Provider Assessment and Feedback Planning Guide

Introduction

The four Evidence-Based Intervention Planning Guides provide tips to help clinic staff, and those who provide technical assistance to them, implement evidence-based interventions to increase screening for breast, cervical, and colorectal cancer.

The goal of provider assessment and feedback is to motivate providers to increase cancer screening recommendations to patients. See the Community Guide recommendation.

Process flow

Implement and integrate provider assessment process into clinic workflow

Output: Provider assessments completed

Measure: Provider assessment reports.

Example: Number of providers assessed divided by the number of providers in the practice.

Example: Number of provider assessments conducted per year.

Implement and integrate process to provide performance feedback to providers

Motivate or incentivize providers through competition. Potential challenges include limited electronic health record system capacity and high cost of manual chart audits.

Output: Increased screening recommendations made by provider

Measure: Provider feedback sessions.

Example: Number of providers receiving feedback divided by the number of providers in the practice.

Example: Number of provider feedback reports distributed per year.

Provider recommends patient for cancer screening, consistent with guidelines and recommendations

Potential challenges include the provider forgetting acreening reminders without prompts and time constraints during visit.

Outcome: Increased screening recommendations made by provider

Measure: Screening recommendations, referrals, and orders.

Example: Number of patients given a recommendation by a provider divided by the number of patients due for screening with appointments.

Example: Number of patients with a screening test ordered divided by the number of patients due for screening with appointments.

Patients complete cancer screening

Outcome: Increased screening and diagnostic tests completed by patients

Measure: Screening completion.

Example: Number of patients completing screening divided by the number of patients referred for screening.

Example: Number of patients completing diagnostic follow-up divided by the number of patients with positive screening tests.

Increased cancer screening

Outcome: Increased clinic-level rates of cancer screening

Measure: Age-eligible clinic population up-to-date with recommended cancer screening.

Example: Uniform Data System (UDS), Healthcare Effectiveness Data and Information Set (HEDIS), National Quality Forum (NQF) 12-month measure used to calculate screening rate.

Components of the intervention

Evaluate provider performance in delivering or recommending screening to patients

• Can patients due for screening be identified? How will the appropriate data on how the providers performed be obtained?
• Have metrics to evaluate been selected (such as percentage of patients who are up to date with screening, by provider; percentage of patients receiving a provider recommendation for testing)?
• Have the methods to calculate metrics, identify data sources, and ensure data quality been determined?
• Can the metrics be tested to assess their accuracy and utility?

Develop a mechanism to provide feedback

• What format will be used (report or dashboard)?
• How often will feedback be delivered to providers?
• Are the data easily interpreted? Which metrics resonate with the providers? (a proportion? actual numbers of patients?) How can data be presented (a table, using data visualization methods)?

Present providers with the results of the assessment

• How will results be delivered to providers? Will results be presented to providers individually or in a group setting?
• Will results describe the performance of individual providers or a group of providers (such as the average performance for a practice)?
• Which staff members will be allowed to see these data?
• Is the process for delivering feedback acceptable to providers and other staff?
• Has the person best suited to present the feedback reports been selected?

Track outputs and outcomes

• Is there a way to track whether the provider recommended or ordered a screening test?
• Is there a way to track patients through screening and diagnostic test completion?
• Have methods and tools for tracking been identified or created?
• Have appropriate and feasible performance measures been selected to monitor potential improvement over time?

Resources to support implementation

Partnerships

• Internal: Across and within clinics, with departments such as billing, claims, radiology, and information technology.
• External: Patient registries and laboratories.

Staff

• Quality improvement (QI) or other staff to define metrics for assessment and determine how they will be calculated.
• Staff to conduct the assessment and develop the feedback (reports or dashboards).
• QI or other staff to deliver feedback to providers.
• Providers that recommend or administer screening tests to patients.

Training or orientation

• For staff on how to conduct assessments and prepare feedback.
• For providers being assessed on screening guidelines or recommendations and metrics used in feedback reports.
• Designate a point of contact for ongoing implementation support and for providers who have questions about the assessment, metrics in the feedback reports, or their past performance.

Tools

• Electronic health records (EHRs), if the practice has a system that can be used for this type of assessment.
• Reference aids for staff, such as data collection forms, a codebook for analyzing narrative data in health records, quality assurance forms, and practice guidelines and recommendations.

Lessons learned from the literature¹

• The infrastructure for provider assessment and feedback may already exist for other uses. Before beginning, find out if it is possible to add cancer screening to an existing system.
• The term "provider" referred only to physicians in the included studies, but this intervention may work for other types of providers, such as physician assistants or nurse practitioners.
• Chart audits of EHRs or other automated methods reduced intervention costs by 90% compared to manual record review in one study.
• The intensity and complexity of this implementation were low unless the system involved multiple departments or organizational partners, or feedback was delivered in frequent face-to-face meetings.
• The intervention was replicated more easily when feedback was delivered by academic faculty to residents. Assessment was seen as part of the academic role.
• Some sensitivity was evident when physicians received feedback from their peers in different specialty areas.
• There was a decline in effect over time if the intervention was not maintained.

Ways to strengthen performance or sustainability

• Integrate performance targets for cancer screening into training requirements or general workplace policies.
• Get buy-in from clinic staff on the frequency of assessing performance and providing feedback, target setting, and the format for providing feedback.
• Consider comparing the performance of individual providers within a practice or among practices, or comparing the average performance of practices to one another, to encourage "friendly competition" among peers.
• Deliver feedback more than once and at regular intervals, such as monthly or during daily huddles.

Community Guide recommendation

The Community Preventive Services Task Force recommends provider assessment and feedback interventions to increase screening for breast, cervical, and colorectal cancer.²

Settings where the intervention was studied¹

• Rural, urban, and suburban areas in the United States and the United Kingdom.
• University-affiliated hospitals, primary care clinics, and Veterans Administration hospitals.

Outcome from the systematic review of effectiveness¹

Completed screenings increased by a median of 13 percentage points for all breast, cervical, and colorectal cancer tests.

References

¹Sabatino SA, Lawrence B, Elder R, et al. Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for The Guide to Community Preventive Services. Am J Prev Med. 2012;43(1):97–118.

²Community Preventive Services Task Force. Updated recommendations for client- and provider-oriented interventions to increase breast, cervical, and colorectal cancer screening. Am J Prev Med. 2012;43(1):92–96.