0920-20PX Colo-rectal Cancer Control Program Survey

Form Approved

OMB No. 0920-0879

Expiration Date 01/31/2021

Background

Your clinic is working closely with the state or tribal health department or their partners on a special program focused on practice improvements to increase colorectal cancer (CRC) screening rates for your patients age 50-75. This program is called the Colorectal Cancer Control Program (CRCCP) and is supported by the Centers for Disease Control and Prevention (CDC). We will refer to CRCCP as “the CRC screening initiative” throughout this survey. Here, we refer to “clinic” to mean one entity within a larger health system. We refer to “health system” as an organization that may include clinics, hospitals, and leadership that are connected through common ownership or joint management.

Evidence-based CRC screening practice improvements

The CRC screening initiative is focused on improving CRC screening rates by implementing one or more of the priority evidence-based interventions listed in The Community Guide for Preventive Services that include the practice improvements listed below:

• Provider reminders: Reminding providers to refer their patients for CRC screening

• Client/patient reminders: Reminding patients that they are due or overdue for CRC screening

• Provider assessment and feedback: Providing assessment and feedback reports for providers on their performance related to screening patients for CRC

• Reducing structural barriers: Diminishing non-economic burdens or obstacles that make it difficult for people to access CRC (e.g., sending patients a fecal screening test via mail so they don’t have to come into the clinic, providing language interpreters, modifying clinic hours to meet patient needs)

Throughout this survey, we will refer to the above activities as CRC screening practice improvements. Clinics may also engage in quality improvement processes to support their efforts to start or improve the CRC screening practice improvements they select. Quality improvement processes are systematic, continuous actions that lead to measurable improvement in services and patient health.

What is the purpose of the survey?

CDC is conducting this survey in collaboration with the University of Washington to learn more about how clinics have implemented these CRC screening practice improvements to increase CRC screening. You have been invited to respond to this survey on behalf of this clinic, as you have been identified as the person most knowledgeable about your clinic’s efforts to increase CRC screening. If there are items where you would like to check with other staff in your clinic for the best response, please do so.

How will these data be used?

CDC will use the survey data to learn more about how the CRC screening initiative is working in clinics, and to identify and share promising practices that will help improve the CRC screening initiative going forward. Respondents and clinics will not be identified in any publications or reports about the survey; data will be presented in aggregate. These data will also be linked to clinic data collected as part of other CRCCP activities.

I am ready to proceed to the survey. ☐

I am not the correct person at this clinic to take this survey, but I have the name and contact information of the person who is. ☐

[new screen] Please write the name and email address of the person at your clinic who would be able to complete this survey here.

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 Email address of person to complete survey: Click or tap here to enter text.

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SECTION 1. RESPONDENT ROLE

1. What is your role at this clinic? Check all that apply.

☐ CRC screening champion

☐ QI specialist/manager

☐ Physician

☐ Physician Assistant

☐ Nurse or nurse practitioner

☐ Patient navigator or Community Health Worker (CHW)

☐ Medical Assistant

☐ Referral specialist

☐ Administrator (e.g., CEO, Director)

☐ Administrative staff

☐ Other, please specify: Click or tap here to enter text.

SECTION 2: POLICY, LEADERSHIP, AND QUALITY IMPROVEMENT

2. Does your clinic have a written CRC screening policy or protocol in use?

☐ Yes; please complete question 2a below.

☐ No; continue to question 3.

☐ Don’t know; continue to question 3.

2a. A CRC screening policy, which may also be referred to as standard operating procedures (SOPs), may include the components below. Check the components that are part of your clinic’s CRC screening policy. Check all that apply:

☐ A defined set of guidelines and procedures in place and in use at the clinic or parent health system to support CRC screening

☐ A team responsible for implementing the policy

☐ A quality assurance structure that supports CRC screening (e.g., professional screening guideline followed, process to assess patient screening history/risk/preference/insurance, process for scheduling screening or referral, procedures to implement the office policy)

☐ None of these

☐ Don’t know [note for programmer: for this and all don’t know questions, participants will be excluded from selecting anything else in the field.]

2. Is there currently a champion for CRC screening internal to this clinic or to your health system? A champion is an individual who dedicates some or all of their time to supporting, marketing or encouraging, and driving practices that promote CRC screening, overcoming organizational indifference or resistance to improve CRC screening.

☐ Yes; please complete questions 3a-3e below.

☐ No; continue to question 4.

☐ Don’t know; continue to question 4.

