Colorectal cancer is the No. 2 killer cancer in Minnesota. While screening is proven to reduce mortality, statewide screening rates for colorectal cancer stood at 64 percent in 2011, according to MN Community Measurement.
To increase the state’s rate of appropriate colorectal cancer screening, the Minnesota Department of Health (MDH), the Institute for Clinical Systems Improvement (ICSI) and the American Cancer Society (ACS) jointly conducted a series of learning collaboratives with Minnesota and Wisconsin clinics from 2011 through 2014. These and other efforts increased screening rates to 69 percent in 2013. However, Cancer Plan Minnesota, a framework for action created by the partners of the Minnesota Cancer Alliance to address the burden of cancer in Minnesota, has a goal of reaching 80 percent by 2016. To help achieve that goal, below are 10 strategies for increasing appropriate screening, proven effective during the three collaboratives.
1. Make screening a key quality-improvement project.
The more people taking ownership of a colorectal cancer-screening program, the better its chance for success. The team should include a physician champion and a registered nurse, plus representatives from such disciplines as quality, marketing, IT, data analysis and care coordination. Conduct a readiness assessment and use such tools as value-stream mapping to help team members visualize challenges, duplication of efforts and areas for improvements. This worked at Tri-County Hospital in Wadena, where a value-stream mapping session identified an inconsistent use of health maintenance tools, challenges with data mining and the need for better patient education.
2. Build patient awareness.
Sometimes, simply getting the message out is the greatest hurdle, due to lack of resources, cultural barriers and limited interest in promotion. Clinics in the collaboratives that understood the importance of promotion devised creative ways to communicate the importance of screenings. Some sent reminders in birthday cards for individuals 50 and older. Others posted informational fliers in exam rooms, elevators and waiting rooms, or put videos on exam room computers. Sanford Health Bemidji held a conference on colorectal cancer screening and staff presented at a women’s expo.
3. Identify appropriate patients and make scheduling easy.
Clinics benefited from creating pre-visit planning processes to check for a patient’s screening status. Some incorporated the process into their EHR, making sure to include appointments for immediate medical needs, as well as prescheduled or preventive care visits. At North Point Clinic in Minneapolis, colorectal cancer screening rates jumped from 23 to 44 percent after staff placed orders for preventive testing in the EHR and began calling patients to inform them of needed lab tests.
4. Practice evidence-based medicine.
Make sure physicians are aware of the evidence so they can treat patients based on best practices guidelines. The ICSI guideline recommends routine screening for individuals at average risk for colorectal cancer ICSI also recommends either a colonoscopy every 10 years, a sigmoidoscopy every five years, a CT colonography every five years or annual stool testing with gFOBT or FIT. Screening is recommended at age 45 for African-Americans and Native Americans.
5. Implement a tracking system.
Robust tracking systems can monitor when a patient is at risk or has opted for a non-colonoscopy screening. Some clinics color code their tracking systems to identify patients overdue for screenings, patients with screenings that are coming up and those who have completed screenings. The Mankato Clinic achieved a callback rate of 47 percent by using a third-party vendor to call patients overdue for screenings.
6. Involve the physicians.
Be transparent with the program and consider creating friendly competition among physicians. Sanford Health Bemidji tracked results by physician, shared data and used its weekly internal newsletter to congratulate physicians who had the highest screening rates.
7. Use shared decision-making.
Office visits present great opportunities for open discussion. Hudson Physicians gave patients “What You Need to Know” brochures prior to their appointments so they could prepare questions ahead of time. This enabled physicians and patients to discuss all screening types and determine the best test for the patient. Others added FOBT and FIT tests to the options available. Make sure physicians have visually appealing, user-friendly educational tools to facilitate shared decision-making.
8. Establish standing orders.
Mayo Clinic Health System rolled out a protocol for independent testing so nurses could schedule screens without the patient having to see a clinician. When expanding the number of people who can order screenings, it is important to generate talking points or scripts so key messages will be communicated.
9. Make the process sustainable.
Stabilizing changes to processes and behaviors makes them sustainable. Successful clinics adjusted rewards and clinic values to reinforce any changes and monitored them carefully to help prevent relapses to old behaviors. Having champions and measurement tools in place is critical.
10. Think outside the box.
Successful programs usually contained a few guerrilla tactics. Some out-of-the-box thinking included encouraging retail clinics to promote screening, waiving co-pays and tying screening messages to other healthcare initiatives, such as flu shots. Staff at Sanford Health Bemidji chose a day to wear blue uniforms and buttons that said, “Ask me why I’m wearing blue.” To address the issue of unreturned FIT kits, North Point placed prepaid stamps and address labels on its kits and had its lab follow up with patients who did not return a kit.
Regardless of the approach, participants in the learning collaboratives agreed that the best colorectal cancer screen is the one that gets done.
For more information on these collaboratives, go to www.icsi.org.