The Impact of an Evidence-Based Multi-component Intervention on Colorectal Cancer Screening in Primary Care at a Healthcare System

Practice Problem: Colorectal cancer is the second leading cause of cancer death in the United States; many of the deaths are preventable with early detection. Adherence rates for colorectal cancer screening with fecal immunochemical test kits (FIT) was below the national benchmark at this facility. PICOT: The PICOT question that guided this project was: Among veterans 50 – 75 years old requiring average risk colorectal cancer screening (CRCS) seen in primary care at a veterans affairs healthcare system facility (P), how does the use of a multi-component intervention (I), compared to the usual care (C), affect the number of patients completing CRCS (O) over a period of 12 weeks (T)? Evidence: Review of high-quality studies suggested a multi-component approach, including increasing provider awareness and increasing patient education and outreach, as the most effective approach to increase colorectal screening compliance. Intervention: The multi-component intervention included a standardized CRCS nurse navigation process through standard work which included the teach-back method, patient outreach, and provider feedback. Outcome: There were clinically significant improvements in adherence with returned FIT kits, follow up for abnormal FIT kits, and statistically significant improvements with nursing documentation of patient teaching. The number of patients overdue for CRCS decreased. Conclusion: The multi-component CRCS screening intervention demonstrated significant improvements in the intervention clinics which is consistent with the body of evidence. COLORECTAL CANCER SCREENING IN PRIMARY CARE 3 The Impact of an Evidence-Based Multi-component Intervention on Colorectal Cancer Screening in Primary Care at a Healthcare System “Dying from embarrassment” may be more than a saying when it comes to colorectal cancer. Colorectal cancer (CRC) is the second most common cause of cancer deaths in the United States (American Cancer Society [ACS], 2020; Centers for Disease Control and Prevention [CDC], 2020). However, the five-year survival rate can be as high as 90% when CRC is detected in its early stage (Agency for Healthcare Research and Quality [AHRQ], 2018; ACS, 2020; CDC, 2020). A critical component in early detection is colorectal cancer screening (CRCS) for adults between the ages of 50 and 75 (AHRQ, 2018; ACS, 2020; CDC, 2020). Despite improvements in access to CRCS, other barriers, such as lack of education, fear, and embarrassment (Reynolds et al., 2018), still pose obstacles in reaching higher screening rates. These barriers contribute to premature deaths that could have been prevented by a simple CRCS (Adams et al., 2018; Brouwers et al., 2011b, 2011a; Dolan et al., 2004). The National Center for Health Promotion and Disease Prevention provides guidance for a comprehensive CRC prevention and screening program (U.S. Department of Veterans Affairs [USDVA], 2020a). At the project site, a Veterans Affairs (VA) healthcare system, the CRCS rate from a 2020 random audit (75.6%) was below the national benchmark of 80% (National Colorectal Cancer Roundtable [NCCRT], 2021; Office of Disease Prevention and Health Promotion [ODPHP], 2020a; U.S. Department of Veterans Affairs [USDVA], 2020c). Mitigating missed opportunities to prevent avoidable deaths by increasing CRCS aligned with the VA’s high reliability organization (HRO) journey (AHRQ, 2019; Grabowski & Roberts, 1997). Significance of the Practice Problem COLORECTAL CANCER SCREENING IN PRIMARY CARE 4 Estimates of deaths due to CRC are over 50,000 per year in the United States (Siegel et al., 2018, p. 8). Tragically, many of these deaths could have been prevented with early screenings (CDC, 2020; National Committee for Quality Assurance, 2020; Redaelli et al., 2003; Wilkins et al., 2018; Wolf et al., 2018). Because CRC does not produce symptoms until the more advanced stages, screening before symptoms appear is crucial for early detection (Wilkins et al., 2018; Wolf et al., 2018). In addition to the societal impact of morbidity and untimely deaths caused by CRC, CRC's economic burden is significant (Dieguez et al., 2017; Yabroff et al., 2008, 2011). Yabroff et al. (2011) estimated CRC costs $14.1 billion per year in the United States. Due to its relatively long disease course, CRC has one of the highest economic cancer burdens (Yabroff et al., 2008). Costs include frequent surveillance procedures, surgeries, chemotherapy, radiation therapy, and inpatient comfort care (Redaelli et al., 2003). In addition to healthcare costs, CRC causes an economic burden due to lost productivity by the patient (Bradley et al., 2011; Pearce et al., 2016). Bradley et al. (2011) projected that lost productivity caused by CRC would be $4.2 billion in 2020 (p.5). Most CRCs begin as slow-growing, pre-cancerous polyps (Tobi, 1999). The identification and treatment of pre-cancerous polyps while the lesions are in a localized stage significantly increase survival chances (ACS, 2020; Siegel et al., 2018). Two methods for CRC screenings include stool-based tests and visual examination (Levin et al., 2008; Wilkins et al., 2018; Wolf et al., 2018). The colonoscopy is the most common visual examination CRCS procedure (Levin et al., 2008; Wilkins et al., 2018; Wolf et al., 2018). An example of a common stool-based test is the fecal immunochemical test or FIT (Levin et al., 2008; Wilkins et al., 2018; Wolf et al., 2018) . Data from 2018 shows that 25% of U.S. adults did not get screened for CRC (CDC, 2021). COLORECTAL CANCER SCREENING IN PRIMARY CARE 5 Reducing the prevalence, morbidity, and mortality caused by cancer is one of the leading health indicators of Healthy People 2020 and Healthy People 2030 (ODPHP, 2020a, 2020b). The goal of both Healthy People 2020 and 2030 is to improve wellness by prioritizing the prevention of health threats on the U.S. population (ODPHP, 2020a, 2020b). To reduce the health threat of CRC, prevention must address cultural disparities and stigma associated with the disease (Goldman et al., 2009; NCCRT, 2021). Health Literacy and Colorectal Cancer A relationship exists between a low health literacy rate and adherence to CRCS recommendations (Arnold et al., 2012; Dolan et al., 2004). The veteran population at this facility may have a higher percentage of low health literacy levels than the general U.S. adult population (Nouri et al., 2019; Rodríguez et al., 2013). This organization’s primary mission is to honor its customers by providing “exceptional health care that improves their health and well-being” (USDVA, 2019, "VHA Mission," para. 6). Therefore, healthcare providers working at the facility had professional and organizational obligations to maximize efforts for improving CRCS rates among veterans.