3a. The champion(s) is/are: Check all that apply.

☐ health system-wide, including my clinic

☐ specific to my clinic only

3a (1) If yes to health-system-wide: How many health system-wide champions exist?

Enter # Click or tap here to enter text.

☐ Check if this number is an estimate

3a (2) If yes to specific to my clinic: How many champions exist at this clinic?

Enter # Click or tap here to enter text.

☐ Check if this number is an estimate

3b. What is the champion’s role in your clinic? Check all that apply.

☐ QI specialist/manager

☐ Physician

☐ Physician Assistant

☐ Nurse or nurse practitioner

☐ Nurse manager

☐ Patient navigator or Community Health Worker (CHW)

☐ Medical Assistant

☐ Referral specialist

☐ Administrator (e.g., CEO, Director)

☐ Administrative staff

☐ Other, please specify: Click or tap here to enter text.

☐ Don’t know

3c. The champion(s) was/were: Check all that apply.

☐ Selected or assigned to be the champion

☐ Emerged naturally and took on the role

☐ Don’t know

3d. The champion(s):

☐ Receive(s) training and/or technical assistance to support their role as a champion

☐ Does/Do not receive training and/or technical assistance

☐ Don’t know

3e. How many times has there been turnover among your champion(s) during the time your clinic has participated in the CRC screening initiative?

☐ Never

☐ Once

☐ 2-3 times

☐ More than 3 times

☐ Don’t know

Topic 1: Clinic Resources to Improve CRC Screening

In this section, questions will address general efforts and resources available to improve CRC screening and implement evidence-based CRC screening practice improvements supported by the CRC screening initiative. These practice improvements include:

• Provider reminders: Reminding providers to refer their patients for CRC screening

• Client/patient reminders: Reminding patients that they are due or overdue for CRC screening

• Provider assessment and feedback: Providing assessment and feedback reports for providers on their performance related to screening patients for CRC

• Reducing structural barriers: Diminishing non-economic burdens or obstacles that make it difficult for people to access CRC (e.g., sending patients a fecal screening test via mail so they don’t have to come into the clinic, providing language interpreters, modifying clinic hours to meet patient needs)

Unless otherwise noted, please answer these questions using the timeframe of the last 18 months.

2. Has your clinic/health center received any incentives (including financial reimbursements) that have come from sources other than CDC (e.g., from HRSA) for scoring well on CRC screening quality measurements (e.g., CRC screening rate)?

☐ Yes

☐ No

☐ Don’t know

2. Please rate your level of agreement with the following statements from 1 (strongly disagree) to 5 (strongly agree).

In the items below, “clinic staff” refers to any providers and staff (front and back-office) in your clinic who are engaged in CRC screening practice delivery and improvements.

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
Clinic staff are expected to help increase CRC screening rates.	☐1	☐2	☐3	☐4	☐5
Clinic staff get the support they need to implement CRC screening practice improvements. This support may include staff training, technical assistance, incentives, workflow/workload changes (e.g., “Five whys,” infinity diagrams, Plan-Do-Study-Act (PDSA) cycles, root cause analysis, process maps).	☐1	☐2	☐3	☐4	☐5
Clinic staff receive recognition for implementing CRC screening practice improvements	☐1	☐2	☐3	☐4	☐5
The clinic leadership has made increasing the clinic’s CRC screening rate a top priority.	☐1	☐2	☐3	☐4	☐5

2. Please rate your level of agreement with the following statements from 1 (strongly disagree) to 5 (strongly agree).

The following are available to make CRC screening practice improvements work in our clinic:

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
Equipment and materials (e.g., physical space, training materials, electronic health record (EHR) system prompts or tracking)	☐1	☐2	☐3	☐4	☐5
Financial and/or staff resources (e.g., staff time)	☐1	☐2	☐3	☐4	☐5
Patient education about the importance of CRC screening (e.g., one-on-one/group education, videos, print materials)	☐1	☐2	☐3	☐4	☐5
Providers support CRC screening initiative	☐1	☐2	☐3	☐4	☐5
A designated team to implement the CRC screening initiative	☐1	☐2	☐3	☐4	☐5
Support from external partners (e.g., health department, university, American Cancer Society, Primary Care Associations)	☐1	☐2	☐3	☐4	☐5
Leadership support	☐1	☐2	☐3	☐4	☐5

2. Please rate your level of agreement with the following statements from 1 (strongly disagree) to 5 (strongly agree). In general, when there is agreement among clinic staff that change needs to happen in the clinic, we have the necessary support in terms of:

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
Budget or financial resources	☐1	☐2	☐3	☐4	☐5
Training	☐1	☐2	☐3	☐4	☐5
Staffing	☐1	☐2	☐3	☐4	☐5
Leadership support	☐1	☐2	☐3	☐4	☐5

Topic 2: CRC Screening Practice Improvement Implementation and Support

The next questions are about the CRC screening practice improvements your clinic is currently implementing.

