Colorectal Cancer Screening

Part 1: Introduction

Part 2: Characteristics for Success: Colorectal Cancer Screening

Part 3: Implementation of Clinical Quality Measure: Colorectal Cancer Screening

Part 4: Improvement Strategies: Colorectal Cancer Screening

Part 5: Holding the Gains and Spreading Improvement

Part 6: Supporting Information

Part 4: Improvement Strategies: Colorectal Cancer Screening 

The actual improvement process is composed of three steps that respond to the following questions:

1. What changes can an organization make?
2. How can an organization make those changes?
3. How can an organization know the changes caused an improvement?

It is important to understand that improvement requires change, but not all change results in improvement. Considering all of the possible changes that can be made to health care systems, considerable effort has been dedicated to creating various quality improvement strategies providing a framework that organizes possible changes into logical categories. Frameworks for change in health care quality improvement are known as quality models and have been tested to guide change. In fact, considering that there are limited resources to dedicate to improvement, most organizations adopt one or more quality models to guide their improvement efforts. There is not a right or wrong approach, and there are many areas of overlap in quality models. Experienced quality improvement teams often use multiple strategies to overcome challenges as they progress. Two approaches often used by teams that are working to improve performance in Colorectal Cancer Screening are the Care Model approach and the Critical Pathway approach.

The case study continues....

The Case Study: The Improvement Journey

1. Care Model Approach: Implementing the changes described in the Care Model is a proven method to improve care delivery. The Care Model is an organizational framework for change and is organized into six domains:
   1. Organization of Health Care
   2. Clinical Information Systems
   3. Delivery System Design
   4. Decision Support
   5. Community
   6. Self-Management Support

   Changes within these domains can effectively leverage transformation of a current reactive care system to one that better supports care for chronic disease conditions, such as colorectal cancer screening. Changes within these domains can effectively leverage transformation of a current reactive care system to one that better supports proactive care. If an organization does not have general experience with the Care Model, reading information on the Care Model before proceeding is recommended. The Care Model recognizes that preventive care, such as Colorectal Cancer Screening for patients requires more proactive systems than the health care system often provides. The Care Model is implemented to improve care by working in six domains, defined below, that transform the way care is delivered:

   Community-To improve the health of the population, a health care organization reaches out to form powerful alliances and partnerships with State programs, local agencies, schools, faith organizations, businesses, and clubs.

   Organization of Health Care-A health care system can create an environment in which organized efforts to improve preventive care of patients takes hold and flourishes.

   Self Management-Effective self management is very different from telling patients what to do. Patients have a central role in determining their care and one that fosters a sense of responsibility for their own health.

   Delivery System Design-Delivery of patient care requires that an organization not only determines what care is needed, but clarify its roles and tasks to ensure the patient receives the care. An organization needs to ensure that all of the clinicians, who take care of a patient, have centralized, up-to-date information about the patient's status, and make follow-up a part of their standard procedures.

   Decision Support-Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. A health care organization integrates explicit, proven guidelines into the day-to-day practice of primary care providers in an accessible and easy-to-use manner.

   Clinical Information System-A registry, that is, an information system that can track individual patients and populations of patients, is a necessity when managing chronic illness or preventive care.

   
   Definitions above adapted from the Institute for Healthcare Improvement Web site ⁽²⁵⁾

   
   Figure 4.1: The Care Model
   In Table 4.1: Care Model Key Changes, key changes are presented that have been used successfully to improve colorectal cancer screening within the Care Model framework.   

   Table 4.1: Care Model Key Changes

   Community	Organization of Health Care	Self Management	Delivery System Design	Decision Support	Clinical Information System
   Develop partnerships with community organizations to promote screening and expand the care team	Provide opportunities for staff to meet regularly and participate in continuing education	Appreciate and consider the culture - provide patient with culturally- and literacy-appropriate educational tools and resources regarding cancer screening and follow-up	Use clinical information systems to identify and remind populations – clarify use of in-reach, outreach, or both for each cancer	Embed evidence-based guidelines in the care delivery system	Establish a registry - a centralized source of information regarding who is due for screening or has an abnormal screening test
   Maintain a resource database on support services available to people diagnosed with cancer	Allocate resources and remove barriers for improving cancer screening access	Use all staff interactions with patients as opportunities to assist in self management, goal setting, and practices	Make notification of results as a routine part of care	Establish linkages with key specialists to ensure that primary care providers have access to expert support	Create a tracking system that identifies abnormal screening, follows the patient's referral progress, and sends reminders
   Establish memorandums of understanding with community partners for screening services	Develop partnerships with other community and health care organizations to ensure that adequate screening and follow- up capacity exists	Develop incentives for cancer screening	Maximize each team member's contribution to care - redesign care roles to create planned and coordinated care for screening and follow-up	Provide skill-oriented interactive training programs for all staff in support of cancer screening	Develop a process for using and maintaining the registry
   Look to community agencies to help reduce barriers to the evaluation of abnormal screens	Assign day-to-day leadership for continued clinical improvement	Create mechanisms for patient peer support and behavior change programs	Anticipate and plan the visit to ensure timely screening and follow-up	Educate patients about guidelines	Use the registry to provide feedback to care team and leaders

