1. Endoscopy units should measure bowel preparation quality routinely, at a minimum annually, on a unit level. Adequate bowel preparation (defined as a BBPS score ≥6, with each segment score ≥2) should be achieved in ≥90% (≥95% aspirational target) of screening and surveillance colonoscopies.
2. Endoscopy units should use a split-dose bowel preparation as the standard preparation strategy in patients undergoing colonoscopy.
3. Bowel preparation instructions should be clearly written at a sixth-grade reading level in the patient’s native language. Units with suboptimal bowel preparation quality should augment preprocedure instructions with additional patient education and support.
4. Endoscopy units should use high-definition colonoscopes for screening and surveillance colonoscopy.
5. Endoscopy units should measure cecal intubation rates on an endoscopist level. Cecal intubation rates should be ≥90% (aspirational ≥95%). The cecal landmarks (appendiceal orifice and ileocecal valve) should be photodocumented in colonoscopy reports.
6. Endoscopy units should measure withdrawal times on an endoscopist level. Mean withdrawal times among normal colonoscopies should be ≥6 minutes (aspirational target ≥9 minutes).
7. Endoscopists should perform a second look of the right colon, either in retroflexed or forward view, to improve the detection of polyps.
8. Endoscopy units should measure and provide feedback on adenoma detection rate at both the endoscopist and unit level on a routine basis, at a minimum annually or when endoscopists have accrued 250 screening colonoscopies.
9. The goal adenoma detection rate for an individual endoscopist should be ≥30% (aspirational target ≥35%). Endoscopists not meeting these thresholds may consider extending withdrawal times, self-learning regarding mucosal inspection and polyp identification, peer feedback, and other educational interventions.
10. Endoscopy units should measure and provide feedback on serrated lesion detection rates on an endoscopist- and unit- level. The goal serrated lesion detection rate for an individual endoscopist should be ≥7% (aspirational target ≥10%). If rates are low, improvement efforts should be oriented toward both colonoscopists and pathologists.
11. Cold snare polypectomy, aiming for a small rim of normal tissue around the polyp, should be used for nonpedunculated polyps 3-9 mm in size. Forceps should generally be avoided for polyps >2 mm in size.
12. Patients with complex polyps without overt malignant endoscopic features or pathology consistent with invasive adenocarcinoma should be evaluated by an expert in polypectomy to attempt endoscopic resection.
13. Endoscopists should document colonoscopy with a detailed report, including procedure indication, extent of examination, bowel preparation quality, findings and interventions, and follow-up plan with rationale.
14. Endoscopy units should inform patients undergoing colonoscopy of the potential for adverse events, warning symptoms and emergency contact information. Units may consider systematic monitoring of delayed adverse events, including post-procedure bleeding, perforation, hospital readmission, 30-day mortality and/or interval colorectal cancer cases, and report these adverse event rates at the unit level.
15. Endoscopists should follow current guidelines to assign appropriate screening and surveillance intervals. All patients with advanced adenomas should have repeat colonoscopy in 3 years. Average-risk patients with normal screening colonoscopies or those with only small distal hyperplastic polyps should not undergo repeat examinations before 10 years.