Estimates of deaths due to CRC are over 50,000 per year in the United States (Siegel et al., 2018, p. 8). Tragically, many of these deaths could have been prevented with early screenings (CDC, 2020;National Committee for Quality Assurance, 2020;Redaelli et al., 2003;Wilkins et al., 2018;Wolf et al., 2018). Because CRC does not produce symptoms until the more advanced stages, screening before symptoms appear is crucial for early detection (Wilkins et al., 2018;Wolf et al., 2018).
In addition to the societal impact of morbidity and untimely deaths caused by CRC, CRC's economic burden is significant (Dieguez et al., 2017;Yabroff et al., 2008Yabroff et al., , 2011. Yabroff et al. (2011) estimated CRC costs $14.1 billion per year in the United States. Due to its relatively long disease course, CRC has one of the highest economic cancer burdens (Yabroff et al., 2008). Costs include frequent surveillance procedures, surgeries, chemotherapy, radiation therapy, and inpatient comfort care (Redaelli et al., 2003). In addition to healthcare costs, CRC causes an economic burden due to lost productivity by the patient (Bradley et al., 2011;Pearce et al., 2016). Bradley et al. (2011) projected that lost productivity caused by CRC would be $4.2 billion in 2020 (p.5).
Most CRCs begin as slow-growing, pre-cancerous polyps (Tobi, 1999). The identification and treatment of pre-cancerous polyps while the lesions are in a localized stage significantly increase survival chances (ACS, 2020;Siegel et al., 2018). Two methods for CRC screenings include stool-based tests and visual examination (Levin et al., 2008;Wilkins et al., 2018;Wolf et al., 2018). The colonoscopy is the most common visual examination CRCS procedure (Levin et al., 2008;Wilkins et al., 2018;Wolf et al., 2018). An example of a common stool-based test is the fecal immunochemical test or FIT (Levin et al., 2008;Wilkins et al., 2018;Wolf et al., 2018) .
Data from 2018 shows that 25% of U.S. adults did not get screened for CRC (CDC, 2021).
Reducing the prevalence, morbidity, and mortality caused by cancer is one of the leading health indicators of Healthy People 2020 and Healthy People 2030 (ODPHP, 2020a(ODPHP, , 2020b. The goal of both Healthy People 2020 and 2030 is to improve wellness by prioritizing the prevention of health threats on the U.S. population (ODPHP, 2020a(ODPHP, , 2020b. To reduce the health threat of CRC, prevention must address cultural disparities and stigma associated with the disease (Goldman et al., 2009;NCCRT, 2021).

Health Literacy and Colorectal Cancer
A relationship exists between a low health literacy rate and adherence to CRCS recommendations (Arnold et al., 2012;Dolan et al., 2004). The veteran population at this facility may have a higher percentage of low health literacy levels than the general U.S. adult population (Nouri et al., 2019;Rodríguez et al., 2013). This organization's primary mission is to honor its customers by providing "exceptional health care that improves their health and well-being" (USDVA, 2019, "VHA Mission," para. 6). Therefore, healthcare providers working at the facility had professional and organizational obligations to maximize efforts for improving CRCS rates among veterans.