2. Please indicate which of the following CRC practice improvements your clinic is currently implementing. Check all that apply.

8a. ☐ Provider reminders. Reminding providers to screen or refer their eligible patients for CRC screening; Please complete question 8a below.

8a.1. In what ways have providers at this clinic typically received reminders for a single average patient due or overdue for CRC screening? Check all that apply.

☐ EHR pop-up message

☐ Flagged patient chart

☐ Flagged patient room

☐ Daily or weekly patient lists generated indicating patients due for screening

☐ Other, please specify: Click or tap here to enter text.

8b. ☐ Client/Patient reminders. Reminding patients that they are due or overdue for CRC screening (e.g., FIT/FOBT, screening colonoscopy) Do not answer about how you remind patients that have received a positive FIT/FOBT about their follow-up colonoscopy.; Please complete questions 8b and 8c below.

8b.1. In what ways has a single average patient due or overdue for screening received CRC screening reminders? Check all that apply.

☐ By mail (letter/postcard)

☐ By text message

☐ By email

☐ By online portal notification

☐ By telephone call

☐ In person/at appointment

☐ Other, please specify: Click or tap here to enter text.

8b.2. When a patient is due or overdue for screening, up to how many reminders to complete CRC screening could they receive? This includes any follow-up reminders if a patient does not respond to the first reminder. For example, if a patient receives two phone calls and a text message, you would answer “3”.

☐1 ☐2 ☐3 ☐4 ☐5 or more

8c. ☐ Provider assessment and feedback. Creating reports for providers on their performance related to screening patients for CRC; please complete questions 8d-f below.

8c.1. Please indicate, on average, how often providers, either individually or as a group, are given feedback on their performance providing CRC screening services.

☐ Weekly ☐ Monthly ☐ Quarterly ☐ Annually

8c.2. Are performance reports de-identified (i.e., names are removed from reports)?

☐ Yes; reports are deidentified.

☐ No; reports identify providers by name.

☐ Don’t know

8c.3. To what is provider performance compared?

☐ To average performance across clinics in the health system

☐ To average performance across all clinic providers

☐ To each individual provider in the clinic

☐ To an individual provider’s own performance in a previous review(s)

☐ To comparative benchmarks and/or goals

☐ There is no comparator used for provider performance

☐ Other, please describe: Click or tap here to enter text.

8d. ☐ Reducing structural barriers that prevent patients from getting CRC screening

(e.g., sending patients a fecal screening test via mail so they don’t have to come

into the clinic); please complete question 8g below.

8d.1. What strategies has this clinic used to reduce structural barriers to facilitate CRC screening? These strategies may have been in place before the CRC screening initiative started at your clinic or they may have been implemented as part of the initiative. Check all that apply.

☐ Expanded clinic hours

☐ Mailed fecal screening test (FIT, FOBT, or FIT-DNA/Cologuard) to patients

☐ Provided pre-paid mail back materials to send completed tests back to clinic/laboratory

☐ Offered weekend clinic hours

☐ Set up alternative screening sites

☐ Provided patients with transportation to/from clinic and/or endoscopic center, including providing vouchers or payments for transportation

☐ Provided onsite translation or language interpreter

☐ Developed methods (e.g., section in EHR) to track patient barriers

☐ Offered patient navigation

☐ Provided or connected patients to childcare

☐ Provided patients with assistance in scheduling appointments for endoscopic screening (e.g., colonoscopy)

☐ Offered fecal screening in conjunction with other visit (e.g., flu shot)

☐ Other, please specify: Click or tap here to enter text.

2. Does your health system and/or clinic currently operate a mailed FIT/FOBT kit program where CRC screening tests are mailed to patients?

☐ Yes; please complete question 9a below

☐ No; continue to question 10.

☐ Don’t know; continue to question 10.

