clarity. 
Line 26-32: the first part of statement related to the QI project. However the
second is the purpose of the paper. I would recommend separating these two
thoughts. 
Methods:
Did the study include all pts (ICU, OB)? Please be as specific as possible.
How was non-emergent defined? 
Phase 1: Team is multidisciplinary and inclusive. How many observations were
made in order to develop the process map? 
Phase 2:
In analyzing the process map, what aspects did the team analyze for? Was it
analyzed for value, efficiency, safety? 
When designing the intervention, what options were considered? How did the
team choose the interventions which were selected? How were operational issues
consider in selecting the final options. 
Appreciate the clear definition of ICBP using the BBPS. 
In the definition of LOS (line39-40, page 7): are the authors referring to just the
LOS for getting the procedure done or do they mean the total LOS for the stay? I
think stating this distincition would be helpful to the reader. 
Results:
Phase 1: I have concern that the process map and subsequent decision were
based on one tracer. In any complex process, there is usually high variability and
work arounds to get the work done. 
Table 3 has some clear drivers of poor preparation. How were these derived? I
see the possible solutions here—were these all adopted? How did you select? 
Phase 2: Please describe in more detail the iterative discussions—were these
more casual? Was this formally done as part of the "S" in PDSA? Many PDSA
cycles are mentioned—can you please show these and note the interventions on
the graph? 
Please provide an example of the EHR text in the supplementary material as
readers will find this beneficial for their own QI work. If it is in figure 2, please
make reference to this. 
Page 10, line 30: This describes how you arrived at the focus units and I
commend you for using Pareto as your guiding source. Were the units selected
the ones with the worst bowel preparation in your baseline data? Also, this is the
scope of your project and can be added to the aim statement earlier in the paper. 
In your regression model, which variables did you control for other than
occupancy? (page 12, line 17)
The statistical analysis is clearly explained and robust. In using a regression, you
are able to control for other factors however the QI/PI approach really does not
control for these factors, instead it is about making observations after an
intervention within a system. You mention the value of this in your conclusion in
line 54, pg 14—I disagree with the conclusion that it is more informative. 
Discussion:
Page 14, line 15: Sampling bias—I understand the explanation that a more
seasoned provider might be able to mitigate poor prep. However, is the change of
having a more seasoned provider versus a novice one equally distributed? In
other words, how are the floors where the intervention took place staffed? 
Pg 15, line 29: do you have data to increased compliance? 
The final paragraph of the manuscript makes assertion well beyond the scope of
this paper and is more a comment about HSE (which needs to be better defined).
I would ask the authors to consider a revision which highlight reasonable
applicability to other inpatient conditions (the two conditions highlighted do not
require the same degree of pre-proceudral preparation). 
Swim lane diagram: Nice use of this too. Is this current state or ideal state?
Please add a figure label. Also, "proceed to procedure" should be in an oval as it
is another end point. 
Figure 3: The manutscript does not provide an interpretation of the run chart.
Based on this chart, the process does not appear to be in control and does not
meet the criteria for a shift in the outcomes based on the intervention
(https://improvement.nhs.uk/documents/2157/run-charts.pdf). Therefore, a
discussion of why the authors think their chosen data analysis approach is valid
for quality improvement when the approaches in analysis lead to two different
interpretations of the data. If there is additional data I would ask the authors to
update the analysis. 
Fishbone: why is a miralax a driver of poor outcomes? 
Was the patient education material provided in other languages? 
Publons Reviewer Recognition
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Yes
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare that I have no competing interests
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
No
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Reviewer’s report
Title: 
A Patient-Centered Framework for Health Systems Engineering in
Gastroenterology: Improving Inpatient Colonoscopy Bowel Preparation
Version: 
0 
Date: 
25 Sep 2020
Reviewer's report:
This submission is a study to examine the approach to developing an
intervention to improve inpatient colonoscopy bowel preparation (ICBP) at a
large academic medical center. The primary outcomes were to increase ICBP
and decrease length of stay (LOS). The paper addresses a common challenge for
inpatient GI and hospital services. 
The paper is organized and easy to read. 
Background: 
Lines 14-16 discuss reasons for possible aborted procedure such as poor bowel
preparation and this is captured in the fishbone diagram. The authors did not
acknowledge the change in clinical status or development of other acute medical
issues which can also cancel or delay exams. There is a comment about this on
page 7 later in the manuscript. 
In lines 26-34, there is thorough review of papers which discuss factors for a
poor bowel preparation. Most of these are outpatient procedures and stating this
would help to highlight the need/gap for this work. 
Page 5, line 13: HSE principles: this is not a commonly understood term and has
many meanings. Please explain. Do the authors mean continuous process
improvement/quality improvement? 