PICOT Question
Exploration of the current state of this organization and available evidence-based literature led to this PICOT question: Among veterans 50 -75 years old requiring average risk CRCS seen in primary care at a VA healthcare system (P), how does the use of a multi-component intervention to increase CRC screening (I), compared to usual care (C), affect the number of patients completing CRCS (O), in twelve weeks (T)?
The CRCS process at VA facilities was governed by the VA national directive 1015 (USDVA, 2020a). The directive alone, however, was insufficient to ensure the evidence-based practice was translated into practice. The purpose of this project was to support the intent of the directive by using a multi-component approach for promoting CRCS. The components included a combination of interventions, which were classified into three categories: a) increasing demand, b) increasing access, and c) increasing provider delivery (Mohan et al., 2019). This scholarly project increased demand and improved provider delivery by standardizing care coordination and navigation through the CRCS process.

John's Hopkins Nursing Evidence-Based Practice Framework
The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Model provided the framework for implementing this project (Dang & Dearholt, 2017). The model was developed for easy practical application in clinical settings by nurses and interdisciplinary teams (Brooks-Staub, 2005). The first step was inquiry into a practice question. Next, a continuous loop of learning and practical application surrounded the core steps of: practice question, evidence, and translation, or PET (Dang & Dearholt, 2017).
For this scholarly project, the evidence-based practice inquiry began with questioning why CRCS rates at this organization were below national benchmarks. This resulted in the development of the PICOT question. The evidence phase involved exploring the available body of literature and scrutinizing findings for quality using the JHNEBP Model for rating evidence (Dang & Dearholt, 2017). The results were synthesized into actionable information.
Consideration of the evidence strength was weighed against the risk-benefit. Alignment with the organization's mission was considered to determine whether the practice change moved forward to implementation or was suspended. The final step was to disseminate outcomes and any new lessons learned (Dang & Dearholt, 2017).

ADKAR Change Management Theory
The change management theory that guided this project was ADKAR (Hiatt, 2006). It was a good fit for this project because ADKAR had been endorsed by the VA as its change management theory (USDVA, 2020a). The acronym ADKAR represents the five components that must be met before a successful change is sustained into practice: awareness, desire, knowledge, ability, and reinforcement (Hiatt, 2006). Since each condition builds upon the other, each step had to be accomplished in sequence to avoid adoption failure (Hiatt, 2006).
The first condition was awareness (Hiatt, 2006). Stakeholders were made aware that a change was necessary (Hiatt, 2006;Wong, 2019). Communication was a critical element in this step. The stakeholders were provided with comparison data that showed their specific clinic's performance and the entire facility's performance compared with that of other facilities across the nation.
The next step was creating desire in the stakeholders to engage the change (Hiatt, 2006;Wong, 2019). The desire to improve CRCS rates was built by illustrating the deadly impact on patients of failure to have timely screening. The leadership sought to make the facility the number one healthcare organization in the country. Sharing substandard performance data drove the stakeholders' desire to change.
Gaining knowledge of how to change and applying it to facilitate changes in workflow were critical steps (Hiatt, 2006). Those involved in the change must be informed about how the change will impact their workflow (Hiatt, 2006). Knowledge gaps were addressed by providing information to the primary care staff on the new standard work process, which structured a procedure for CRC care coordination to help patients navigate the CRCS process.
Once the affected individuals possessed relevant knowledge, they had to be able to execute the change (Hiatt, 2006). For example, discussing CRC screening concerns with the patient may have been ineffective if the clinician was unable to move the conversation to a private place. The most significant gap in ability was correctly documenting in the electronic health record (EHR) clinical reminder system as well as using the available reports through the CRC aggregate database. The final change model step was reinforcement (Hiatt, 2006). Previous estimates reported 70% of organizational changes that were attempted were not sustained (Jones-Schenk, 2019;Leonard & Coltea, 2013;Nohria & Beer, 2000). During the project, graphs and charts of the metrics were provided for the daily huddle board. In the future, creating and using an automated visual management system, such as a digital dashboard, would help maintain ongoing awareness and sustainability (Silver et al., 2016;Ulhassan et al., 2015).

Evidence Search Strategy
The search strategy utilized many databases through the University of St. Augustine for Health Sciences (USAHS) and the facility's online libraries. These included ProQuest, PubMed, and CINAHL. The inclusion criteria were: peer-reviewed, original research articles, in English, that were published between 2010 to present (October 2020). The timeframe was limited to the past ten years to ensure results were current. Keywords for the search guided by the PICOT question were "colorectal cancer screening," "intervention," "study," "compliance," "adherence," and a truncated, wildcard version of the word multi-component (multi$ or multi*). The Boolean operator "OR" was used for the search "compliance OR adherence." Due to the large number of initial ProQuest results (number), an additional search filter was applied: "primary care," and the subject was limited to "colorectal cancer."

