Clinicians and staff at a Clearwater Valley primary care clinic in rural Idaho.

Improving colon cancer screening rates in a rural health system

By Heather Hodges, Director of Quality at Clearwater Valley Hospital and Clinics in Idaho

In the quality realm, there are a plethora of metrics that can be tracked and reported. At our three primary care clinics in rural Idaho, we felt we were spread too thin to make a great impact on any one measure. In other words, we were doing a little on a lot.

Our holding company, Essentia Health, had identified a focused list of strategic quality measures. With the pared-down list, we used PICK chart to select our high-priority measures based on ease/difficulty of change and low/high impact on patient outcomes. One of the measures we selected was increasing our colorectal cancer (CRC) screening rates. Before we started, our average clinic compliance rate was only 37 percent.

We designed our CRC screening initiative to include three main components: data validation and accuracy, improving screening opportunities at the point of care, and increasing compliance through outreach.

Step 1: Collect and validate data
The first step was to gather data—and to make sure it was accurate. One of our major hurdles was establishing a baseline: We did not have an accurate picture of who our patients were and where they were in terms of screening compliance. We worked closely with our IT staff to create reports that captured our current workflows and documentation practices.

Data validation came next. Once IT built the reports, I distributed patient lists to our nursing staff, who “scrubbed” them by asking questions such as:

  • Were the patients within the correct age range?
  • Were they still active patients?
  • Was the PCP assigned appropriately?

After the first round of data clean-up and validation, our compliance rate jumped from 37 percent to 49 percent.

Step 2: Share data transparently
Open communication and data transparency have been critical to our success. Initially, we presented the project at a nurse staff meeting to set shared goals and expectations. We distributed patient lists by PCP, and as time allowed, the nursing staff would “work the lists”—meaning they would contact patients who were due for screening, follow up with patients who were scheduled, etc. Each clinic’s overall performance was shared monthly on a bulletin board, along with individual provider performance that included PCP names. Using transparent data promoted healthy competition among our nurses, and the monthly data display evolved from the bulletin board to flat screen TVs in the nursing pods.

Our providers also receive monthly data showing their performance over time in comparison to their peers and the clinic average. We use all of this transparent data to guide discussions about our progress on a regular basis.

Step 3: Routinely ask about preventive screenings
With awareness raised and a goal in sight, our nurses were empowered to ask about preventive screenings at every clinic visit, and if appropriate, to order the needed tests through a standing order. We also started pushing an alternative screening option if patients refused a colonoscopy: a fecal immunochemical (or FIT) test. This is a cost-effective, annual screening option that boosted our compliance rates among patients who refused a colonoscopy for a multitude of reasons, including financial constraints.

Step 4: Reach out to patients and community members
Next, we worked on outreach efforts for both patients and community members. We mailed reminder letters with educational information on different screening options to help with shared decision making. Our nurse case manager followed up with a phone call, which proved more effective than the initial letter in motivating patients to get screened. Our clinics tried to have a presence at a variety of community events—providing health education materials, information on the health insurance exchange, and free blood pressure and blood glucose checks, BMI measurement, FIT tests, etc.

Our team-based approach was key
As with any improvement initiative, it will require vigilance and continued effort to sustain our progress.

Our initiatives and interventions have not been profound, but our improvements have been significant: Today, our colorectal cancer screening compliance rate is 68 percent. We still haven’t reached our goal of 73 percent, but we continue to improve slowly and consistently.

For our team, the root of our success has been just that: the team. This is not a quality department project; this is a facility-wide initiative. Bringing the entire clinic together—including front-office staff, nurses, and providers—is helping us achieve a common goal: We are screening our patients, our co-workers, our neighbors, and our family members. And as our screening rates increase, so do the number of lives saved!

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