Lung Cancer Screening: An Evidence-Based Practice Change Project

Practice Problem: Lung cancer is the leading cause of global cancer deaths and is a significant health issue in the US, claiming more than 155,000 lives each year. Lung cancer screening through low dose computed tomography (LDCT) can reduce lung cancer mortality by 20 percent but unfortunately, lung cancer screening is underutilized. PICOT Question: The PICOT question that guided this project was: in a patient population eligible for LDCT lung screening (P), how does auditing of practice with feedback to the providers (I), compared to not doing the interventions as mentioned above (C), increase LDCT lung cancer screenings in the identified population (O), in an eight-week period (T)? Evidence: A thorough literature review was conducted to determine if audit and feedback is an evidence-based strategy for increasing cancer screening rates. The literature review produced ample evidence supporting audit and feedback as an effective strategy for significantly increasing cancer screening rates. Intervention: A lung cancer screening audit tool with essential elements for determining patient eligibility for LDCT lung cancer screening was created for this project, and the face validity of the audit tool was obtained. During the project’s intervention and evaluation phase, each audit tool submitted was analyzed for completeness, and performance feedback was given to the clinic’s providers on a weekly basis. Outcome: Although Chi-Square analysis did not show statistical significance, the number of LDCT lung cancer screening scans nearly doubled during the intervention phase compared to the baseline phase of the project. Conclusion: The continued usage of the lung cancer screening audit and feedback tool is recommended for increasing the number of LDCT lung cancer screenings.

contain more screening-eligible patients yet have fewer primary care physicians per capita (Pham et al., 2020).

PICOT Question
The population (P), intervention (I), comparison (C), outcome (O), and time (T) question is a useful framework for defining practice questions while establishing proposed solutions (Riva et al., 2012). In a patient population eligible for LDCT lung screening (P), how does auditing practice with feedback to the providers (I), compared to not doing the interventions as mentioned above (C), increase LDCT lung cancer screening in the identified population (O), in an eightweek period (T). Studies show that healthcare providers narrow the gap between their current practice and established benchmarks when they are given performance feedback (N. Ivers, 2012). Audit and feedback is widely used as an evidence-based method for improving patient outcomes (N. Ivers, 2012). In regards to compliance with ordering recommended cancer screening, studies show that audit and feedback has a significantly favorable impact on increasing screening rates (Hwang et al., 2019). The targeted population for this evidence-based project were individuals that met LDCT lung screening criteria as defined by the US Preventive Services Task Force (USPSTF); these criteria include asymptomatic individuals between the ages of 55 and 80 years with a smoking pack-year history greater or equal to 30 years and who have quit smoking within the last 15 years or who currently smoke (Moyer, 2014).

Evidence-Based Practice Framework & Change Theory
The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Model was used as a framework for this EBP change project. The inquiry phase was predicated upon an organizational needs assessment, which identified a worthwhile practice concern (Dang & Dearholt, 2018). The practice element of the JHNEBP Model encompasses the nursing process and all nursing activities (Dang & Dearholt, 2018). The practice element is no longer based simply on policies and protocols but must be grounded on evidence (Dang & Dearholt, 2018).
The learning component of the JHNEBP Model, regarding this EBP project incorporated a thorough review of the literature to ensure that the practice change was based on evidence (Dang & Dearholt, 2018).
Kotter's change model was utilized for this EBP change project. The eight-stage change process posited by Kotter is an effective method for facilitating organizational transformation (Pollack & Pollack, 2015). The first stage of Kotter's change model is to create a sense of urgency; failure to do so is the most critical error when seeking organizational change (Pollack & Pollack, 2015). Data was presented to the organization that showed missed lung screening opportunities while depicting the benefits of LDCT lung screening, and how it bolsters the organization's vision. This was critical step in the project since communicating the vision of change promotes visibility within the organization for the desired change (Pollack & Pollack, 2015). During the project's planning phase, stakeholders were identified, and a coalition for planning and implementing the change was established in accord to Kotter's change process (Pollack & Pollack, 2015). The final phase of this project, according to Kotter's change model was to ensure that the change became sustainably embedded into the organization's culture (Pollack & Pollack, 2015).