Evidence Search Results
The exhaustive search returned CINAHL (52 articles), PubMed (170),and ProQuest (was 2,473,reduced to 192). After removing duplicates, the studies that addressed the PICOT question (n=14) were analyzed with a full-text reading of each. Four additional articles found during a review of reference lists of the 14 included studies were deemed suitable for full text review. The final 18 studies included randomized control trials, quasi-experimental studies, cross-sectional cohort studies, and three systematic reviews. See Figure 1 for the Prisma search strategy.
The evidence strength and quality were appraised using the Johns Hopkins Evidence Rating scheme (Dang & Dearholt, 2017). See Figure 2 for the JH Nursing Evidence-Based Practice Evidence Strength Rating. Evidence rating allowed for scrutiny of the studies, which resulted in the calculation of an overall strength level.
The first component (level of evidence) was determined by the study type. Level I is considered the highest level and includes studies such as randomized-controlled trials. The lowest level (Level V) includes non-research publications such as quality improvement and case reports (Dang & Dearholt, 2017). The quality rating ranges from low to high, with specific criteria for each category based on evidence level (Dang & Dearholt, 2017). For example, for evidence Levels I to III, a randomized-controlled study with adequate sample size, definitive, generalizable results supported by the body of evidence would rank as high quality.
Evidence tables in Appendices A and B provide ratings of the study strengths. Nine individual studies were appraised at Level I, randomized controlled trials (RCT) of high quality, or Grade A (Baker et al., 2014;Coronado et al., 2018;Davis et al., 2017;Fitzgibbon et al., 2016;Green et al., 2013Green et al., , 2017Hendren et al., 2014;Wong et al., 2018). Dodd et al.'s (2019) study was appraised at Level C for concerns with validity due to insufficient sample size. Five studies were appraised to be Level II, and four were Grade A (Chou et al., 2016;Fortuna et al., 2014;Tu et al., 2014;Yu et al., 2018) and one Grade B (Basch et al., 2015). Three systematic reviews directly relevant to the PICOT question were also included (see Appendix B). For evidence levels, one was appraised as Level I (Dougherty et al., 2018), and the other two were All three were graded as high quality.

Themes with Practice Recommendations
A thorough and rigorous review of the existing literature on the use of a multi-component strategy to increase CRCS revealed several themes (see Appendix C).

Patient Outreach
The use of patient outreach through non-tailored reminder letters was demonstrated as effective in numerous studies. These included six randomized control trials (RCTs) of high quality (Baker et al., 2014;Coronado et al., 2018;Green et al., 2013Green et al., , 2017Hendren et al., 2014;Myers et al., 2013) two quasi-experimental, high quality studies (Fortuna et al., 2014;Yu et al., 2018) and one level II good quality systematic review, or SR (UDHHS, 2019). Only Myers et al.
(2013) compared tailored versus non-tailored reminder letters in a high quality RCT, and the results failed to show any statistically significant difference between the two. Colorectal cancer screening rates increased with the use of automated voicemails in three high quality RCTs and one SR (Baker et al., 2014;Fortuna et al., 2014;Hendren et al., 2014;USDHHS, 2019;Wong et al., 2018). Results using text messaging were inconsistent.
One high quality RCT demonstrated an increase with text messages (Baker et al., 2014). Two studies, one high quality RCT (Wong et al., 2018), and one high quality quasi-experimental study (Fortuna et al., 2014) showed no difference in CRCS rates with either automated phone messages or text messages.
Navigators help patients manage medical conditions by guiding care and providing education (National Cancer Institute, n.d.). The use of navigators showed consistently effective results. Five RCTs (four high quality; one low quality), three quasi-experimental studies of good to high quality, and three high quality SRs (one Level I; two Level II) (Baker et al., 2014;Basch et al., 2015;Dodd et al., 2019;Dougherty et al., 2018;Fortuna et al., 2014;Green et al., 2013;Myers et al., 2013;USDHHS, 2019;Wong et al., 2018;Young et al., 2019;Yu et al., 2018) showed increases with CRCS rates. However, there were inconsistencies in the type of staff used for navigators.

Patient Education
Two SRs (one Level I and one Level II, both high quality) demonstrated benefits of with patient education when coupled with other interventions (Dougherty et al., 2018;USDHHS, 2019). The results from a Level II high quality SR by Young et al. (2019) showed that the outcome was inconclusive. The effectiveness varied with the delivery mode of the information.

Clinician Interventions
The final theme identified was clinician-directed interventions. One strategy to change provider behavior was educating (academic detailing) physicians and mid-level providers. It showed promising results. Academic detailing (AD) refers to using peer subject matter experts to provide education on a targeted practice issue (AHRQ, 2013). Fitzgibbon et al. (2016), in a high quality RCT, demonstrated that AD was effective. Still, Basch et al. (2015), in their quasiexperimental, good quality study, did not have statistically significant differences with AD.
However, there were improved CRCS adherence rates in the intervention group.

Practice Recommendations
The overwhelming body of evidence supported the use of a multi-component intervention to address the PICOT question, which focused on increasing CRCS in primary care (PC) clinics.
The systematic review by the Community Preventive Services Task Force, or CPSTF (USDHHS, 2019), a group of independent subject matter experts, also served as a clinical practice guideline for this clinical issue. The multi-component intervention aimed at a practice change within the primary care clinics included a standardized CRCS nurse navigation process and provider feedback.
These elements were selected as the multi-component bundle for several reasons. First, the literature strongly supported these interventions as the most effective and targets all three categories in the CPSTF guideline (see Figure 3). Secondly, the organization's infrastructure allowed for ease of implementation because of the existing national Colorectal Cancer Screening and Surveillance (CRCS/S) database and the primary care RN care managers already in place. Lastly, the interventions were able to be executed with minimal cost impact to the organization.

