|July 5th, 2017 :: Authors: Nancy Beaumont and Judy Beck, RN, MSN
On February 1, 2017, Great Plains Quality Innovation Network (Great Plains QIN) became an honoree recipient of the 2017 80% by 2018 National Achievement Awards, a program designed to recognize individuals and organizations who are dedicating their time, talent and expertise to advancing needed initiatives that support the shared goal to regularly screen 80% of adults 50 and over by 2018.
Nancy Beaumont, the State Program Director for the South Dakota Foundation for Medical Care, has been an active member of the South Dakota Council on Colorectal Cancer (2004-present), a statewide alliance of individuals and organizations working together to reduce the burden of colorectal cancer. Nancy serves as an advisor to the South Dakota Comprehensive Cancer Control Plan Advisory Committee (2007-present), and is a member of the South Dakota Chronic Disease Partners Steering Group (2007-present). Additionally, Nancy serves on the American Cancer Society South Dakota State Leadership Board, volunteering her time and efforts by engaging key stakeholders in the development of key processes to allow informed decision making and improved health outcomes.
Judy Beck, RN, MSN, serves as the Quality Improvement Program Director for Quality Health Associates of North Dakota. She is the State Program Director for North Dakota serving the Great Plains QIN. Judy has experience as a certified oncology nurse and a nurse manager of a cancer center. In this role, she participated in the health system’s cancer committee to address colorectal cancer screening and colorectal cancer rates. Judy serves as co-lead for the Great Plains QIN’s regional efforts to improve colorectal cancer screening rates in North Dakota, South Dakota, Nebraska, and Kansas.
Hi, Judy and Nancy! We’re excited to feature your work on the 80% by 2018 Blog. Can you tell us a little about yourself and how you ended up working on colorectal cancer screening?
[Nancy] Colorectal cancer has been a priority of mine as it is known to be preventable through early detection and screening and too many adults are not getting tested as recommended, leading to considerable suffering to families. The need to raise awareness aligns with my ongoing commitment to the advancement of a high quality, patient centered, and cost effective health care system. Throughout my career, I’ve had the opportunity to work alongside of clinicians, community members / consumers, and employers in state-wide coalitions and task forces to collectively push toward a common goal of preventing cancers and saving lives. In my role as Quality Director at the South Dakota Foundation for Medical Care, I continually work to create an environment of collaboration, engaging key stakeholders in the development of processes to allow informed decision making and improved health outcomes.
[Judy] My 30+ years of experience as a nurse includes working with cancer patients as a certified oncology nurse. In this role, I cared for patients with colorectal cancer, some survived while others did not. Many of us know someone with colorectal cancer. Personally, this includes family and friends. As the Quality Improvement Program Director for Quality Health Associates of North Dakota, I’m working with a talented team from the Great Plains QIN to tackle colorectal cancer in a big way.
Tell us a little bit about the Great Plains Quality Innovation Network.
The Great Plains Quality Innovation Network-Quality Improvement Organization (GP QIN-QIO) was awarded the Centers for Medicare and Medicaid Services (CMS) contract to serve as the QIN‐QIO for Kansas, Nebraska, North Dakota, and South Dakota in 2014. Through this contract, we work with healthcare providers, including primary care physicians, to implement data-driven quality initiatives to improve health care. We offer technical assistance, tailored education, best practices, tools, and resources. Through these efforts, we intend to improve patient safety, reduce harm, and improve clinical care at the local and regional levels.
When and why did the Great Plains QIN decide to focus on increasing colorectal cancer screening?
Data revealed that the four states we serve have colorectal cancer incidence rates that are higher than the national average and colorectal cancer screening rates that are far below the national average. According to data from the Centers for Disease Control and Prevention, the national average incidence of colorectal cancer is 39.9/100,000. Incidence rates in our Midwest region range from 44/100,000 in North Dakota, to 39.8/100,000 in Kansas. The 2012 Behavior Risk Factor Surveillance System (BRFSS) data showed colorectal cancer screening prevalence among our states with North Dakota ranked 42 of 51, Nebraska 38 of 51, South Dakota 32 of 51, and Kansas 25 of 51. The data indicated there was significant room for improvement in our care delivery systems within our region. To address this, we submitted a proposal and were awarded funding from CMS with a two-year special innovation project. Our project currently supports primary care physicians from 57 clinics committed to improving their colorectal cancer screening rates, which in turn saves lives by preventing or finding the disease early and increasing the possibility of survival.
How did you recruit clinics to work on colorectal cancer screening?
To recruit clinics, we first reached out to those who were working with our QIN-QIO on other quality improvement efforts. By sharing the statewide incidence and screening data for each state, we recruited clinics wanting to impact this data by improving their screening rates. Over 80% of the clinics working on this project have confirmed this commitment by taking the 80% by 2018 pledge. Most of the health systems working with this project are smaller, rural clinics that lack the same level of resources found within large health systems. Many are Federally Qualified Health Centers (FQHCs) and Rural Health Centers.
What kinds of training and technical assistance do you offer clinics? And how do you communicate and collaborate with them across such a large region?