Evidence Search Strategy
A thorough literature search was conducted to assess the effectiveness and validity of the The search terms used for the first search item were "audit and feedback." The filters used for the first search were abstract, peer-reviewed, English language, "find all my search terms", and a date range between 2016 and 2021. In addition, the term "screening" was searched within the abstracts.

Evidence Search Results
The multiple database literature search yielded 140 articles. Although the multiple databases excluded some duplicates, other duplicates remained. In total, 89 duplicates were excluded, and 50 articles remained for further review. Six of the remaining articles were not primary research and were excluded, leaving 44 articles. The remaining results contained 22 articles that were excluded because although the research pertained to audit and feedback but the studies did not apply these interventions for improving health screening. The 22 remaining articles contained nine articles that were irrelevant to audit and feedback as an intervention.
Three of the remaining 13 articles were excluded because audit and feedback was directed at the patient and not the healthcare providers. After exclusions, the final number of articles selected was 10. A summary of the literature search, exclusions, and selections is shown in Figure 1.
The John Hopkins Nursing Evidence-Based Practice (JHNEBP) model and its Evidence Level and Quality Guide was used to appraise the level of evidence and quality of the selected 7 literature. The JHNEBP model helps nurses incorporate the most up-to-date research findings into nursing practice (D. Dang & Dearholt, 2017). Table 1 shows the summary of the primary research evidence. Five of the selected articles were quasi-experimental and included quality improvement studies; of these five articles, three were level II with low to good quality. The remaining three quasi-experimental articles were level III and the evidence was low to good quality. Seven articles were retrospective and prospective cohort studies; of these studies, one was a level 1 randomized control trial (RCT) with high quality evidence and a statistically significant sample size. Three of the retrospective and prospective studies had level II evidence; each of these had good quality findings.

Themes with Practice Recommendations
Numerous studies suggest that audit and feedback can be an effective intervention for improving professional behaviors (Ivers, 2012). Ivers' monumental work on audit and feedback showed that improvement in professional compliance through this intervention achieved a median gain of 4.3% among 82 comparisons within 49 studies (Ivers, 2012). Individual behavior change theories posit that audit and feedback reveal areas for improvement that are otherwise unknown to individuals (Ivers, 2012).
A review of the literature specific to the PICOT question revealed several functional themes for improving preventive screening. First, PCPs are underutilizing the recommended preventative screening for eligible patients Feldman et al., 2017;HughesCarter & Hoebeke, 2016;Jonah et al., 2017;Singh et al., 2021). Huges-Carter & Hoebeke (2016) found that only 0 to 43 percent of patients seen at the primary care clinic studied received recommended diabetic kidney disease screening. Feldman et al. (2017) showed that over half of 8 the participants did not receive the recommended baseline screenings for colorectal and breast cancer. Jonah et al. (2017) showed that a third of patients failed to obtain preventive cancer screening.
The second and crucial theme discovered within the literature was that audit and feedback is an evidence-based and effective intervention for improving preventative screening rates Feldman et al., 2017;Hughes-Carter & Hoebeke, 2016;Hwang et al., 2019;Jonah et al., 2017;Rohweder et al., 2019;Singh et al., 2021;Weiss et al., 2018). The randomized control trial by Hwang et al. (2019) included 96 providers and 6363 patient participants; this study showed that an audit and feedback intervention increased cervical cancer screening from 65.3% to 77.7% and increased colorectal cancer screening from 64.6% to 72.5%. Jonah et al. (2017) utilized an audit and feedback intervention for 7866 PCPs for colorectal screening, 7833 PCPs for breast screening, and 7852 PCPs for cervical cancer screening. Patients of physicians who received regular audit and feedback on preventive screening practices were significantly more likely to receive recommended cancer screening (Jonah et al., 2017). In a study of PCPs that served more than 31,000 patients, audit and feedback increased colorectal cancer screening by a weighted average of 8.0% (Rohweder et al., 2019). Providing a large physician group that treats more than 35,000 patients annually with audit and feedback alerts significantly increased cancer screening rates (Feldman et al., 2017). This study experienced an increase in cervical cancer screening by 11% (p < 0.05), breast cancer screening by 9% (p<0.05), and colorectal cancer screening by 11% (p<0.05) (Feldman et al., 2017).
Another theme repeated within the literature for audit and feedback is that feedback specific to providers can increase positive practice behaviors (Feldman et al., 2017;Hwang et al., 9 2019;Weiss et al., 2018). Provider-specific feedback on preventative screening practices was an essential component of the statistically successful audit and feedback study by Wiess et al. (2018). Preventative cancer screening data on overdue patients was provided to each physician participant in the study by Feldman et al. (2017). In this study, physicians were sent electronic lists of their patients overdue for screening and were given an opportunity to send reminders to the respective patients (Feldman et al., 2017). The study by Hwang et al. (2019) concluded that sustainability for a successful audit and feedback program for improving cancer screening is more likely when the feedback is specific to each provider.
The last theme discovered from the literature on audit and feedback was that providing peer comparison data to providers may improve preventative screening rates (Feldman et al., 2017;Hwang et al., 2019;Jonah et al., 2017;Rohweder et al., 2019;Weiss et al., 2018). Provider