Line 17-20: Please add the population of focus, being as specific as possible to
the aim statement. Line 21, mentions intervention—please state which
intervention you are referring to in order to improve clarity. 
Line 26-32: the first part of statement related to the QI project. However the
second is the purpose of the paper. I would recommend separating these two
thoughts. 
Methods:
Did the study include all pts (ICU, OB)? Please be as specific as possible.
How was non-emergent defined? 
Phase 1: Team is multidisciplinary and inclusive. How many observations were
made in order to develop the process map? 
Phase 2:
In analyzing the process map, what aspects did the team analyze for? Was it
analyzed for value, efficiency, safety? 
When designing the intervention, what options were considered? How did the
team choose the interventions which were selected? How were operational issues
consider in selecting the final options. 
Appreciate the clear definition of ICBP using the BBPS. 
In the definition of LOS (line39-40, page 7): are the authors referring to just the
LOS for getting the procedure done or do they mean the total LOS for the stay? I
think stating this distincition would be helpful to the reader. 
Results:
Phase 1: I have concern that the process map and subsequent decision were
based on one tracer. In any complex process, there is usually high variability and
work arounds to get the work done. 
Table 3 has some clear drivers of poor preparation. How were these derived? I
see the possible solutions here—were these all adopted? How did you select? 
Phase 2: Please describe in more detail the iterative discussions—were these
more casual? Was this formally done as part of the "S" in PDSA? Many PDSA
cycles are mentioned—can you please show these and note the interventions on
the graph? 
Please provide an example of the EHR text in the supplementary material as
readers will find this beneficial for their own QI work. If it is in figure 2, please
make reference to this. 
Page 10, line 30: This describes how you arrived at the focus units and I
commend you for using Pareto as your guiding source. Were the units selected
the ones with the worst bowel preparation in your baseline data? Also, this is the
scope of your project and can be added to the aim statement earlier in the paper. 
In your regression model, which variables did you control for other than
occupancy? (page 12, line 17)
The statistical analysis is clearly explained and robust. In using a regression, you
are able to control for other factors however the QI/PI approach really does not
control for these factors, instead it is about making observations after an
intervention within a system. You mention the value of this in your conclusion in
line 54, pg 14—I disagree with the conclusion that it is more informative. 
Discussion:
Page 14, line 15: Sampling bias—I understand the explanation that a more
seasoned provider might be able to mitigate poor prep. However, is the change of
having a more seasoned provider versus a novice one equally distributed? In
other words, how are the floors where the intervention took place staffed? 
Pg 15, line 29: do you have data to increased compliance? 
The final paragraph of the manuscript makes assertion well beyond the scope of
this paper and is more a comment about HSE (which needs to be better defined).
I would ask the authors to consider a revision which highlight reasonable
applicability to other inpatient conditions (the two conditions highlighted do not
require the same degree of pre-proceudral preparation). 
Swim lane diagram: Nice use of this too. Is this current state or ideal state?
Please add a figure label. Also, "proceed to procedure" should be in an oval as it
is another end point. 
Figure 3: The manutscript does not provide an interpretation of the run chart.
Based on this chart, the process does not appear to be in control and does not
meet the criteria for a shift in the outcomes based on the intervention
(https://improvement.nhs.uk/documents/2157/run-charts.pdf). Therefore, a
discussion of why the authors think their chosen data analysis approach is valid
for quality improvement when the approaches in analysis lead to two different
interpretations of the data. If there is additional data I would ask the authors to
update the analysis. 
Fishbone: why is a miralax a driver of poor outcomes? 
Was the patient education material provided in other languages? 
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons upon publication of the manuscript. If you have already registered at
Publons, they will notify you of the receipt of this review and update your profile
as per your settings and their policy. If you are not registered with Publons, you
will receive an email from them asking you to register in order for them to be
able to recognize your review on your new profile page. Publons may use the
Review Data to generate derivative metadata for the benefit of Publons and you
as a reviewer, carefully considering the sensitivity of such information. For
example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help
editors to identify candidate reviewers. Please find the details of processing in
Publons’ privacy policy 
https://publons.com/about/terms
Yes
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare that I have no competing interests
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
No
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Please review this paper.
user
Reviewer’s report
Title: 
A Patient-Centered Framework for Health Systems Engineering in
Gastroenterology: Improving Inpatient Colonoscopy Bowel Preparation
Version: 
0 
Date: 
25 Sep 2020
Reviewer's report:
This submission is a study to examine the approach to developing an
intervention to improve inpatient colonoscopy bowel preparation (ICBP) at a
large academic medical center. The primary outcomes were to increase ICBP
and decrease length of stay (LOS). The paper addresses a common challenge for
inpatient GI and hospital services. 
The paper is organized and easy to read. 
