Clinic Quality Improvement Efforts
Finding several ways to make improvements has a big impact in clinics in Iowa, Illinois, Montana, Rhode Island, California, and Arkansas.
Research shows that making multiple quality improvements can increase screenings.
Doctors at Primary Health Care, a federally qualified health center in Iowa, have a limited amount of time to spend with each patient to discuss colorectal cancer screenings. To address this, clinic staff developed a new pre-visit process. The day before scheduled appointments, they wrote the names of patients who needed to be screened for colorectal cancer on a white board in the nursing station, and a staff member was assigned responsibility for each patient’s screening. After the visit, a check mark was placed by each patient’s name if he or she was given a stool test kit or a prescription for a stool test, scheduled a colonoscopy, or had been tested already. Staff gathered to find out how well they did after a day of seeing patients. If any patient was not offered screening, the assigned staff member was required to follow up.
As a result, one clinic raised its colorectal cancer screening from 8% in 2018 to 50% in 2019. Another clinic increased its screening from 26% in 2018 to 39% in 2019.
A health center’s colorectal cancer screening use remained low even though they had tried to improve it in several ways. Part of the problem was lack of time for doctors to educate patients and order stool test kits.
A group of staff members at the health center focused on finding ways to increase its colorectal cancer screening use. They trained medical assistants on colorectal cancer and how to educate patients, and sent text messages to patients to remind them to get screened and to return their stool test kits. They also improved provider reports to show the number of patients they saw who should have been offered a screening, the number they placed screening orders for, and the number of their patients who completed screening.
Screening increased from 27% to 49% in four years. For Hispanic patients, staff saw an increase in the number of tests ordered (17% to 50%) and returned (3.5% to almost 37%).
In Montana, the Benefis health care system had a low colorectal cancer screening use of 39%. The Montana Cancer Control Program learned that six clinics were not documenting completed screening results in the same way, and some were not entering results into electronic health records at all. Because of this, the program was not sure that screening was reported accurately.
The Montana Cancer Control Program and Benefis reviewed patient information to check the recording of test results and look for incomplete or wrong entries. They also set up a new process for recording colorectal cancer screening test results. About 300 patients’ medical charts were checked and updated, if needed, to correctly document whether a screening test was done or if a referral was made.
After mistakes in the data were corrected, colorectal cancer screening increased 10%. Now that Benefis knows their true screening prevalence, they can set goals to increase it in the future. The Montana Cancer Control Program will use the guidelines it developed for Benefis with its other health care partners.
Providence Community Health Centers serve the largest and most diverse population of all the Rhode Island Colorectal Cancer Program’s health system partners, but just 8% were up to date with colorectal cancer screening in 2014.
The Rhode Island Colorectal Cancer Program and Providence Community Health Centers worked together to raise screening use in three ways. First, they set yearly goals for every doctor and sent them reports every month to let them know what percentage of their patients had been screened. Second, they sent text messages to patients reminding them to get screened for colorectal cancer. Finally, they paid medical assistants to enter the results of 3,500 colorectal cancer screening tests into patients’ electronic health charts. Later, the laboratory that processed the stool tests directly entered the test results into the health center’s electronic health records.
As a result, Providence Community Health Centers went from being the lowest performing partner health system in Rhode Island to the fifth highest performing one. In four years, they increased colorectal cancer screening use to 60%, and 4,664 more underserved patients were screened.
Neighborhood Healthcare is a federally qualified health center. Almost all its patients have an income less than 250% of the federal poverty level, and about half are Hispanic or Latino.
In 2015, fewer than half of the patients at eight of Neighborhood Healthcare’s participating clinics had been screened for colorectal cancer. Patients said they missed their appointments or didn’t complete their stool test kits because they didn’t have transportation to the clinic, or because their doctor didn’t explain why screening was important.
Neighborhood Healthcare’s quality improvement team used two problem-solving tools, Root Cause Analysis and a Plan-Do-Study-Act cycle, to decide what changes needed to be made. Neighborhood Healthcare started using doctor reminders in its computer system. It also worked with the American Cancer Society to train medical assistants on colorectal cancer screening, shifting responsibility from doctors to other clinic staff. Through an existing partnership with LabCorp, the health center offered free stool test kits to uninsured patients, as well as stamped envelopes to make it easier for patients to return their test kits.
As a result, the percentage of patients who were screened for colorectal cancer at all eight clinics combined went up from 49.6% to 62.2%; and 61.2% of patients who received a stool test kit returned it. Also, colorectal cancer screening data are now included in doctors’ yearly evaluations at all Neighborhood Healthcare clinics.
Smaller, rural clinics in Arkansas continued to have low colorectal cancer screening use. At ARcare, a federally qualified health center with 31 clinics, patients were not completing and returning stool tests. The health center believed this was because patients had trouble getting transportation to the clinic and clinical staff needed additional screening education.
ARcare partnered with Arkansas Foundation for Medical Care, a quality improvement agency, to look at their processes and plan to raise their screening use. First, postage-paid envelopes were given to patients who couldn’t get back to the clinic to return their stool tests. To remind staff to tell patients about stool tests, nurses began carrying sample test kits in their pockets, and a test kit with educational handouts was kept in every exam room. Doctors and staff were provided additional training on colorectal cancer screening.
Within three years, ARcare’s overall screening increased by 12%, and the highest single clinic increased 31%. Due to the success of this project, ARcare changed their health system policy to include colorectal cancer training during orientation for clinical staff.