Practice Recommendations
The literature clarified that a gap existed between preventative screening recommendations and preventative screening practices Feldman et al., 2017;Hughes-Carter & Hoebeke, 2016;Jonah et al., 2017). Multiple studies within numerous practice settings concluded that audit and feedback is an effective intervention for statistically improving cancer screening rates Feldman et al., 2017;Hwang et al., 2019;Jonah et al., 2017;Rohweder et al., 2019). Effective audit and feedback interventions include providerspecific feedback, and peer comparison has been shown to create a sense of healthy competition among providers and improve screening rates (Feldman et al., 2017;Hwang et al., 2019;Rohweder et al., 2019;Weiss et al., 2018).
The PICOT question is, in a patient population eligible for LDCT lung screening (P), how does auditing of practice with feedback to the providers (I), compared to not doing the interventions as mentioned above (C), increase LDCT lung cancer screening in the identified population (O), in an eight-week period (T). The practice recommendation for improving lung cancer screening was to establish an audit and feedback program that was provider-specific and contained peer comparisons.

Setting, Stakeholders, and Systems Change
This DNP scholarly project occured within a primary care clinic affiliated with one of the health system's community hospitals. The overarching health system is one of the largest in the US, with 180 hospitals and care sites within 21 states. The mission of the primary care clinic is that of the hospital: "above all else, we are committed to the care and improvement of human life". The vision of the hospital is "to be an excellent place for employees to work, and an excellent place for physicians to practice medicine, resulting in an excellent place for patients to receive care." The primary care clinic is one of four clinics affiliated with the main hospital, located in Florida. The health system is for-profit and has an organizational culture that is highly driven by metrics and financial performance. The primary care clinic staff included six primary care physicians, an office manager, medical assistants, system-level care coordinators, a systemslevel director, and a systems-level executive director.
The inclusion criteria for patient participants for this project was identified according to the US Preventative Services Task Force (USPSTF) 2004 recommendations for LDCT lung screening eligibility. Although the USPSTF recommendations for LDCT lung screening was modified during the writing of this project's proposal (US Preventative Task Force, 2021), the 2004 recommendations will be used since reimbursement is currently based on the 2004 guidelines. The participants were patients who were current smokers or had a history of smoking and were ages 55 to 80 years (Moyer, 2014). The setting for the project was in a primary care clinic that serves the residents within and around its respective zip code. The estimated population within the zip code is 38,231, had a median age of 37.3 years, and an average household income of $53,988 (CDX Technologies, n.d.). Deaths from lung cancer within the clinic's zip code were among the highest in the county; this population reported 85 lung cancer attributable deaths between 2015 and 2019 (Florida Department of Health, n.d.).
The organizational need for this DNP project was determined by corporate benchmarks within the health system, coupled with local demographic data respective to smoking and cancer rates. The number of LDCT lung screening performed on the patients at the primary care clinic in question was far less than that of other primary care clinics within the health system and with similar demographics. This DNP project had strong organizational support from the hospital's Vice President (VP) of Operations, the Cardiovascular Services (CV) Administrator, and the Lung Nodule Program Coordinator at the health system's division and local level.