Project Overview
The intervention was applied at three primary care (PC) Patient Aligned Care Teams (PACT) clinics (Clinics J, K and L) located on the main campus of a high complexity VA healthcare system in California. The PACT team is the VA's version of the medical home model (USDVA, 2020d). This VA is undergoing a lean, cultural transformation and was also pursuing Magnet to support their vision of becoming an HRO.
The number of patients eligible for average risk CRCS during the 12-week period was 3623. The number of eligible patients who were dispensed a FIT kit during the 30-day data collection period was 189. The participant size was adequately powered based on Wong et al.'s (2018) randomized, eight-month, three-arm study comparing CRCS interventions. They calculated 600 participants as the sample size necessary to provide 80% power to detect an 11% increase in the intervention group (Wong et al., 2018). The observation period for this Doctor of Nursing (DNP) project was one month, which was 1/8 th of Wong et al.'s study duration.
Therefore, this project's participant count of 189 was appropriate to determine significance. Since most female patients within this organization opted to receive their care in the Women's Clinic instead of the PC clinic, most of the patients impacted were male patients ages 50 to 75 (see Table   3).
The need for this project was identified by evaluating data from the VA's quality tracking program (Strategic Analytics for Improvement and Learning Value Model -SAIL). It compiles data from approximately 170 nationwide facilities and includes 25 measures and multiple submeasures (USDVA, 2020b). This facility's ranking for the CRCS measure was below other comparable facilities and therefore identified as a need. The preceptor, the deputy associate director for patient care services endorsed and confirmed support for the project. She was also part of the executive leadership team. The PC leadership team and the PACT RN Coordinator also supported the project.

Interprofessional Stakeholders
A great deal of interprofessional stakeholder collaboration was needed for this project.
Those directly impacted were nursing, medical, and clerical staff in the primary care (PC) clinics.
Assistance from medical media, patient education, and public affairs staff was needed to develop and modify patient education materials. The supply chain department manager and the FIT kit vendors were also stakeholders. Leadership stakeholders included the PC physician and nurse chiefs, the directors for nursing (director and deputy for patient care services), and the chief of staff, who had ultimate clinical practice oversight in PC.

Systems Change
The scopes for changes that DNPs impact are categorized into three levels: macro, micro and meso (Moran, 2020;Rubio & Scott, 2011;Trautman et al., 2018). Macro level changes occur within a large-scale population, such as at a national level (Moran, 2020). A more localized group, such as a city or community, is considered the meso level (Moran, 2020). Micro level changes are those that take place at an organizational level, like those achieved by this scholarly project (Moran, 2020). Although this evidence-based project was scoped at the micro-level to change primary care's CRCS process at the facility level, the plan is to expand to the meso level by partnering with other local and state organizations who provide care to similar populations.
The SWOT (strength, weakness, opportunities, threats) analysis is a method to assess factors that may positively impact or put the project at risk (Stonehouse, 2018). The SWOT analysis for this project showed many strengths, such as RN care managers who were already in place and an existing lean process improvement culture (see Appendix D). The most concerning threat was the impact of the COVID-19 pandemic on project implementation or completion. The project's process metrics were closely monitored to ensure threats or weaknesses were quickly identified and mitigated. See Table 2 for metrics that were monitored.

Project Plan
After receiving approval for the project proposal implementation from the University's DNP Evidence-Based Practice Review Council and the facility IRB, the intervention took place over 12-weeks between March and June 2021 at three primary care (PC) clinics (clinics J, K, and L). The full schedule of activities is outlined in Appendix E. As the project manager, the DNP student was critical in implementing the project and following it through sustainment (Burson & Moran, 2020). A skilled project manager is critical because they must strategically plan and anticipate potential barriers along the change management process (Conrad, 2020). Failing to adequately prepare to manage the change process can cause the project to fail (Campbell, 2020).
The essential skills of a project manager to produce a successful team collaboration include effective communication skills, leadership, creativity, ability to inspire others, and change management (Harris, 2015). Coaching and guiding the team to stay motivated and persist amid multiple projects is another crucial function for the project manager (Harris & Ward-Presson, 2015).
The preceptor, faculty, and the nurse scientist served as coaches to guide the project manager through the project. The executive sponsor, who was also the preceptor, was the deputy associate director for patient care services. She provided the necessary executive level support to vet the project's importance and support for utilizing resources for the project. The PC chief physician and the chief nurse helped mitigate change resistance encountered at the PC staff level.
Other professionals required for collaboration included the gastroenterology (GI) providers, the data analyst, the supply chain department manager, and the laboratory manager. Collaborating with the GI providers offered insight from their experience as providers receiving consultations for patients referred for colonoscopies from positive CRCS tests. The data analyst was needed to assist with data mining and extraction of performance reports. The supply chain department supplied the FIT kits, and their expertise was necessary to maintain adequate supplies and to determine cost.