   This toolkit is meant as a guide to help organize ideas, but is also designed to allow flexibility for creative planning.
   Note: An organization may choose to adapt and refine a tool to assist improvement for the measure, Colorectal Cancer Screening. Testing the measure before fully implementing it offers a way to try something new and modify it before additional resources are spent.

   The case study continues....

   The Case Study: The QI Team 

2. Critical Pathway Approach: As with all critical pathways, good performance relies on many different systems and processes working together efficiently. An organization is encouraged to map its own critical pathway for Colorectal Cancer Screening or refer to the schematic in Figure 4.2. Often when a QI team maps its pathways, it readily can see how complex each step is. It is common for different team members to do the same step differently. Workflow inefficiencies become clear when an organization visualizes how each step is completed and the interdependencies among the steps. Some teams are overwhelmed by the possibilities of changes that can be made in their systems; others focus only on a specific group of factors.

   One way to organize the factors that have an impact on the systems is to consider that some are controlled by the patient, others are primarily controlled by the care team, and still others are inherent in the system of care delivery. All three sets of changes must be considered to improve systems of care. In general, these categories can be defined as follows:

   • Patient changes-efforts to support self-management efforts, patient engagement, and navigation of the care system
   • Care team changes-changes in job duties or workflow that assist to retain patients in care and ensure timely evidence-based colorectal cancer screening
   • Health system changes-changes that have an impact on how care is delivered, independent of who delivers it

   A team should use the steps along the critical pathway to target improvements. For this measure, Colorectal Cancer Screening, influences and performance begin by ensuring that the appropriate screening is completed (not simply ordered), as indicated by the fifth step in the critical pathway, colorectal cancer screening completed.

   An organization should ensure that patients are appropriately educated regarding the importance of regular colorectal cancer screening based on their level of risk. Providing education to patients also affords an organization the opportunity to assess patient barriers to screening, such as, lack of insurance or cost. Successful organizations have often aligned resources in the community for screening at a reduced cost for patients creating a true partnership in patient care.

   An organization can think through each part of the critical pathway in turn, teasing out what happens and what could be improved. In Table 4.2, changes that have worked for other QI teams are matched with the part of the system on which they have the most impact. These ideas are not meant to be inclusive, but to start a dialogue of what may improve each part of the critical pathway in an organization, and thus improve it overall. 

   Changes That Work 

   Table 4.2: Sample Changes That Work That Are Linked to the Critical Pathway for Colorectal Cancer