Interprofessional collaboration was an essential prerequisite for this DNP project to realize its goals. Although strong organizational support had been displayed at the health system level and hospital level, obtaining buy-in from the medical providers and staff at the primary care clinic was essential. The first step of the lung screening process started with an accurate assessment of each patient's smoking history; this assessment was be completed by the medical assistants (MA) or the primary care providers. A strength, weaknesses, opportunities, and threats (SWOT) analysis suggested that vacancies and staff turnover within the primary care clinic undoubtedly presented a barrier towards hard-wiring the process into daily routines (seen in Appendix A). Reinforcement of the project's mission by the office manager, primary investigator (PI), care coordinators, and medical providers were essential to ensure that the project started and ended effectively.
The system-level change that will sustain this project begins with a clearly defined process for identifying eligible patients for LDCT lung screening. A process for ongoing audit and feedback was implemented so that all essential components of lung screening eligibility are addressed and documented.

Establishing a sense of urgency
Kotter's eight-stage change process was used to facilitate this DNP project. Kotter's change process is a widely adopted change theory with proven success across various industries and organizations (Pollack & Pollack, 2015). Kotter's change process starts by establishing a sense of urgency (Pollack & Pollack, 2015). In the early months of 2021, the health system's VP of operations (VPO) informed the administrative director of cardiovascular services (CVS) that imaging centers in similar-sized areas performed much more LDCT scans than at the respective 13 health system. The data shared by the VPO strongly suggested that more efforts were required to ensure those eligible for lung cancer screening were receiving this life-saving diagnostic. The administrative director of CVS was challenged to increase lung cancer screening performed at the health system's imaging center.

Creating the guiding coalition and develop a vision and strategy
The second and third stages of Kotter's process are forming a coalition with power to effect change and develop a vision and strategy (Pollack & Pollack, 2015). A strong alliance for this project was created during the planning phase of this project. This coalition was championed by the VPO and the administrative director of CVS. In the months leading to this project, numerous meetings attended by key stakeholders reviewed lung screening rates and discussed strategies for improvement. One of the essential strategies identified at these meetings was this DNP project to improve physician documentation for lung cancer screening.

Communicating the change vision
Kotter's fourth stage is to communicate the change vision (Pollack & Pollack, 2015).
During the first week of the project's intervention, a succinct PowerPoint outlining the efficacy of LDCT lung screening and the shared decision-making process was presented to the primary care providers and office staff (see Appendix B). The PowerPoint emphasized LDCT lung screening eligibility criteria, risks, benefits, alternatives, and the evidence supporting this only screening method for improving lung cancer survival (Pyenson & Tomicki, 2018). Kotter emphasizes the multiple efforts for communicating the vision of change should be utilized (Pollack & Pollack, 2015). In addition to the informative PowerPoint, the clinic's care coordinator and manager reviewed the LDCT screening criteria and associated documentation 14 with the medical assistants (MAs) so that they too could reinforce the change vision. A sequential overview of the project's interventions, listing the responsible individuals, can be found in Appendix C. Brochures for patients to become more informed about lung cancer screening were placed in the clinic's patient lobby (seen in Appendix D).

