Clinic Quality Improvement Project
Project Aim: To provide your clinic with a picture of existing cancer screening practices and policies and to assist with sustainable infrastructure building that
ensures breast, cervical and colorectal cancer screening guidelines are being followed and your client population receives appropriate care.
 Part One (Initial Clinic Assessment) Purpose: To explore clinic screening practices related to breast, cervical, and colorectal cancer services.
Part One Process: Your clinic and the Colorado Department of Public Health and Environment [CDPHE] will work together to ensure all concerns are
addressed and needs met. Broad information about your clinic’s existing cancer screening policies and procedures, as well as your electronic health record
[EHR] system will be gathered via a phone or in person interview by an American Cancer Society [ACS] Screening Systems Specialist.
Sample of Items to be Explored:
o
o

How clients needing cancer screenings are identified
Existing clinic policies related to cancer screening services
Part Two (Second Clinic Assessment) Purpose: To survey clinic screening practices related to breast, cervical, and colorectal cancer services. Part Two will
be more in depth than Part One in order to establish priority areas for the clinic to develop a quality improvement action plan with CDPHE.
Part Two Process: Following this initial clinic assessment in Part One, the ACS Screening Systems Specialist will survey more in depth about the EHR system
used in your clinic, as well as existing cancer screening policies and procedures.
Sample of Items to be Surveyed:
o
o
Types of breast, cervical, and colorectal cancer screenings offered
Procedures for client check-in of abnormal screening results
 Part Three (Clinic Baseline Screening Measures) Process: Client-specific information needed by CDPHE, to determine your baseline cancer screening
rates, will be completed through a random sampling of client charts in the clinic’s EHR system.
 Part Four (Clinic Quality Improvement Action Plan): Based on the baseline data, policies and practices will be adjusted as needed towards providing
sustainable, high quality breast, cervical, and colorectal cancer screening services.
Potential Activities:
o
o
o
Creation of a comprehensive cancer screening policy
EHR reporting and cancer screening tracking capacity modifications
Refinement of clinic cancer screening policies
Clinic Quality Improvement Project Aim: To provide your clinic with
a picture of existing cancer screening practices and policies and to
assist with sustainable infrastructure building that ensures breast,
cervical and colorectal cancer screening guidelines are being followed
and your client population receives appropriate care.
Part One
(Initial Clinic
Assessment)
Broad
information
about your
clinic’s
existing
cancer
screening
policies and
procedures,
as well as
your
electronic
health record
[EHR]
system will
be gathered
via a phone
or in person
interview by
an American
Cancer
Society
Screening
Systems
Specialist.
Part Two
(Second Clinic
Assessment)
Project Contact:
Following
this initial
broad
interview, the
ACS
Screening
Systems
Specialist will
survey more
in depth
about the
EHR system
used in your
clinic, as well
as clinic
cancer
screening
policies and
procedures.
Part Three
(Clinic Baseline
Screening
Measures)
Clientspecific
information
needed by
CDPHE, to
determine
your baseline
cancer
screening
rates, will be
completed
through
random
sampling of
client charts
in the clinic’s
EHR system.
Kelly Means 303-692-2528 kelly.means@state.co.us
Part Four
(Clinic Quality
Improvement
Action Plan)
Based on the
baseline data,
clinic policies
and practices
will be
adjusted as
needed
towards
providing
sustainable,
high quality
colorectal,
cervical, and
breast cancer
screening
services.