Objectives and Timeline
The primary objective was to increase CRCS adherence. The outcome measure was the percent of returned FIT kits within 30 days of distribution. The target was to increase the return rate by at least 10% from the baseline of 16.7%. The intervention included a multi-component strategy. This included a standard work that guided the RN care managers through a systematic process for monitoring CRCS status, navigating the patient successfully through the screening (see Appendix H), and providing feedback to the PACT teams on their performance with CRCS.
Another objective was to increase the number of PC nurses who used the Colorectal Cancer Screening Surveillance (CRCS/S) database, which contained data to facilitate CRC prevention. There was a gap in a standardized approach for CRC prevention. The inconsistencies contributed to the substandard CRCS adherence rates. The standard work provided guidance on using the CRCS/S database, thereby improving the nurses' ability to function more effectively as navigators.
The final objective was to decrease the number of CRCS-positive patients waiting for provider follow up over 30 days by 20%. The mean number of patients waiting at baseline for the three intervention clinics was 16. By utilizing a report in the CRCS/S database that identified patients waiting for follow up, the care managers were able to collaborate with the provider and patient to remove barriers to follow up.

Implementation Framework
The JHEBP model guided the project (Dang & Dearholt, 2017). Any CRC rates below the 80% national benchmark published by the NCCRT (2021) was a significant clinical practice issue.
Failing to meet the benchmark meant that patients were needlessly dying from preventable cancer.
The translation of evidence into practice included implementing a multi-component CRCS standard work multi-component bundle.
Raising awareness and creating the desire to change were accomplished by disseminating and explaining the rationale for each step in the standard work. The knowledge and ability to implement the change was validated by the RN care manager and nurse manager, who audited the application of the new standard work in clinical practice. The reinforcement component of the change model was initiated through random audits of the nursing documentation in the EHR.
Feedback about the PC team's performance on the metrics (see Table 2) was shared by displaying the weekly metrics at the daily huddle board. These metrics supported sustainment.

Budget
Expenses for the project above normal operation costs were minimal (see Table 1). The costs included the salary for additional time to provide comprehensive patient teaching and follow up phone calls. The total salary estimated for the duration of the project was $20,631. Details of the other costs such as costs associated with photocopying and supplies are outlined in Table 1.

Results
The Intellectus Statistics (2021) online program was utilized for descriptive and quantitative statistical analyses. Participants were patients enrolled at one of the intervention clinics (Clinic J, K, or L), ages 50 to 75, and eligible for average-risk CRCS. Patients considered high risk, such as those with a history of CRC or under surveillance for suspicious polyps, were excluded. The participants were predominantly male (n = 1672, 96%), 4% female (n = 77), with a mean age of 64.1 (see Table 3).

FIT Kits Returned
The primary outcome included the number of CRCS FIT kits returned by the patient within 30 days. Thirty days of data were compared at baseline and post-intervention. The result of the two proportions z-test did not reach statistical significance based on an alpha value of 0.05, z = -1.02, p = .307, 95% CI = [-0.12, 0.04]. This suggests the difference between FIT kits returned pre and post-intervention were not statistically significant (see Table 4). However, Figure 4 displays the upward trend in the number of FIT kits returned. The upward trend is clinically significant as it shows an improvement in returned FIT kit rates. The early detection of CRC is contingent on a robust FIT test monitoring program. The median turnaround time for patients to turn in their FIT tests is 44.5 days (Haas et al., 2019). Twelve weeks may have been an insufficient duration for demonstrating the full impact of the intervention due to the average lag time for returning FIT kits.

Follow-up for Abnormal FIT Screens
A secondary outcome metric was the number of patients pending follow-up greater than 30 days from the time of positive FIT test results. A two-tailed independent samples t-test was conducted to compare the total numbers of patients pending at baseline (n=49) and postintervention (n=37). Normality assumption was met through the Shapiro-Wilk test (Razali & Wah, 2011). The result was not statistically significant based on an alpha value of 0.05, t(4) = 0.45, p = .675, (see Figure 5). Reasons the results may have failed to reach statistical significance may have been due to the short duration of the project and the small participant size for this subset. In addition, the "creating desire portion" of the ADKAR change model took much longer than expected. Furthermore, Clinic L's performance appeared to be an outlier caused by one provider's practice (see Figure 6). There was, however, a downward trend in the number of patients pending over 30 days for an abnormal FIT test follow-up, which is clinically significant as this means there was an improvement in patients receiving timely follow-up for abnormal FIT screenings.