Empowering broad-based change and generating short-term wins
Empowering broad-based change and creating short-term wins is the next stage of Kotter's change process (Pollack & Pollack, 2015). Since the clinic's EHR does not have the capability of automated prompts for lung cancer screening, utilizing a checklist to determine if patients are eligible for screening had the potential to improve physician compliance. An audit and feedback lung cancer screening tool was created by the project manager (seen in Appendix E) to serve as a checklist for physicians of the critical components for determining eligibility for lung cancer screening. Audits and feedback of the lung cancer screening audit tool empowered providers and office staff with up-to-date information regarding the project's status and key performance measurements.
Recognizing short-term wins were achieved through celebrating each lung screen order and increased compliance with the associated documentation. Feedback was communicated through project updates on the clinic's communication boards and via emails to the office manager and medical providers. Staff was praised for each LDCT lung screening that was ordered during the project.

Consolidating gains, producing more change, anchoring new approaches
The final stages of Kotter's change process are to consolidate gains, produce more change, and anchor new approaches (Pollack & Pollack, 2015). Kotter's change process recognizes that sustainable change takes time for anchoring (Pollack & Pollack, 2015). Until the audit and feedback process are an automated feature of the clinic's EHR, ongoing audit and feedback will be essential for consolidating gains. After the project was completed, the manager of care coordination and office managers for the primary care clinic were tasked with continuing audit and feedback of LDCT lung screening efforts.

Budget considerations
This EBP practice change project did not require any additional full-time-equivalents (FTEs) or overtime. The manager of care coordination was previously conducting chart audits for performance and outcome metrics and planned to incorporate lung cancer screening audits into the ongoing and routine workflow. The only additional expense for this project was the cost of paper and toner needed to print the lung cancer screening audit tool.

Establishing a baseline
Baseline data for the total number of LDCT lung screens ordered and completed was retrospective and covered a four-week period before implementing the audit and feedback intervention. Data for completed LDCT orders and completed scans was obtained from the manager of the health system's imaging center. There was no baseline data for provider compliance for LDCT lung screening documentation on the audit tools, since no data existed prior to this project.

Potential risks to participants and inclusion criteria
Lung cancer screening is not without risks and includes radiation exposure, unnecessary invasive procedures, false-positive results, and emotional distress (Center for Disease Control and Prevention, 2020). However, efforts taken to minimize risks included offering lung cancer screening only to those who met recommended guidelines. In addition, the primary care provider conducted a shared decision-making session to explain risks, benefits, and alternatives with respective patients before ordering lung cancer screening (Moyer, 2014).
The audit inclusion criteria was for patients between the ages of 55 and 80 years that were current smokers or had a history of smoking; this age group was selected based on the USPSTF recommendations for lung cancer screening (Moyer, 2014). Inclusion criteria for LDCT lung screen orders was for patients that met all of the following criteria: the patient was between the age of 55 and 80 years, a current smoker or one who quit smoking within the past 15 years, had no symptoms of lung cancer, had at least a 30 pack-year smoking history, and was willing to undergo treatment for lung cancer (McDonnell et al., 2019).

Data collection
The data for this project was collected by the project manager. Data was retrieved from the lung cancer screening audit tool. Weekly updates from the health system's imaging center was provided regarding the number of LDCT lung screens ordered. Data during the preimplementation period and throughout the project's lifespan was collected on a weekly basis and entered into the data collection tool (seen in Appendix F). Face validity of the lung cancer screening audit tool and the data collection tool was determined after it was reviewed by the lung nodule program's administrative director.

Data storage
The data collected did not contain any patient identifiers and was stored within the project manager's personal computer and the project manager's cloud drive. The project manager's personal computer was protected with password and facial recognition technology. No data that may have revealed the identity of the participants was used. No information that may readily identify participants was recorded within any of the data collection tools used for this audit and feedback project.

Evaluation design and evaluation tools
The evaluation of outcomes for this project was achieved through a pre and post-design.
Data used included descriptive and nominal statistics of the participant population and medical providers. Outcome, process, balancing, and sustainability measures are depicted in Appendix G.
Data analysis was performed using the Intellectus software. The chi-squared test was used to test the effectiveness of the intervention on the identified outcomes. Since lung cancer screening can reduce lung cancer deaths by 20 percent, clinical significance was be determined by a significant increase in LDCT lung cancer screening from the baseline data (Velez Martinez et. al. 2020). A timeline of the project's schedule is shown in Appendix H.

