Systems change: Determine clinic's area of focus
Do: Step 1
This process has four elements:
The National Colorectal Cancer Roundtable developed a useful guide to increasing colorectal cancer screening rates in a primary care practice. Although the Primary Care Clinician’s Evidence-Based Toolbox and Guide focuses on CRC, the systems change concepts presented can be applied broadly to cancer screening and chronic disease prevention. The toolbox’s checklist for increased screening includes:
Evidence has shown that a recommendation from a doctor is the most powerful single factor in a patient’s decision about whether to obtain cancer screening. This positive impact has been demonstrated for breast, cervical and colorectal cancers. A comprehensive approach to screening will ensure all appropriate patients receive a recommendation, even if they don’t come in for regular exams. For instance, if a patient comes in for a blood draw or flu shot, it’s an opportunity to check whether he or she is up to date on preventive screenings.
It’s important to remember that other providers and support staff (nurses, medical assistants, front desk) can be a crucial link in referring a patient for screening and follow-up. Standing orders can empower clinic staff to refer a patient for a cancer screening or schedule a follow-up test. For instance, team-based approaches have been shown to increase the number of patients with controlled blood pressure. To ensure a consistent recommendation occurs, the other elements — an office policy, reminder systems and effective communication — must also be part of the practice.
Office policy and work flow
An office policy lays out the clinic’s commitment to screening and prevention. It’s often useful to accompany an office policy with a work flow plan and step-by-step procedure for staff to follow. This work flow can be used as a living document that can be revisited and improved as the clinic works through process improvements.
While adhering to national standards, a clinic should develop a policy to fit its practice; there’s no “one size fits all” policy. It should consider the realities of local standards of care, insurance coverage and patient preference. A comprehensive policy should also include risk assessment for patients of differing risk levels.
The chart in the link below is a visual representation of a policy for CRC and is a good way to communicate the policy to office staff who'll implement it.
Reminder systems can be targeted toward either patients or providers. Reminders for patients include “cues to action,” such as postcards, phone calls and letters. Reminders for providers include chart prompts, which can be physical stickers or paperwork highlighting that a patient is due for a screen or built into the clinic’s electronic health record to automatically flag the provider if a screening is due.
Another highly effective way of having patients complete screenings for chronic disease is to schedule while the patient is in-office. Providers, nurses and medical assistants can use a standardized note card to communicate with the front desk about scheduling follow-ups, screenings and lab tests.
Shared decision-making can make a patient more likely to get a screening test. By exploring different options with a patient, the provider can find the test that the patient is most likely to complete.
Another strategy is stage-based communication, which can be used to give patients a “sales pitch” appropriate to their stage. Patients who have never heard of a specific screening need basic information to increase their awareness, while those who are hesitant will need to be convinced of the benefits and acceptability. For more information, refer to the Primary Care Clinician’s Toolbox.