Overdue Colorectal Cancer Screening
The proportion of overdue CRCS in the intervention clinics was one of the process metrics. The number of eligible patients overdue compared to all eligible patients was analyzed with the two-tailed independent samples t-test pre and post-intervention. The result was not significant based on an alpha value of 0.05, t(4) = 0.34, p = .754 (see Figure 7). It is very likely that the duration of this project was insufficient to demonstrate the impact on all eligible patients.

Nursing Documentation
Another process metric was a manual charting documentation audit. The audit of the EHR was done pre and post to monitor compliance with patient teaching about the FIT kit process (see Appendix G). The normality assumption was met using the Central Limit Theorem (CLT) (Pituch & Stevens, 2015). The result of the two proportions z-test was significant based on an alpha value of 0.05, z = -5.62, p < .001, 95% CI = [-0.65, -0.31], (see Table 5). The statistical significance means that compliance with patient education documentation improved post-intervention (see Figure 8). This result is clinically significant because educating patients about the importance of completing the screening is critical in improving FIT kit return rates. In addition, patients need to be informed about their role in health promotion and illness prevention as a means for empowering patients to take charge of their health.

Colorectal Cancer Screening and Surveillance Database Use
The third process metric was the frequency of CRCS/S database use pre and postintervention collected through an internally created questionnaire (see Appendix F). The face validity for this internally developed tool (see Appendices F and G) was established through consulting six subject-matter experts who deemed the tool valid. The result of the two proportions z-test comparing the difference in the database use pre and post was not significant based on an alpha value of 0.05, z = -0.82, p = .414, 95% CI = [-0.46, 0.19], (see Table 6). The baseline usage rates may have been falsely elevated due to staff confusion about the term "database" and interpreting it as the clinical reminder used in the EHR. There was, however, an uptrend in the usage of the database post-intervention (see Figure 10). Although not statistically significant, the increased use is clinically significant because consistent usage of the database is important for efficiently identifying the status of CRCS and pending follow-up for each patient.
Using the database consistently can ensure patients receive timely management of CRC.

Balancing Metric and Data Security
The balancing metric monitored was the amount of overtime caused by the potential increase in nurse workload from the project. Payroll data was extracted through a centralized database to assess the impact on overtime caused by the intervention. The results showed no increase in overtime as a result of the intervention (see Figure 9).

Data Integrity and Protection of Human Participants
Automatically extracting data reduces the potential for human error (Mathes et al., 2017;Pandey et al., 2020). Therefore, the majority of the data were extracted automatically from the EHR and the centralized data warehouse. The only data manually extracted were the chart audits for nursing documentation and the CRCS/S questionnaire. To mitigate the risk of disclosing personally identifiable information (PII) and protect the patient, PII was coded, and data was stored electronically within the facility's restricted computer network. Access to the network is limited only to those who have a facility-issued microchipped access card and PIN. Electronic files with PII were restricted to the project manager and the preceptor.

Impact
Creating awareness was the first step in the ADKAR change model. The project alerted several significant clinical opportunities. This project was the first step in aligning this specific department to the organization's HRO journey and the HRO principles of preoccupation with failure and reluctance to simplify. This project highlighted and created awareness about the importance of monitoring routine health maintenance tracking processes.
For sustainment, the PC nurse leaders and champions have taken over as project managers to spread the multi-component approach to CRCSs to other PC locations and specialty clinics. A sustainment toolkit was provided, including process control spreadsheet templates, a video on how to conduct data analysis and CRCS database use, and a cheat sheet for clinicians on where to go for data and additional resources. The plan is to continue refining the standard work, audit the process, and continue tracking outcome metrics.
The project also highlighted significant challenges the clinicians face because of the antiquated EHR system, which may be contributing to alert fatigue. The need for the VA to modernize its EHR is well documented (Torres, 2014;USDVA, 2021). A locally created dashboard to simplify data interpretation will be critical for providing an efficient visual management tool for successfully sustaining positive outcomes.
Limitations of the project included competing priorities with the COVID-19 pandemic.
Many of the regularly assigned staff and leaders in PC were reassigned out of PC to support pandemic-related activities, thus limiting their availability for the project. Finally, the project's duration was another limiting factor and a barrier to reaching some targeted goals. For example, the FIT kit return rates and the number of FIT positive patients pending follow-up greater than 30 days may have reached targets with a longer project duration.

Dissemination and Future Plan
The project outcomes were disseminated locally within the organization. The venues included presentations at various meetings including the facility's systems redesign and improvement team, Magnet ambassadors, PC staff, and the nursing research committee. A virtual session was recorded to allow staff not in attendance to watch at a later time.
In addition, presentations will be done at the facility-wide director's meeting. The director showcases facility projects every Friday morning at the director's meeting. The director's meeting is designed as the communication platform from the director to the chiefs but is open for any staff to attend. The facility's nursing grand rounds and evidence-based practice committee are other forums for future dissemination. The plan is to disseminate the findings to a greater audience outside of the local organization such as the annual nursing research conference, co-sponsored by this facility, its neighboring university's academic affiliate, and the parent organization's national nursing evidence-based poster presentation forum.
Plans for dissemination also include submitting the manuscript for publication to The Federal Practitioner journal. The Federal Practitioner is an appropriate match for manuscript submission and publishing because this peer-reviewed journal focuses specifically on the veteran population (MDedge, 2020). The Federal Practitioner uses a web-based editorial manager for peer review and is the only scholarly journal that addresses unique issues related to the veteran population and the VA healthcare system. The database used for implementing this project is unique to the VA. The Federal Practitioner readers would have access to this database, making the information generalizable to other veterans. Finally, the project will be submitted to the University of Saint Augustine for Health Sciences Library, Scholarship and Open Access Repository (SOAR) for archiving.