Data collection tools and data collection process
Baseline data was collected by the PM for the four weeks prior to the intervention phase of the project. The clinic's manager of care coordination provided a weekly report that contained the number of patients treated each week, including the patient's age and sex; this demographic information, without any patient identifiers, was recorded in the data collection tool (see Appendix F) during all phases of the project. The weekly demographic and patient volume reports were generated directly from the clinic's EHR. The weekly demographic reports were stored on one of the clinic's computers and were password protected. During the intervention and evaluation phase of the project, the Lung Cancer Screening Audit Tool (LCSAT) was completed by the medical assistants assigned to each medical provider (see Appendix E). The completed information was shared with the medical provider to determine if each patient met LDCT lung cancer screening eligibility. The LCSATs contained no patient identifiers and were stored by the PM in a file drawer contained within one of the clinic's offices. Participant inclusion criteria for the LCSAT were patients ages 55 to 80 years and who were active or former smokers; this inclusion criterion was per the USPSTF guidelines (Moyer, 2014). All information from the LCSATs was also entered in the data collection tool by the PM. The PM created all data collection tools, and the face value for each tool was verified by the health system's Administrative Director of Cardiovascular Services.

Evaluation design
The project used a pre and post-evaluation design for outcome, process, balancing, and sustainability measurements (see Appendix G). The primary outcome measure was an observed increase in the number of LDCT lung cancer screens from the baseline to intervention and evaluation phases of the project. The data collected and analyzed included nominal and interval data. All data analysis was completed through the Intellectus software.

Analysis of the evaluation data
Descriptive statistics were obtained, and the Chi-square test was used to analyze the data. The project intervention phase (n = 1383, 36.4%), contained the largest number of patients seen at the clinic, followed by the baseline phase (n = 1218, 32%), and lastly the evaluation phase (n = 1197, 31.5%) (see Appendix I, Table 1). The most frequently observed category for LDCT Audit Forms submitted for evaluation per patient was (n = 3545, 93.3%), 19 followed by patients that did not have an LDCT Audit Form submitted (n = 253, 6.7%) (see Appendix I, Table 1). The most frequently observed category for LDCT orders during the project was No (n = 3779, 99.5%), meaning that an LDCT was not ordered, followed by Yes (n = 19, 0.5%), meaning that an LDCT was ordered (see Appendix I, Table 1). The most frequent observation regarding the determination of whether the patients met LDCT lung screen eligibility per the LDCT Audit Forms was No (n = 235, 84.2%), followed by Yes (n = 35, 12.5%), and Unable to determine (n = 9, 3.2%) (see Appendix I, Table 2). The rate of completion of the LDCT eligibility criteria questions on the submitted LDCT Audit Forms was Yes (n = 251, 89.96%) compared to No (n = 28, 10.04%) of the submitted LDCT Audit Forms that were not completely filled out (see Appendix I, Table 3). A "No" answer to any of the questions on the LDCT Audit Form would make the patient ineligible for LDCT lung cancer screening. The most frequent reason that a patient was ruled out for LDCT lung cancer screening, per the LDCT Audit Forms, was because the patient quit smoking more than 15 years ago (n = 146, 52.33%), followed by patients having a pack-year history less than 30 (n = 116, 41.58%) (see Appendix I, Table 4 for a complete listing of reasons the patients were ineligible for LDCT lung cancer screening). The intervention phase of the project had nearly double the number of LDCT orders compared to the baseline (baseline n = 5, intervention n = 9). Determination of whether the number of LDCT orders was dependent on the project phase was established by a Chi-square test. The Chi-square test did not show a statistically significant relationship (p = 0.609), based on an alpha value of 0.05, between the project intervention phase and the number of LDCT orders (see Appendix I, Table 5).