9a. Mailed FIT/FOBT kits are managed

☐ Centrally by the health care system

☐ By this clinic

9b. Monitoring FIT/FOBT return rates is a way to assess how well your clinic is doing to increase CRC screening. To calculate a return rate, both the distribution and return of FIT/FOBT kits must be tracked. Does your clinic or health system track the FIT/FOBT kit distribution and return? This includes kits that are distributed to patients either at point-of-care (e.g., in the clinic) and/or by mail.

☐ Yes, this clinic tracks both the number of FIT/FOBT kits distributed, and the

number of FIT/FOBT kits returned

☐ No, this clinic tracks neither FIT/FOBT distribution nor return

☐ This clinic tracks FIT/FOBT distribution, but does not track return

☐ This clinic tracks FIT/FOBT return, but does not track distribution

☐ Don’t know

2. Does your clinic actively conduct outreach to recruit new patients?

☐Yes

☐ No

☐ Don’t know

2. Indicate the frequency with which each type of support from an outside agency or organization was provided to your clinic to implement any of the CRC screening practice improvement(s) indicated above.

	Never	Once	2-3 times	4 or more times
Support conducting clinic workflow assessment (e.g., “Five whys,” infinity diagrams, PDSA cycles, root cause analysis, process maps)	☐1	☐2	☐3	☐4
Technical assistance on developing practice improvement tools or materials (e.g., developing patient reminder systems)	☐1	☐2	☐3	☐4
Assistance improving your EHR system to better capture CRC screening rates	☐1	☐2	☐3	☐4
Assistance integrating practice improvements into your EHR system
Technical assistance on developing a CRC screening policy.	☐1	☐2	☐3	☐4
Assistance identifying and/or training a clinic champion.	☐1	☐2	☐3	☐4
Assistance educating clinic staff about strategies to increase CRC screening	☐1	☐2	☐3	☐4
Assistance identifying resources for follow-up colonoscopies for patients with positive FIT tests	☐1	☐2	☐3	☐4

2. Do you have access to:

	Yes, at my clinic	Yes, through my health system	Yes, through another organization or partner	No	Don’t know
Person(s) that specialize in Health information technology (IT) support	☐1	☐2	☐3	☐4	☐5
Person(s) that specialize in quality improvement	☐1	☐2	☐3	☐4	☐5

Topic 3: Sustainability of CRC Screening Practice Improvements

2. The following questions aim to assess sustainability planning, or formal processes in which health systems and clinics are engaged to sustain CRC screening practice improvements. Think about sustaining the CRC screening practice improvements after support from the CRC screening initiative ends. On a scale of 1 (not at all) to 5 (to a very great extent) please indicate the extent to which you think your clinic has each of the following in place:

	Not at all	To a small extent	To a moderate extent	To a great extent	To a very great extent
Leadership Support: Internal and external environments that support your practice improvements (e.g., champions advocate for the program and garner resources; program has support both within and outside the health care system)	☐1	☐2	☐3	☐4	☐5
Funding Stability: A consistent financial base for your practice improvements	☐1	☐2	☐3	☐4	☐5
Organizational Capacity: Necessary support and buy-in from clinic staff to effectively manage your practice improvements and their activities (e.g., having CRC screening champion, functioning EHR, standing orders for CRC screening, workflows that integrate CRC screening practice improvements)	☐1	☐2	☐3	☐4	☐5
Program Adaptation: Ability to take actions that adapt your practice improvements to ensure its ongoing effectiveness	☐1	☐2	☐3	☐4	☐5

Topic 4: Integration

2. Please rate your level of agreement with the following question from 1 (strongly disagree) to 5 (strongly agree).

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
Using CRC screening practice improvements is compatible with current activities/practices that increase use of preventive services in the clinic.	☐1	☐2	☐3	☐4	☐5

2. Are the clinic’s CRC screening practice improvement efforts integrated with other efforts to improve screening or patient care for other conditions (e.g., offering annual flu vaccines and FOBT/FITs at the same time; bundling provider reminders for breast, cervical, CRC, and other types of screening)?

☐ Yes; please complete question 16a.

☐ No; continue to question 17.

☐ Don’t know; continue to question 17.

15a. Are the CRC screening practice improvements integrated with any of the following? Check all that apply.

☐ Other cancer (e.g., breast, cervical) screening

☐ Other conditions (e.g., flu vaccines, diabetes control)

Topic 5: Spill-over effects and unintended consequences of the CRC screening initiative

2. Has the clinic benefitted from participating in the CRC screening initiative to increase CRC screening in any of the following ways? Check all that apply.

☐ The quality of the EHR data has improved, overall.