   Table 4.2: Sample Changes That Work

   Area of Critical Pathway	Patient Changes	Care Team Changes	Health System Changes
   Patient presents for visit	Educate patients with educational resources regarding the importance of routine colorectal cancer screening Assess barriers to colorectal cancer screening; address barriers in partnership with patients Provide access to care team member who can provide patient education	Promote colorectal screenings for patients 50 and older at every patient encounter Ensure messaging from the care team regarding importance of periodic screening Query electronic medical records or billing system monthly (patients 50 & older)	Prompts for colorectal cancer screening (patients 50 & older) due at point of care - registry and flow sheets Implement standing orders for screening per protocol Implement on-site FOBT that correlates with higher rate of testing Implement Colon Health Patient Navigator & policy and procedures
   Screening /risk assessment & education provide opportunities for colorectal cancer prevention	Education for patients on importance of colorectal cancer screening, including guidelines and test options Assess patient beliefs for screenings Assist with appropriate self-management goal setting and strategies to overcome barriers Consider health literacy screening	Designate care team member to outreach to patients due for colorectal cancer screening Culturally-competent education for patients to support colorectal cancer screening	Implement triage to screen higher-risk patients first CME's for providers that support culturally-competent screening and education supporting appropriate colorectal cancer screening Display culturally-appropriate posters and brochures in patient areas to encourage patients to talk to providers about screening
   Determine if patient meets the screening criteria using evidence-based guidelines	Provide evidence-based guidelines for colorectal cancer screening including risk assessments Consider health literacy screening	Continued education for age-appropriate screening and risk assessment Providers should agree on guidelines so that care among providers is congruent	Clinical guidelines for colorectal risk assessment and age-appropriate screenings Providers have continuing educational opportunities to stay current with appropriate interventions Prompts for the screening are not turned off when test ordered, but rather when results received Appointments default to PCP (primary care provider)
   Patient determined to be out of guidelines but reinforce care guidelines & provide education and counseling level	Education for patients on importance of colorectal cancer screening, including guidelines/risk factors	Continued education for age-appropriate screening and risk assessment Providers should agree on guidelines so that care among providers is congruent	Patient routinely given documentation of current care plan Tools to support colon cancer screening Providers have continuing educational opportunities to stay current with appropriate interventions Display culturally-appropriate posters and brochures in patient areas to encourage patients to talk to providers about screening
   Patient & provider choose appropriate screening pathway	Education for patients on importance of colorectal cancer screening pathway, including guidelines and test options in a cultural-competent manner	Share clinical guidelines in patient-friendly format Share screening procedure & associated screening prep details regarding chosen screening pathway Ensure screening is ordered when it is due, regardless of reason for visit Document current treatment plan and share copy with the patient	Provide list of free or low-cost colorectal screening services Develop routine colonoscopy referral for patients 50 and older
   Colorectal cancer screening completed	Education on f/u & importance of receiving test results once complete	Document current treatment plan and share copy with the patient Recall system/log to ensure screening complete	Implement patient follow-up and recall system to ensure screening follow-through Clear procedures for how screening results are routed once received – usually to a provider or another health professional who can act on the results by protocol
   Assuming the results received and routed to designated person occurs	Education for patients on importance of receiving test results	Assign patients with colonoscopy to follow-up managers Ensure outreach to patient with test results and achieving targets per guidelines; no news is good news strategy for notifying patients about lab tests is not aligned with good care	Monitor patient contacted with results Set data tracking and evaluation systems for timely patient contact Implement a tracking system that monitors screening results and that prompts if results not logged as expected
   Positive findings?	Education on the importance of treatment of positive findings Resources for patient support	General referral for treatment Help patients to make follow-up appointments Assess current care plan, barriers to following care plan, and collaborate with patient on care plan modifications	Partnerships with specialist for low-cost interventions Culturally-competent education materials readily available for specialist referral
   Reinforce care guidelines & ensure appropriate referral for appropriate intervention or care & appropriate follow-up	Schedule self-management support between visits as indicated	Set clear expectations for follow-up Assess current care plan, barriers to following care plan, and collaborate with patient on care plan modifications Patient satisfaction survey on navigating system	Ensure patient receives guidance about access to the practice with interim concerns Financial considerations and referral source for low-cost interventions Implement Patient Satisfaction Survey for Colon Health Navigation

   This toolkit is meant as a guide to help organize ideas, but is also designed to allow flexibility for creative planning.

    

   While an organization may choose to adapt and refine a tool to assist improvement for the measure, Colorectal Cancer Screening, testing the measure before fully implementing it offers a way to try something new and modify it before additional resources are spent.

Earlier in this module, examples are provided of changes that have led to improved organizational systems of care and better patient health outcomes (Critical Pathway and Care Model). Because every change is not necessarily an improvement, changes must be tested and studied to determine whether the change improves the quality of care. This concept is addressed in detail in the Testing for Improvement module.

It is important that these changes be tested in the context of an organization's staff, current processes, and patients. The goal is that the change results in lasting improvements within an organization.

Organizations commonly use tools to manage change as they work to improve their systems. For a comprehensive discussion of change management, refer to the Testing for Improvement and Redesigning a System of Care to Promote QI modules. Here are a couple of tools that are worth mentioning in the context of this measure:

1. Small tests of change Model for Improvement and PDSA (Plan-Do-Study-Act)
2. Process mapping

3. Model for Improvement

   The Model for Improvement ⁽²⁶⁾ identifies aim, measure, and change strategies by asking three questions:

   
   Figure: AIM Measure Change

   These questions are followed by the use of learning cycles to plan and test changes in systems and processes. These are referred to as PDSA (Plan-Do-Study-Act) cycles. The PDSA Cycle is a test-and-learning method for discovering effective and efficient ways to change a current process. In Figure 4.3: The PDSA Cycle, the graphic provides a visual of the PDSA process:

   
   Figure 4.3: The PDSA Cycle

   
   An organization focusing its improvement efforts on Colorectal Cancer Screening for its patients benefits from implementing PDSAs to test change processes that have an impact on obtaining the appropriate screening for colorectal cancer. Those organizational processes tested may focus on outreach, operational procedures, or patient education interventions ensuring that patients have timely access to care. A few examples of such processes relating to Colorectal Cancer Screening are listed below:

   • What system is in place to provide patients with timely reminders regarding colorectal cancer screening?
   • What are the assigned roles, duties, and tasks for planned visits to a multidisciplinary care team? Are members of the team cross-trained?
   • Does the patient population understand its specific role in obtaining the appropriate screen for colorectal cancer or is there an opportunity for education?
   • Is there an opportunity to educate the community on the importance of screening for colorectal cancer in a group visit setting?
   • Are there cultural, linguistic, and literacy barriers that the organization may need to address?