To improve colorectal cancer screening rates, we implemented interventions to promote system changes within primary care practices. To accomplish this, we provided education and technical assistance to support clinics to implement the four essentials found in the NCCRT evidence-based toolkits, Steps for Increasing Colorectal Cancer Screening Rates: A Manual for Community Health Centers and How to Increase Colorectal Cancer Screening Rates in Practice: A Primary Care Clinician’s Evidenced-Based Toolbox and Guide. The four essentials include making a physician recommendation, developing a screening policy, implementing reminder systems, and measuring practice progress.
Our special innovation project used a regional Learning and Action Network (LAN) as the foundation to provide access to tools, resources, education, subject matter experts, and networking opportunities. We partnered with the American Cancer Society and other stakeholders to offer webinars on topics covering current knowledge and guidelines about appropriate colorectal cancer screening, evidence-based practices for improving screening rates, and strategies for overcoming barriers to screening. We used an “all teach, all learn” approach. One of the webinars featured one of our recruited Kansas clinics, who shared their lessons learned from their successful journey in which they exceeded the 80% screening goal. Using webinars and posting resources on the Great Plains QIN website enabled us to extend our reach to all clinics across the four-state region. Readers outside our region are welcome to visit the site to download tools and view archived webinars.
What kinds of changes have the clinics implemented? And how did they select their interventions?
Clinics have engaged in a wide variety of changes based on their technological capacity, staffing structure, and current screening goals. Interventions range from placing a fecal immunochemical test (FIT) kit on the counter as a reminder to the provider to hiring a colorectal cancer screening coordinator to better manage the complex patient reminders and testing follow-up. Key elements to successful screening rate improvements include electronic health record optimization and screening navigation to ensure FIT kits are returned and colonoscopy preparation and procedures are conducted.
One clinic used jelly beans to track if the provider or the nurse recommended the screening and the corresponding percentage of patients who followed through. We’ve found that developing fun and easy ways to track a rapid improvement cycle or create some competition among healthcare teams helps to engage the staff.
I understand several clinics piloted providing patients with FIT kits during annual flu shot clinics (FluFIT).
In a regional effort to promote colorectal cancer screening methods including annual stool tests, various partners collaborated to promote and implement the FluFIT program across our four-state region. Partners included the American Cancer Society, Great Plains Tribal Chairmen’s Health Board, North Dakota Department of Health, South Dakota Comprehensive Cancer Control Program, and the South Dakota Department of Health.
We worked from the four essentials highlighted in NCCRT’s toolkits for primary care and www.flufit.org to develop a FluFIT LAN, which included a webinar series, “office hours” teleconference calls, and technical assistance planning meetings. Our “Fast Track to FluFIT Webinar Series” covered how to assemble a FluFIT team, develop a FluFIT workflow, and systems to support follow up. We then used the office hours to troubleshoot obstacles and share best practices, tools, and resources. To provide technical assistance, Great Plains QIN staff conducted site visits and conducted individual planning meetings.
Thirty sites implemented FluFIT clinics in the fall of 2016, including FQHCs, Indian Health Service clinics, a pharmacy site, and others, many in rural areas. Learn more about this regional initiative in the “FluFIT: Double Disease Prevention” poster, shared at the CMS Quality Conference in December 2016.
Kaitlin Nolte from Kansas Foundation for Medical Care (left) and Tasha Peltier (right) from Quality Health Associates of North Dakota
What success have you seen? How did you measure that success?
Of the 43 clinics that are currently able to track their colorectal cancer screening rate, all have reported improvements, with one screening as many as 84% of eligible patients. It’s early to see measurable impact from the FluFIT clinics since this was the inaugural flu season for the project, but early indicators are promising. Clinic sites who have operationalized and/or hosted FluFIT programs along with other evidence-based interventions in previous seasons have documented increases in colorectal cancer screening rates.
What lessons learned would you share with others that support primary care clinics with training and technical assistance related to colorectal cancer screening?
Aligning our efforts with state and regional stakeholders also committed to the 80% by 2018 campaign supported not only our recruited clinics, but helped spread efforts across each state. We have learned from clinics some of the challenges they encounter with using their electronic health record systems to track their screenings rates, which may result in the need for costly upgrades. Using the “all teach, all learn” approach allowed clinics to discuss their challenges and share strategies with each other. One-on-one technical assistance provided through coaching calls and/or site visits helped clinics successfully implement interventions from NCCRT’s primary care toolkits.
Do you have any final tips for our readers that are working to achieve 80% by 2018?
We learned so much from this work, but the following three themes emerged as essential keys for success:
- Developing strong partnerships and promoting collaboration resulted in a greater reach and network of organizations interested in quality improvement efforts.
- Identifying and unifying the efforts of champions across organizations increases credibility and creates accountability for continued progress.
- Providing tools for implementing policy and systems change is a key factor for implementing a sustainable quality improvement effort.
Thank you for sharing your story with us! We look forward to hearing more about your work and Great Plains QIN’s progress in the future.
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