A Quality Improvement Initiative to Increase Colorectal Cancer (CRC) Screening: Collaboration between a Primary Care Clinic and Research Team

Research Article

J Fam Med. 2017; 4(3): 1115.

A Quality Improvement Initiative to Increase Colorectal Cancer (CRC) Screening: Collaboration between a Primary Care Clinic and Research Team

Green BB1,2*, Fuller S¹, Anderson ML¹, Mahoney C¹, Mendy P² and Powell SL²

¹Kaiser Permanente Washington Health Research Institute, USA

²Kaiser Permanente Washington, USA

*Corresponding author: Beverly B. Green, Kaiser Permanente Washington Health Research Institute and Kaiser Permanente Washington, 1730 Minor Avenue, Seattle, WA 98101, USA

Received: March 07, 2017; Accepted: March 30, 2017; Published: April 05, 2017


Background: Multiple randomized controlled trials have demonstrated that mailed fecal testing programs are effective in increasing colorectal cancer screening participation. However, few healthcare organization in the US have Implemented such programs.

Methods: Stakeholders from one clinic in an integrated healthcare system in Washington State initiated collaboration with researchers with expertise in CRC screening, aiming to increase screening rates at their clinic. Age-eligible individuals who were overdue for CRC screening and had previously completed a fecal test were randomized to receive mailed fecal immunochemical test kits (FIT) at the start of the project (Early) or 6 months later (Late). Outcomes included comparing FIT completion at 6 months by randomization group, and overall CRC screening rates at 12 months. We also assessed implementation facilitators and challenges.

Results: Overall 2,421 FIT tests were mailed at a cost of $10,739. At 6 months, FIT completion was significantly higher among the Early compared to the Late group (62% vs.47%, p <0.001). By 12 months, after both groups had received mailings, 71% in each group had completed a FIT. The clinic’s overall CRC screening rate was 75.1% at baseline and 78.0% 12 months later. Key constructs associated with successful program implementation included strong stakeholder involvement, use of evidence-based strategies, simplicity, and low cost. Challenges included lack of a plan for maintaining the program.

Discussion: Collaboration between clinic stakeholders and researchers led to a successful project that rapidly increased CRC screening rates. However, institutional normalization of the program would be required to maintain it.

Keywords: Quality Improvement; Healthcare system; Colorectal cancer screening; Primary Care


Despite the potential of colorectal cancer (CRC) screening to reduce CRC mortality, CRC remains the second-leading cause of cancer deaths [1]. In 2017, an estimated 135,000 adults in the U.S. will be diagnosed with CRC, and 50,000 will die from the disease [1]. Better treatments have improved survival rates, but morbidity and mortality could be more rapidly and cost-effectively reduced by achieving higher uptake and adherence to CRC screening [2].

There are now multiple studies demonstrating that screening participation can be improved by mailing fecal tests directly to ageeligible individuals who are not current for CRC screening [3-8]. However, most health care organizations and clinics in the U.S. have not implemented mailed fecal test screening programs [3-8].

Group Health is a large, integrated health system with clinics in Washington State. One of the clinics in this system was interested in increasing its CRC screening rates. The clinic already had aboveaverage HEDIS (Healthcare Effectiveness Data and Information Set) CRC screening rate of over 74%, compared to national average HEDIS rate of 61% in 2015 [9]. However, the clinic wanted to do better, in part because one of their physicians died prematurely from CRC. Thus, two of the clinic stakeholders, a physician and clinical operations manager, contacted an expert in colorectal screening (Green) from Group Health Research Institute, who was conducting research in this area.

The group had several discussions and came up with some creative ideas to increase CRC screening, such as using videos in the waiting room, and sending out fecal test kits with a pamphlet telling the story of the physician who had died prematurely from CRC. His partner and daughter had given permission for his story to be used, in the hope that it would motivate patients to participate in CRC screening. The researchers provided input that the evidence of the effectiveness of narratives was scant, and that testing this idea would add to general knowledge but might or might not be successful in increasing screening rates. The researchers suggested an additional idea based on a sub-analysis of an ongoing trial, The Systems of Support to Increase CRC Screening and Follow-up trial (SOS, R01CA121125). In year 3 of the SOS trial, the research team re-randomized study participants who were still eligible for screening and who had received mailed fecal tests in years 1 and 2, to either Stopped or Continued mailed interventions. Compared to Stopped, Continued arm patients were significantly more likely to be screened at 12 months (net difference 16%) [10]. However, the Continued mailed intervention was only successful in the subgroup of participants who had previously responded to mailed interventions during years 1 and 2 of the parent study. The net difference in screening rates between the Continued and Stopped groups was 2%, 11%, and 27% among participants who had completed 0, 1, and 2 fecal tests in years 1 and 2 respectively. The percent of individuals completing fecal testing in the continued group was 18%, 45%, and 77%. This research suggested that mailing kits to patients overdue for screening, but who had previously completed fecal testing, might be an effective, efficient, and low cost way to increase screening rates

The clinic stakeholders and researchers discussed the evidence, examined the baseline data, made an evaluation plan, and determined the resources available to complete the project. This paper describes the collaboration between the clinic stakeholders and the researchers and the process for planning, implementation, evaluation, and maintenance of the project to increase the CRC screening rates.


The study was supported in part by the clinic and in part by a grant from the National Cancer Institute (R01CA121125). Group Health’s institutional review board reviewed the project and determined that it constituted quality improvement, meaning that full IRB review was not required, and the need for patient consent was waived.