   As an organization plans to test a change, it should specify who, what, where, and when so that all staff know their roles clearly. Careful planning results in successful tests of change. Documentation of what happened – the S or study part of the PDSA – is also important. This can help a team to understand the impact of changes to a process as unanticipated consequences may occur.

   The case study continues....

   The Case Study: PDSA Cycles in Action

   Tips for Testing Changes

   • Keep the changes small and continue testing.
   • Involve care teams that have a strong interest in improving colorectal cancer screening.
   • Study the results after each change. All changes are not improvements; do not continue testing something that does not work!
   • If stuck, involve others who do the work even if they are not on the improvement team.
   • Make sure that overall aims are improving; changes in one part of a complex system sometimes have an adverse effect in another.

• Process Mapping

  Process mapping is another valuable tool that an organization focused on improvement often uses. A process map provides a visual diagram of a sequence of events that result in a particular outcome. Many organizations use this tool to evaluate a current process and again when restructuring a process.

  The purpose of process mapping is to use diagramming to understand the current process; i.e., how a process currently works within the organization. By looking at the steps, their sequence, who performs each step, and how efficiently the process works, a team can often visualize opportunities for improvement.

  Process mapping can be used before or in conjunction with a PDSA cycle. Often, mapping out the current process uncovers unwanted variation. In other words, different staff may perform the process differently, or the process is changed on certain days or by specific providers. By looking at the process map, a team may be able to identify gaps and variation in the process that have an impact on colorectal cancer screening for patients.

  Both of these improvement strategies are illustrated in Example 4.1:

  Example 4.1: Illustrations of Improvement Strategies

  ---

  Successful referral to a patient navigator

  At a small clinic in the northeast, the organization's improvement team found that 25 percent of its patients aged 50 to 80 years had an appropriate screening for colorectal cancer. Further investigation revealed that the main reason for a missed appointment for screening was fear. The improvement team decided to look at the process and decided to use the patient navigator at the hospital to contact patients for screening. The referral process to the patient navigator was:

  1. Patient navigator appointment ordered by the provider at time of the patient's visit.
  2. MA schedules an appointment at the hospital and provides information to the patient.
  3. Documentation of patient visits with the patient navigator or no-shows received by the health center.
     

  The team felt that Steps 2 and 3 were potential problems in the process and analyzed how they could be improved. Phone calls were made to five patients who had been referred to the patient navigator to assess their experiences. Two had attended their appointments but had difficulty finding the navigator's office; two had not attended because they felt that it would not be worthwhile, and one developed a schedule conflict after the appointment had been made. There was no notation that the three patients had no-showed their appointments in the patients' charts.

  The QI team considered various strategies, such as, providing clearer instructions for patients, providing education on site, and improving the feedback loop between the navigator and the provider. The team investigated the option of contracting with the patient navigator for a half day per week to work on site and found that it could be reimbursed for her services. This arrangement was put in place as a three-month trial and referral completion rates were monitored monthly. Although attendance was not perfect, it was significantly better than when patients were referred off site. The team also emphasized that notes from the visit, or that the patient no-showed, was critical information that must be documented in the patient's chart.

  The team strategy was successful. By having the patient navigator on site, access to the service was simplified and was perceived by patients to be more integrated with their provider's care.

  Process mapping, when used effectively, can identify opportunities for improvement and support testing changes in the current system of care. Additional information, including tools and resources to assist an organization in adapting process mapping as an improvement strategy within its organization, can be found in the Redesigning a System of Care to Promote QI module.

Measures and data are necessary to answer this question. Data is needed to assess and understand the impact of changes designed to meet an organization's specified aim. Measurement is essential in order to be convinced that changes are leading to improvement. Organizations that have experienced successful improvement efforts found that data, when shared with staff and patients outside the core improvement team, led to the spread of improvement strategies, in turn generating interest and excitement in the overall quality improvement process.

Measures are collected prior to beginning the improvement process and continue on a regularly scheduled basis throughout the improvement program. Once an organization reaches its specified goal, frequency of data collection may be reduced. Additional information regarding frequency of data collection, tracking, and analyzing data can be found in the Managing Data for Performance Improvement module.