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Quality improvement collaboratives (QICs) have long been used to facilitate group learning and implementation of evidence-based interventions (EBIs) in healthcare. However, few studies systematically describe implementation strategies linked to QIC success. To address this gap, we evaluated a QIC on colorectal cancer (CRC) screening in Federally Qualified Health Centers (FQHCs) by aligning standardized implementation strategies with collaborative activities and measuring implementation and effectiveness outcomes. In 2018, the American Cancer Society and North Carolina Community Health Center Association provided funding, in-person/virtual training, facilitation, and audit and feedback with the goal of building FQHC capacity to enact selected implementation strategies. The QIC evaluation plan included a pre-test/post-test single group design and mixed methods data collection. We assessed: 1) adoption, 2) engagement, 3) implementation of QI tools and CRC screening EBIs, and 4) changes in CRC screening rates. A post-collaborative focus group captured participants' perceptions of implementation strategies. Twenty-three percent of North Carolina FQHCs (9/40) participated in the collaborative. Health Center engagement was high although individual participation decreased over time. Teams completed all four QIC tools: aim statements, process maps, gap and root cause analysis, and Plan-Do-Study-Act cycles. FQHCs increased their uptake of evidence-based CRC screening interventions and rates increased 8.0% between 2017 and 2018. Focus group findings provided insights into participants' opinions regarding the feasibility and appropriateness of the implementation strategies and how they influenced outcomes. Results support the collaborative's positive impact on FQHC capacity to implement QI tools and EBIs to improve CRC screening rates.

Introduction Practice facilitation involves trained individuals working with practice staff to conduct quality improvement activities and support delivery of evidence-based clinical services. We examined the feasibility of using practice facilitation to assist federally qualified health centers (FQHCs) to increase colorectal cancer screening rates in North Carolina. Methods The intervention consisted of 12 months of facilitation in 3 FQHCs. We conducted chart audits to obtain data on changes in documented recommendation for colorectal cancer screening and completed screening. Key informant interviews provided qualitative data on barriers to and facilitators of implementing office systems. Results Overall, the percentage of eligible patients with a documented colorectal cancer screening recommendation increased from 15% to 29% (P < .001). The percentage of patients up to date with colorectal cancer screening rose from 23% to 34% (P = .03). Key informants in all 3 clinics said the implementation support from the practice facilitator was critical for initiating or improving office systems and that modifying the electronic medical record was the biggest challenge and most time-consuming aspect of implementing office systems changes. Other barriers were staff turnover and reluctance on the part of local gastroenterology practices to perform free or low-cost diagnostic colonoscopies for uninsured or underinsured patients. Conclusion Practice facilitation is a feasible, acceptable, and promising approach for supporting universal colorectal cancer screening in FQHCs. A larger-scale study is warranted.

D iabetes is a chronic disease that affects > 25.8 million Americans.1 In the United States, the total annual economic cost of diabetes in 2007 was estimated to be $174 billion.1 In North Carolina, > 640,000 adults (9.3%) have been diagnosed with diabetes, and it is estimated that another 232,000 are undiagnosed and 376,000 have prediabetes. Diabetes is the seventh-leading cause of death in North Carolina. The prevalence rates for diabetes include 15.6% in African Americans, 12.4% in American Indians, 8.4% in whites, and 6.1% in Hispanics.2 North Carolina's Medicaid program spent $525 million for diabetes-related medical care and prescription drugs for 127,991 adults from July 2007 to July 2008. The prevalence of diagnosed diabetes was 15.7% in the Medicaid population, which was 64% higher than the prevalence in the state's general adult population.3 The average expenditure per adult with diabetes within the Medicaid program was $4,098.3 Figure 14 illustrates the categories of Medicaid expenditures for people with diabetes, with skilled and intermediate nursing care, physician and other medical services, and hospital services and outpatient clinics accounting for the largest proportion of expenditures. On average, Medicaid spent $1,224 for skilled and intermediate nursing care, $1,192 for physician and other medical services, and $235 for prescription drugs per person with diabetes during this period.4 Appropriate medical care, diabetes self-management education (DSME), and medication must be available to everyone with diabetes to prevent complications. DSME teaches people with diabetes how to manage their disease with medications, diet, exercise, and stress reduction. DSME is such a crucial part of diabetes care that medical treatment without it is considered inadequate.5 Yet, the 2008 N.C. Behavioral Risk Factor Surveillance Survey showed that only 45% of adults with diabetes had ever taken a class on how to manage …

Article-at-a-Glance Background Multisite quality improvement (QI) initiatives, often known as collaboratives, involving primary care practices such as community health centers, academic practices, and managed care groups have been reported. Yet relatively little is known about the sustainability of these QI initiatives after the initial project, and frequently its funding, has ended. A series of practice characteristics that constitute critical elements for QI sustainability activities, as described in a Sustainability Pyramid Model, were proposed. Methods Approximately five months after the cessation of formalized activities of the final collaborative, 25 in-person interviews were conducted in 13 primary care practices that had participated in the three North Carolina Chronic Disease Management collaboratives, which initially involved 33 practices. Clinical outcomes were not considered. Findings Twelve of the 13 practices stated that the collaborative work resulted in improvement in one or more process and/or outcome clinical measures and those improvements have been continued. Five of the 13 practices reported that sustaining improvements had been a challenge since the collaboratives ended. Content analysis of the interviews indicated that the practices variously cited the practice characteristics, as included in the Sustainability Pyramid Model: regular meetings to study practice population data, leadership commitment, availability of infrastructure/staff support, pursuit of additional funding, publicity, and strategic partnerships. Discussion Although the improvement activities initiated during the collaborative were sustained, the process of developing and implementing new QI activities appeared to be more challenging for almost half of the practices. The practices that could accomplish this ongoing new QI process had "institutionalized" their QI strategies—a finding with important implications for sustainability.

Article-at-a-Glance Background The Bureau of Primary Health Care (BPHC) adopted a collaborative approach that used the Chronic Care Model and quality improvement methods. The North Carolina Diabetes Prevention and Control Branch has partnered with the 12 participating community health centers since early 2000. Methods Team leaders of the first four centers that participated in the collaboratives were interviewed. Information obtained included previous diabetes efforts, benefits of the collaborative, success factors, and barriers to sustainability. Case Study In one of two case studies, a nonprofit community health center made Chronic Care Model-based changes to the organization of health care, clinical information systems, and delivery system design. Results Centers tracked used the electronic registry to establish a baseline, trend key process and outcome measures, and raise the standard of care. Success factors included senior leadership support, physician champions, multidisciplinary teams, and priority of collaborative activities. Barriers included staff turnover and low priority in strategic planning. Glycohemoglobin (A1C) values from aggregated reports demonstrated improvement. Discussion Useful strategies for future collaboratives may include providing provider-specific data, imparting vision to new team members, ensuring that leadership provides collaborative structure and resources, and pairing veteran and new participating sites.