The study was conducted was conducted from October 2015 to November 2016 at Group Health Cooperative, and within one clinic within Group Health primary care medical center in Olympia Washington that cares for about 44,000 patients. The clinic is an accredited patient centered medical home (PCMH) and usual care includes strategies at clinic visits (in-reach) and outreach to increase CRC screening uptake [11]. As part of PCMH, medical assistants use the electronic health record (EHR) and embedded reports to see if patients are overdue for recommended screening tests, immunizations, and care for chronic conditions and pre-order or provide these services, including giving out fecal immunochemical test (FIT) kits, or reminding the provider to discuss other CRC screening options if the patient is overdue. The PCMH also includes outreach outside of clinic visits. Group Health sends its members an annual birthday letter that includes information on screening, immunizations, or care that is overdue. Medical assistants also reviews EHR lists of the provider patients overdue for preventive and chronic care services and calls patients to remind and assist them in completing needed care. In Olympia, medical assistants call patients to see if they want a FIT kit mailed to them, or mail it directly without a call if there are no other care needs requiring a telephone call. Group Health laboratory facilities also distribute FIT kits to patients who are due for CRC screening when patients present to the lab for other reasons. Batch-ordering for FIT testing is in place at Group Health, meaning that the primary care provider signs one set of annual orders for patients eligible for CRC screening. When the patient sends the FIT kit to the lab, the order is already in place and is activated. In February of 2017, after the study was completed Group Health was acquired by Kaiser Permanente, and the clinic is now part of Kaiser Permanente Washington.

Planning the quality improvement project

The clinic stakeholders and research team met several times to discuss different options and examine baseline data, with the goal of increasing HEDIS rates for CRC screening at the clinic. They applied for internal funding to create a pamphlet and video based on the story of the physician who died prematurely from CRC, but were not selected for funding, with a concern being that the narrative might be relevant only to their specific clinic. The stakeholders were disappointed but not deterred, and a decision was made to pursue the researchers suggested project of mailing FIT kits to patients who were overdue for CRC screening but who had completed at least one fecal test in the past.

Project costs

Material resources, including FIT kits and pre-paid return envelopes, were provided by the clinic. Mailings were conducted by the research institute’s survey program, which had experience with mailing kits for the SOS study. Mailing costs were paid for in part by the clinic and in part by the research team, who received permission to use funding remaining from the study for this implementation project. The total cost of the mailings was $10,739, which included personnel time and costs associated with mailing the kits.


EHR and administrative data were used to identify eligible patients among all enrollees at the Olympia Medical clinic on September 30, 2015. A total of 5,520 patients were identified who were age-eligible (age 51-75) for CRC screening, had no HEDIS criteria exclusions (enrolled in the prior calendar year, no CRC, no total colectomy), and were due for screening (or would be due for screening by December 31, 2016). Of these, 3412 (61.8%) had completed a fecal test in the past (any time since health plan enrollment), and were eligible for the quality improvement initiative intervention.


The mailed intervention was adapted from the SOS study which includes up to 3 mailings. In the SOS study the first mailing includes a pamphlet on CRC screening choices based on US Preventive Services Task Force and Group Health guidelines that states that they are due for CRC screening and will soon receive a FIT kit unless they request one of the other recommended tests (colonoscopy or flexible sigmoidoscopy). The second mailing includes the FIT kit, pictographic instructions and a letter emphasizing the importance of completing screening. If the FIT kit is not received and processed by the lab within 3 weeks, a reminder letter is mailed. The intervention mailing materials are available at the National Cancer Institute Research-Tested Intervention Programs (RTIPs) web site [12].

For the quality improvement initiative, the clinic generally followed the SOS model, but decided not to send the introduction letter because of limited resources. The letter sent with the kit was signed by the medical director of the clinic.


The clinic wanted all eligible patients to receive the intervention, since the overall goal of the project was to improve clinic-wide CRC screening rates. To evaluate the success of the program, the researchers proposed that eligible patients be randomized to either Early or Late intervention groups, stratified by the numbers of fecal tests they had done prior (1 versus >1). Patients in the Early group received intervention mailings within the first few weeks after randomization (mailings were completed between Oct 23 and Nov 20, 2015), and patients in the Late group, who were still overdue for screening, received the intervention 6 months later (mailings May 2-6, 2016). The effect of the mailed kit intervention was based on screening outcomes between randomization and 6months (before the Late group received the intervention). This also provided the clinic with an opportunity to stop the program if the expected increase in FIT uptake in the Early group did not occur.


The collaboration between the clinic and researchers provided an opportunity to explore key implementation and outcome factors, which the researchers used key domains from the Consolidated Framework for Implementation Research (CFIR) and the Institute for Healthcare Improvement (IHI) “Triple Aims” to describe (Table 1) [13,14]. CFIR was developed by the Veterans Affairs Quality Enhancement Research Initiative as a framework for constructs that are associated with effective implementation of interventions or programs and takes into account contextual factors including the external environment (e.g. policies, incentives), internal setting (e.g. organization culture, priorities), individuals (e.g. champions, expertise), intervention characteristics (e.g. relative advantage, adaptability), and the process of change. The CFIR framework does not include outcomes, such as population reach, effectiveness, and costs, for which we used the IHI’s Triple Aims, improving healthcare (excellent quality and service), health (improving patients’ health outcomes and quality of life), and efficiency of care (providing efficient care and affordability).