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• The non-compliance rates of colon cancer screen documented in resident clinic note for our single internal medicine clinic decreased from 57.97% to 43.14% ( a decrease of 25.58 %, p = 0.054).

• The non-compliance rates of GI referral given by the resident physician for colon cancer screen not performed decreased from 89.66% to 66.07% (a decrease of 26.31%, p = 0.004).

• The process that was not directly related to our internal medicine clinic was colon cancer screen performance. During the post – intervention phase, attrition in our gastroenterology department led to a decrease in the number of physicians that could perform colonoscopies. Despite our efforts to improve documentation and referral practices in resident clinic, the non-compliance rate for colon cancer screen performance increased from 49.28% to 60.78% (an increase of 23.33%, p = 0.157).

Implementation of Six Sigma to Reduce Colon Cancer Screening Non-compliance Rates

Gbeminiyi Samuel MD1, Alex Onyemeh MD1, Mustafa Mustafa MD1, Victor Adimoraegbu MBA1, Iman Boston1, Leah Mitchell1, Morayo Fakiya MD, CLSSBB1

1Department of Internal Medicine, Howard University Hospital

• Colorectal cancer (CRC) is the 3rd most commonly diagnosed cancer 1.

• Rates are highest in African Americans and lowest in Asian Americans/ Pacific Islanders2. Incidence is about 43.9 per 100000 in District of Columbia placing it among the top 10 states 2.

• Incidence and mortality have trended down in the US. Screening may account for 53% of observed reduction in mortality3.

• While screening initiatives have increased, colonoscopy is the most commonly used screening test. Compliance with screening recommendations remains poor, with only 40% of cases diagnosed early 4-5.

• In our center, majority of our patients population are African American.

Background

D.M.A.I.C Model of Six Sigma

Summary

References

1. Torre LA, Bray F, Siegel RL, et al. Global cancer statistics, 2012. CA Cancer J Clin 2015; 65:87.

2. SEER*Stat Database: North American Association of Central Cancer Registries (NAACCR) Incidence-Cancer in North America (CiNA) Analytic File, 1995-2013, for NHIA v2 Origin, Custom File With County, American Cancer Society (ACS) Facts and Figures Projection Project

3. Centers for Disease Control and Prevention (CDC). Vital signs: Colorectal cancer screening, incidence, and mortality--United States, 2002-2010. MMWR Morb Mortal Wkly Rep 2011; 60:884.

4. Edwards Society AC. Colorectal Cancer Facts & Figures 2014–2016. Atlanta: American Cancer Society; 2014.

5. Howlader N, Noone AM, Krapcho M. et al. SEER Cancer Statistics Review, 1975–2008. Bethesda, (MD: ): National Cancer Institute; http://seer.cancer.gov/csr/1975_2008/, based on November 2010 SEER data submission, posted to the SEER web site, 2011 (Accessed Dec, 2015).

Measure

Analyze

Fishbone (Cause and Effect) diagram of colon cancer screening non-compliance

Improve

Control

Outcome Statement: Utilization of the DMAIC methodology of six sigma led to significant improvement in GI referral for colon cancer screen performance.

Define

Problem Statement:

• According to the United States Preventive Services Task Force (USPSTF), clinicians should screen average risk patients between the ages of 50 and 75 years for colon cancer. In the 2013 academic year, our single internal medicine resident clinic located in an urban academic center in Washington DC had deficiencies in colon cancer screening.

Aim Statement:

• Decrease the non-compliance rates of colon cancer screen documented in resident clinic note for our single internal medicine clinic by 20% over a four month period.

• Decrease the non-compliance rates of GI referral given by the resident physician for colon cancer screen not performed by 20% over a four month period.

Interdisciplinary Team:

• Our team consisted of the clinic attending physician who also served as the certified Six Sigma Black Belt process owner, clinic resident physicians, medical students, medical assistants, and patient navigator.

Current Colon Cancer Screening Process Map