☐ The clinic improved use of EHR data for other conditions.

☐ The clinic is applying QI systems we developed for CRC screening to other conditions/initiatives.

☐ The clinic received training that we are applying to other initiatives.

☐ The clinic is implementing practice improvements for other conditions (e.g., reminding patients they are due or overdue for a diabetes check).

☐ Other, please describe: Click or tap here to enter text.

2. To the best of your knowledge, are all clinics in this health system participating in the CRC screening initiative?

☐ N/A; there is only one clinic in this health system.

☐ Yes; all clinics in this health system are participating in the CRC screening initiative.

☐ No; only some (or one) clinic(s) in this health system are (is) participating in the CRC screening initiative.

☐ I don’t know if other clinics in the health system are participating in the CRC screening initiative.

2. Did the clinic experience any negative, unintended consequences of participating in the CRC screening initiative? Check all that apply.

☐ Other clinic priorities are neglected

☐ The accuracy of screening reporting/data entry in the EHR was improved, and we observed a decrease in screening rates due to poor measurement in the past.

☐ Some patients screened with positive FIT/FOBT results did not have resources to get a colonoscopy to finish the screening cycle.

☐ Other, please describe: Click or tap here to enter text.

Topic 6: Health Information Technology

The following questions ask about Health Information Technology (HIT). HIT refers to the electronic systems health care professionals and patients use to store, share, and analyze health information. These can include but are not limited to electronic health records (EHR), electronic prescribing, and patient/provider communication via an online portal.

2. Have you used HIT to improve the collection, accuracy, and validity of CRC screening data? This could involve standardizing data definitions used to document a patient’s colorectal cancer screening, entering colonoscopy screening reports into EHR, improvements to EHR, training staff on properly entering CRC screening test data in EHR, etc.

☐ Yes

☐ No

☐ Don’t know

2. Which of the following CRC screening practice improvements are both integrated into your electronic health system and used? Check all that apply.

☐ Provider reminders (e.g., EHR automatically generates reminders for providers to refer patients who are due or overdue for screening)

☐ Client/Patient reminders (e.g., EHR automatically generates reminders for patients)

☐ Provider assessment and feedback (e.g., EHR produces reports on providers’ performance screening patients for CRC)

☐ Recording patient barriers (e.g., maintaining notes about circumstances of patients that require various types of accommodation offered by the clinic)

☐ Addressing structural barriers. EHR tracks mailed or point-of-care FIT/FOBT kit distribution and return

☐ None of these CRC screening practice improvements are integrated into our EHR.

☐ Other, please describe: Click or tap here to enter text.

2. Please indicate which of the following ways your clinic has used HIT.

	Yes	No	Don’t know
Monitoring CRC screening rates	☐	☐	☐
Tracking results of FIT/FOBT and following up with patients with abnormal results	☐	☐	☐
Ensuring people with abnormal/positive screening tests are referred for colonoscopy	☐	☐	☐
Tracking distribution and return of FIT/FOBT kits	☐	☐	☐
Tracking results of colonoscopies/follow-up colonoscopies	☐	☐	☐
Other, please describe: Click or tap here to enter text.	☐	☐	☐

2. How do you validate accuracy of your EHR-reported CRC screening rate? Check all that apply.

☐ Chart review

☐ Compare against other reports

☐ We do not regularly address accuracy of EHR-reported CRC screening rates [note for programmer: if this option is selected, no other responses should be selected.]

☐ Don’t know

☐ Other, please specify: Click or tap here to enter text.

2. Does your clinic or health system verify whether patients referred for colonoscopy complete the procedure?

☐ Yes; please complete question 23a below.

☐ No; End of survey

☐ Don’t know; End of survey

23a. Colonoscopy completion is verified: Check all that apply.

☐ By the patient

☐ Through the EHR

☐ Based on receipt of the endoscopy report

☐ Based on communication (other than receipt of endoscopy report) with the

endoscopy office (e.g., phone call)

☐ By another means (please describe): Click or tap here to enter text.

2. You have reached the end of the survey. Is there any additional information you would like to share about your clinic’s participation in the CRC screening initiative?

Thank you for taking time to complete this survey. Your contributions will improve our understanding of how the CRC screening initiative is working at the clinic level. The data you shared will enable us to identify and share promising practices that will help improve the CRC screening initiative going forward. If you have questions, please contact Sarah Hohl ([email protected]) or Peggy Hannon ([email protected]).

CDC estimates the average public reporting burden for this collection of information as 20 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).