improving colon cancer screening rates july 31, 2013

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  • Improving Colon Cancer Screening Rates

    July 31, 2013

  • PresentersMatt FloryHealth Care Partnerships DirectorMidwest Division American Cancer Society (ACS)

    Beverly Annis, RNCommunity Quality Improvement ConsultantFormer member of MNCMs Measurement and Reporting Committee

    Sue Schneider, HIMClinic Coder, Health Information Management DepartmentRenville County Hospital and Clinics

    Jerri Hiniker, RN, BSN, CPHERProgram ManagerStratis Health

  • This webinar is sponsored by:

    Stratis HealthAmerican Cancer Society Minnesota Community MeasurementAligning Forces for Quality Improvement

  • Objectives Describe cancer screening measures and procedures Identify tools and resources to help improve screening rates Develop a plan to increase screening rates in your clinic


  • Why Not Colonoscopy for All?Screening rates are disappointingly lowPatient preference Many individuals dont want an invasive test or a test that requires a bowel prepSome may not have access to the invasive tests due to lack of coverage or local resources

    Greater patient requirements for successful completion of tests that detect both polyps and cancersEndoscopic and radiologic exams require a bowel prep and an office or facility visitEvidence does not support best test or gold standardColonoscopy misses 5 10% of significant lesions in expert settingsQuestions about efficacy in proximal colonHigher potential for patient injury than other testsTest performance is highly operator dependent

  • Fecal Occult Blood TestsRationaleDetect blood in the stoolCancers tend to bleedLarge polyps also may bleed (although less likely to bleed than cancers)Two methods: Guaiac (gFOBT)Immunochemical (FIT)

  • Guaiac Tests (gFOBT)Most common type in U.SBest evidence (3 RCTs)Need specimens from 3 bowel movementsNon-specificResults influenced by foods and medicationsOlder forms (Hemoccult II) have unacceptably low sensitivityBetter sensitivity with newer versions (Hemoccult Sensa)

  • Immunochemical Tests (FIT)Specific for human blood and for lower GI bleedingResults not influenced by foods or medicationsSome types require only 1 or 2 stool specimensHigher sensitivity than older forms of guaiac-based FOBTSlightly more costly than guaiac testsFIT use in the U.S. will likely increase due to recent elimination of guiaic- based testing by LabCorp and Quest Labs

  • High Quality Stool TestingCRC screening by FOBT should be performed with high-sensitivity FOBT either FIT or a highly sensitive gFOBT (such as Hemoccult SENSA)Older, less sensitive guiaic tests (such as Hemoccult II) should not be used for CRC screeningTests should be repeated yearlyIn-house FOBT is essentially worthless as a screening tool for CRC and should be strongly discouragedAll positive screening tests should be evaluated by colonoscopy

  • FOBT Quality IssuesGuidelines recommend that all positive FOBTs be evaluated with a colonoscopy. However:

    Follow up of abnormal test (2005)Repeat FOBT 29.7%Follow up of abnormal test (2010)Repeat FOBT 17.8%

  • Clinicians Reference

  • Using the Four Essentials

    Be clear that screening is important, but also ask/engage your patient in the decision.

    Involve clinic staff to create and implement a stronger plan using a team approach.

    A simple tracking system will help you follow up with patients as needed.

    Measure your progress to tell if you are doing as well as you think. Make adjustments.

  • Follow a continuous improvement model

  • Essential #1Determine the screening messages you and your staff will share with patients.

    Make a RecommendationEssential #1Explore how your practice will assess a patients risk status and receptivity to screening.

  • Essential #2Create a standard course of action for screenings, document it, and share it.

    Develop a Screening PolicyEssential #2Compile a list of screening resources and determine the screening capacity available in your community.

  • Essential #3Determine how your practice will notify patient and physician when screening and follow up is due.Be Persistent with RemindersEssential #3Ensure that your system tracks test results and uses reminder prompts for patients and providers.

  • Essential #4Discuss how your screening system is working during regular staff meetings, and make adjustments as needed.

    Measure Practice ProgressEssential #4Have staff conduct a screening audit, or contact a local company that can perform such a service.

  • CommunicationHow are the members of your team communicating with each other throughout your process?

    How are the members of your team communicating with other healthcare professionals? (i.e., medical specialists)

    How are your team members communicating with the patient?


  • Renville County Hospitals and ClinicsLocated in the city of Olivia, Minnesota, in Renville CountyCritical Access Hospital with three rural health clinics in: HectorRenvilleOliviaProviders include:5 family practice physicians3 physician assistants 2 nurse practitionersmultiple consultants in many different specialties

  • Improve Data EntryEnsure that data reflects services renderedAt check-in ask patient if they have had tests ordered or completed by other providersCapture data in appropriate data locationHealth Maintenance section of EHR = GoodFree text in progress note = BadEnsure that scanned reports are filed or results are entered in discrete data fieldsPerform data clean-up as appropriate

  • Improve Data Entry (cont.)Consider:Is the information available to providers and staff that will be doing future screening?Is the information available within the EHR to generate reminders?Is the information available to report on overall clinic performance and queries of patients due for screening?

  • Integrating RemindersReminders and alertsMust be timelyExamples from within EHRPop-up alertColor-coded alertExamples generated through EHR reportsPhone remindersLettersEmails

  • Integrating TrackingElectronic flow sheetsExamples: health maintenance, immunization, chronic diseaseRegistriesAllows a clinic to maintain a list of patients with a specific condition or finding

  • Reduce BarriersRedesign workflowsExample: EHR alert prompts staff rooming patient to offer information sheet on CRC screeningUse standing orders when appropriateObtain provider consensusAdopt related policies and procedures

  • Increase Patient Follow-throughDevelop scripted messages for staffLink screening to staying healthy for familyProvide educational materials with screening information and timeframes

  • Increase Staff EngagementProvide data to care teams on a regular basisRecognize teams with high and improved performanceProvide missed opportunity reportsHold periodic meetings of staff to generate ideas for process changes



  • Action Plan to help you start

  • Worksheets for Planning

  • Tools and Templates


  • Thank You!Matt Flory [email protected]

    Beverly Annis [email protected]

    Jerri Hiniker [email protected]

  • This material was prepared by Stratis Health, the Minnesota Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 10SOW-MN-C9-13-17 073013


    **************Brief reference for the group***