Determination of a clinical significance
The National Lung Screening Trial (NLST) showed that LDCT lung cancer screening could reduce mortality rates among high-risk patients by 20% (Honey, 2020). The number of patients needed to screen to produce clinically significant findings is 320 (Moyer, 2014).
Although just 18.6% of patients diagnosed with lung cancer have a five-year survival rate, 88% of patients diagnosed with lung cancer in its earliest stage live ten years after the lung cancer diagnosis (Pyenson & Tomicki, 2018). The completed LDCT lung cancer screening scans during this project showed that most of the patients scanned (n = 8, 42.1%) had negative findings (see Appendix I, Table 6). However, three of the scans yielded positive results, with nodules ranging from two to five millimeters (see Appendix I, Table 6). The patients with positive findings will be followed by the health system's lung nodule coordinator for further evaluation and treatment to optimize the chances of survival.

Effect on practice problem and practice
The practice problem for this DNP project pertained to increasing LDCT lung screening at a primary care clinic through an audit and feedback intervention. Although the results of the project were not statistically significant, the number of LDCT lung screenings nearly doubled during the intervention phase of the project (n = 9) in comparison to the baseline phase (n = 5).
However, during the evaluation phase, the number of LDCT lung screenings was that of the baseline quantity. The use of the Lung Cancer Screening Audit Tool (LCSAT), which was introduced to practice during the intervention phase of the project, allowed the providers to gain 21 knowledge of all criteria necessary to determine whether patients met LDCT lung screening eligibility. Prior to using the LCSAT, the clinic's providers had no way of knowing whether patients met eligibility criteria until after the LDCT lung screen was ordered. This lack of clarity within the EHR may have contributed to fewer LDCT lung screen orders.

Future implications and recommendations for sustainability
To prevent duplication of work, future modifications to the EHR that includes LDCT lung screen eligibility requirements within the social history may increase provider awareness and LDCT lung screen orders. Until the EHR can be modified appropriately, continued use of the LCSAT will ensue. For the sustainability of this project, the Manager of Care Coordination expanded the use of the LCSAT within all of the health system's clinics and has tasked each clinic's manager with ongoing audit and feedback.

Barriers and limitations
The most significant limitation of the audit and feedback intervention was that it bifurcated and duplicated the provider's workflow. In addition to documenting each patient's smoking status within the EHR, the providers were expected to document the same information on the LCSATs. This duplication of work negatively affected staff buy-in and compliance.
As this DNP project unfolded, it became apparent that the site of the project had numerous competing priorities. The project took place during the peak of the COVID 19 pandemic for its locals. The leaders and providers at the clinic were undoubtedly concerned with how the pandemic would impact operations and the care of their population. In addition, the clinic was experiencing a challenging level of turnover among its frontline clinical staff.

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Another significant limitation was that the audit process required manual audits of data from the LCSATs. Manual audits can be a barrier to sustainability since it is costly and timeconsuming. Furthermore, with manual audits, there is no way of determining if the information gleaned from the LCSATs is congruent with the data entered into the EHR.
Incorporating the entire process into the EHR would streamline the workflow and provide opportunities for electronic audits in the future.

Dissemination Plan
An essential component of DNP practice is evaluating nursing practice, reviewing best practice within the literature, and disseminating the best evidence into practice (American The intent of this DNP project was to increase the number of lung cancer screenings within a primary care clinic in Duval County, Florida. Studies show that audit and feedback is an evidence-based strategies for increasing preventative screening (Hwang et al., 2019;Murphy et al.,2017). Although this DNP project was able to increase lung cancer screening through the use 25 of audits and feedback, the results were not statistically significant. Until the lung cancer screening eligibility determination process is hard-wired within the EHR, sustainability for this project will be achieved through ongoing audit and feedback. ColonCancerCheck program. Current Oncology (Toronto, Ont.), 24 (1)

For Patients 55-80 years old (WITH A CURRENT OR FORMER SMOKING HISTORY)
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