The mission of Northland Health Centers (NCHC), an organization of Federally Qualified Health Centers (FQHCs) in North Dakota, is “to strengthen the health status in the communities we serve.” When NCHC was invited to participate in a region-wide project to improve colorectal cancer screening rates (CRC) in their patient population, they accepted the opportunity in response to that mission.

This work stemmed from a project conducted by the Great Plains Quality Innovation Network (QIN) as part of a Special Innovation Project to improve CRC screening rates in the QIN’s four-state region. Great Plains QIN staff were on hand to assist NCHC in reviewing their current screening rates, setting screening goals and implementing process changes to meet those goals.

NCHC’s clinics in the North Dakota communities of Turtle Lake, McClusky, Rolette, Rolla, Ray, Bowbells and Minot began by reviewing the four essentials of the American Cancer Society’s “Primary Care Clinician’s Evidence-Based Toolbox and Guide.” Great Plains QIN staff held regular coaching calls with staff at each site to discuss the implementation of each essential.

“The help we received from Great Plains QIN and the ND Department of Health really gave us the jump start we needed to get the project moving. The one-on-one meetings with each clinic helped bring awareness to CRC screening opportunities and provided our staff with tools and ideas for implementation.” commented Julie Wagner, NCHC Performance Improvement Coordinator. “These two agencies working in tandem, in addition to the grant we received through the ND Department of Health, strengthened our focus on CRC screenings.”

Each clinic was given an opportunity to review their screening rates and set a screening goal based on their 1st quarter 2017 rate. With their screening goals set, NCHC staff began dissecting what process changes needed to be implemented to meet that goal. Staff immediately identified that a team approach was necessary to affect change in workflow to assure that documentation was recorded correctly in the EHR, patient tracking and follow- up was completed and pre-visit preps were being done consistently.

The pre-visit preps provided an additional positive result. “We started pre-visit preps based on the push to improve our CRC screening rates, but we began to see how helpful it could be for all population health measures like mammograms, pap smears, immunizations, diabetes lab work and INRs, and I think we will find that we improved in all these measures as a result of this work”, Renee Miller, Turtle Lake Clinic.

The improvement strategies adopted by NCHC’s staff contributed to every clinic improving their screening rate with two of the clinics exceeding their screening goal. Overall, NCHC showed a relative improvement rate of 14 percent.  When asked what changes contributed to the improvement, Linda Haggerty, LPN, at the Rolette Clinic stated, “We came to a point where we recognized that we had to ‘just do it’—from all the work of the order to entries into the EHR to tracking the information. Instead of saying, ‘it won’t work in our system,’ change the system to do what you need to accomplish your goal. Make it a habit!” Haggerty went on to share, “Persistence pays off so don’t give up! Sometimes people just need to know how much you care.”

The success did not come without challenges. Early on, creating consistency in how information was recorded, in the EHR within and across clinics, took a lot of focused effort especially when there was staff turnover. Several strategies were used to bring consistency to the process including staff training, step-by-step procedures in the EHR, reinforcing consistency at weekly staff meetings, daily huddles and Skype meetings with individuals when additional training was needed.

“The process changes we have made across our clinic system are key to helping us sustain our improvement and will help push us forward,” said Jennifer Saueressig, Nurse Supervisor for Northland and Registered Nurse, McClusky Clinic. “Seeing progress has been a motivating factor to keep our staff engaged. They have experienced firsthand how simple changes can make a huge difference.” Saueressig stated she is certain sustainment will be driven by continuing to focus on consistency in processes, utilizing the previsit preps to ensure all patients receive the necessary screening tests, and reviewing screening rates frequently to avoid backsliding.

NCHC’s staff is committed to continuing the journey to make their contribution toward the national goal of 80 percent by 2018. New challenges lie ahead, including the implementation of a new EHR throughout the clinic system, but with effective process changes embedded in daily patient encounters, the future looks promising for stretching to meet the screening goals established by each clinic at the beginning of the project.