Background: 
Lines 14-16 discuss reasons for possible aborted procedure such as poor bowel
preparation and this is captured in the fishbone diagram. The authors did not
acknowledge the change in clinical status or development of other acute medical
issues which can also cancel or delay exams. There is a comment about this on
page 7 later in the manuscript. 
In lines 26-34, there is thorough review of papers which discuss factors for a
poor bowel preparation. Most of these are outpatient procedures and stating this
would help to highlight the need/gap for this work. 
Page 5, line 13: HSE principles: this is not a commonly understood term and has
many meanings. Please explain. Do the authors mean continuous process
improvement/quality improvement? 
Line 17-20: Please add the population of focus, being as specific as possible to
the aim statement. Line 21, mentions intervention—please state which
intervention you are referring to in order to improve clarity. 
Line 26-32: the first part of statement related to the QI project. However the
second is the purpose of the paper. I would recommend separating these two
thoughts. 
Methods:
Did the study include all pts (ICU, OB)? Please be as specific as possible.
How was non-emergent defined? 
Phase 1: Team is multidisciplinary and inclusive. How many observations were
made in order to develop the process map? 
Phase 2:
In analyzing the process map, what aspects did the team analyze for? Was it
analyzed for value, efficiency, safety? 
When designing the intervention, what options were considered? How did the
team choose the interventions which were selected? How were operational issues
consider in selecting the final options. 
Appreciate the clear definition of ICBP using the BBPS. 
In the definition of LOS (line39-40, page 7): are the authors referring to just the
LOS for getting the procedure done or do they mean the total LOS for the stay? I
think stating this distincition would be helpful to the reader. 
Results:
Phase 1: I have concern that the process map and subsequent decision were
based on one tracer. In any complex process, there is usually high variability and
work arounds to get the work done. 
Table 3 has some clear drivers of poor preparation. How were these derived? I
see the possible solutions here—were these all adopted? How did you select? 
Phase 2: Please describe in more detail the iterative discussions—were these
more casual? Was this formally done as part of the "S" in PDSA? Many PDSA
cycles are mentioned—can you please show these and note the interventions on
the graph? 
Please provide an example of the EHR text in the supplementary material as
readers will find this beneficial for their own QI work. If it is in figure 2, please
make reference to this. 
Page 10, line 30: This describes how you arrived at the focus units and I
commend you for using Pareto as your guiding source. Were the units selected
the ones with the worst bowel preparation in your baseline data? Also, this is the
scope of your project and can be added to the aim statement earlier in the paper. 
In your regression model, which variables did you control for other than
occupancy? (page 12, line 17)
The statistical analysis is clearly explained and robust. In using a regression, you
are able to control for other factors however the QI/PI approach really does not
control for these factors, instead it is about making observations after an
intervention within a system. You mention the value of this in your conclusion in
line 54, pg 14—I disagree with the conclusion that it is more informative. 
Discussion:
Page 14, line 15: Sampling bias—I understand the explanation that a more
seasoned provider might be able to mitigate poor prep. However, is the change of
having a more seasoned provider versus a novice one equally distributed? In
other words, how are the floors where the intervention took place staffed? 
Pg 15, line 29: do you have data to increased compliance? 
The final paragraph of the manuscript makes assertion well beyond the scope of
this paper and is more a comment about HSE (which needs to be better defined).
I would ask the authors to consider a revision which highlight reasonable
applicability to other inpatient conditions (the two conditions highlighted do not
require the same degree of pre-proceudral preparation). 
Swim lane diagram: Nice use of this too. Is this current state or ideal state?
Please add a figure label. Also, "proceed to procedure" should be in an oval as it
is another end point. 
Figure 3: The manutscript does not provide an interpretation of the run chart.
Based on this chart, the process does not appear to be in control and does not
meet the criteria for a shift in the outcomes based on the intervention
(https://improvement.nhs.uk/documents/2157/run-charts.pdf). Therefore, a
discussion of why the authors think their chosen data analysis approach is valid
for quality improvement when the approaches in analysis lead to two different
interpretations of the data. If there is additional data I would ask the authors to
update the analysis. 
Fishbone: why is a miralax a driver of poor outcomes? 
Was the patient education material provided in other languages? 
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons upon publication of the manuscript. If you have already registered at
Publons, they will notify you of the receipt of this review and update your profile
as per your settings and their policy. If you are not registered with Publons, you
will receive an email from them asking you to register in order for them to be
able to recognize your review on your new profile page. Publons may use the
Review Data to generate derivative metadata for the benefit of Publons and you
as a reviewer, carefully considering the sensitivity of such information. For
example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help
editors to identify candidate reviewers. Please find the details of processing in
Publons’ privacy policy 
https://publons.com/about/terms
Yes
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare that I have no competing interests
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
No
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
assistant