Conclusion
The intent of the project was to increase CRCS in the underserved population treated at this organization. This goal was met by implementing a CRCS multi-component intervention, including a standard work for PC nursing staff to function more effectively as CRCS navigators and by providing feedback on CRCS performance metrics. The standard work offered a systematic process for the current best-known way for identifying patients who are due for CRCS, those who have not returned their FIT kit, and those awaiting follow-up from a positive FIT test.
The project was limited to three PC clinics in one location. Disseminating this project's results will allow this EBP to spread to other PC clinics and specialty outpatient clinics.
Implementing the project at specialty clinics such as the women's and spinal cord injury clinics would be just as important as in PCs. The project can also be implemented at other VA facilities across the nation.

Tailed Independent t-Test
Baseline Goal

FIT kit returned in intervention clinics
Calculated by dividing the total number of patients issued a FIT kit by the number returned within 30 daysdata source: CRCS/S X X X X X X X X X X X X X X X X 65% > 75%

Abnormal FIT follow-up in intervention clinics
The mean number of patients who have an abnormal FIT test pending follow up > 30 daysdata source: CRCS/S X X X X X X X X X 16 < 12.8

Patients overdue for CRCS in intervention clinics
The number of patients who are overdue on their CRCS > 30 daysdata source: CRCS/S. Denominator = number of pts due for CRCS within a time period. Numerator = number of patients who completed the CRCS.
X X X X X X X X X 35.4% < 25%

EHR nursing documentation audit
Random manual audit of EHR nursing documentation of CRCS patient counseling. Denominator = number of audited charts. Numerator = number of nursing documentation reflecting CRCS patient counselingdata source: EHR X X X X X X X X X X X X X X X 28.3% 100%

Figure 3
Analytic Framework: Multi-component Interventions to Promote Breast, Cervical, and Colorectal Cancer Screening Note. From: U.S. Department of Health and Human Services. (2020). Cancer screening: Multicomponent interventions-Colorectal cancer. https://www.thecommunityguide.org/findings/ cancer-screening-multicomponent-interventions-colorectal-cancer Nursing Documentation Compliance with Documentation of Patient Teaching
Comparison: Usual care = standard processes for CRCS = providing information and ordering tests during routine clinical encounters.
Intervention: Before the appointment, patients received pre-paid FIT kit with return postage; educational print-out about the importance of CRCS. Information reviewed at MD appointment Comparison: Usual carepatients received printed CRC educational print-out.
Not stated, but the study approach is consistent with the health promotion model where the goal is to prevent illness and promote wellness (Johns et al., 1987) Primary outcome = self-reported CRCS.
No statistically significant differences between the intervention and control on knowledge.

Provider intervention:
The authors identified the Health Belief Model as the framework that provided the foundation for the patient intervention portion of the study. They also identified Deming's Quality Improvement Primary outcome measures = CRCS (home FOBT, FS, or colonoscopy) Providers who attended intervention sessions recommended CRCS at a higher rate during patient visits compared to those who did not attend 64% vs 54% of visits (p < .01) Also, the patients of providers who attended intervention sessions One-hour feedback sessions every 4-6 months with data about screening performance framework as the guiding framework for the provider intervention portion.
Arm 2: Letter + Automated callsame as arm 1 plus up to 5 automated call reminders Arm 3: Letter + Automated call + Paper Visit Prompt: Same as arm 2 plus addition of education sheet encouraging screening at the time of visit with the physician.  (Green et al., 2013 SDS tool has been studied as valid and reliable in previous studies (Myers et al., 1994;Vernon et al., 1997).
TNI Group intervention = mailings with colonoscopy instructions and/or stool blood tests according to reported test preference, and received a navigation call from a nurse navigator The SI Group intervention = mailings with an informational booklet on CRCS, a personalized letter with phone numbers to a nurse, scheduling colonoscopy or SBT kit request. Reminder letter mailed at 30 days post-randomization. Arm 3 -MD intervention -reminders via the electronic health record as a pop-up alert and also available for reviewing any time. One-click ordering option with choices of screening options.
Arm 4 -MD control -Comparison: Control group was educated on the alerts but did not have the alerts turned on.
Not stated by the authors. The approach of the study is consistent with the Precaution Adoption Process. The aim of the study was to explore if providing education and information to patients impact the engagement and decision of health behaviors (Weinstein & Sandman, 1992