Preventive Care - Key Activity 1


Convene a Multidisciplinary Implementation Team for Cancer Screening


This activity involves preparing the practice to address all seven elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.


This activity provides guidance for developing, launching and sustaining the multidisciplinary team within your practice that will be responsible for the planning and implementation of all of the key activities in this guide and overseeing related quality improvement and equity efforts, as outlined in Appendix C: Developing a Robust Measurement Strategy.

The implementation team is so important that it appears first in our sequenced list of key activities. Improving your practice’s key outcomes for each population of focus and reducing equity gaps requires the aligned efforts of all care teams and nearly all functional areas of the practice, not just those working directly with patients.

This team is responsible for ensuring that all key activities in this guide, including those related to screening for social needs, are implemented. As you put together this multidisciplinary implementation team, you should identify a diverse group of staff who are reflective of the community served and who represent the lived experience of patients. In addition to implementing the activity focused on and applying a systematic approach to decrease health inequities, the team should apply an equity lens to every step outlined in this guide to help ensure that any improvements are equitably spread among the patient population. To achieve optimal functioning and impact, all members of this diverse multidisciplinary team should have their perspectives proactively included.

Relevant health information technology (HIT) capabilities to support this activity include care guidelines, registries, clinical decision support, care dashboards and reports, quality reports, outreach and engagement, and care management and care coordination (see Appendix E: Guidance on Technological Interventions). To enable team coordination, thought must be given to how to access relevant technology and how data is consistently captured, can be distributed, integrated into workflows, and how data is accessible across team members. Where possible, it is desirable to avoid duplication of data entry, siloing of information in standalone applications and databases, and the need to work in multiple applications requiring separate logins.

Action steps and roles

1. Develop a time-limited group of leaders within the practice to start this process.

Suggested team member(s) responsible: Chief medical officer or equivalent and office manager or quality improvement coordinator.

Start with a small group of leaders from your practice (some of whom will be on the implementation team) who can help refine the charge or scope of work of the implementation team and both identify and engage the people/roles that will be required to implement the scope of work of the team.


2. Develop a preliminary scope of work or charge outlining the responsibilities of the implementation team.

Suggested team member(s) responsible: Time-limited group of practice leaders.

This scope or charge includes but may not be limited to enabling, aligning, leveraging and supporting the planning and implementation of all foundational key activities in this implementation guide for pregnant people so that the practice meets the foundational competencies for providing high-quality prenatal care.

However, there may be further foundation building work needed at your practice in order for you to succeed at the above key activities. The Population Health Management Capabilities Assessment Tool (PhmCAT) is a multidomain assessment that is used to understand current population health management capabilities of primary care practices. This self-administered tool can help your practice identify opportunities and priorities for improvement.

If your practice has not scored highly in the domains of leadership and culture; the business case for population health management, technology and data infrastructure; or empanelment and access, consider implementing the activities listed in the four guides on Building the Foundation before or in parallel to working on key activities related to adult preventive care.

The multidisciplinary implementation team should include those empowered to make changes in workflows, policies and staff assignments. They should be respected influencers in the organization (early adopters) who can also guide the change management process. They should also include those with expertise in partnering with patients on cancer screenings.


3. Identify leadership and key actors for the implementation team.

Suggested team member(s) responsible: Time-limited group of practice leaders.

  • Appoint a “champion” or lead person (e.g., “pregnant people implementation coordinator” to oversee the implementation and coordination of the team.
  • Identify key staff who will be the core members of the implementation team. Ensure diversity of position and diversity of gender/race/language. Compensate non-employee members of the team equitably for their time (e.g., patients or community members with lived experience).
  • For the adult prevention multidisciplinary implementation team, it is important to include members of the care team, the patient support team, outreach team, social support team, and the electronic health record (EHR) or data team. This could include a core team and an expanded team. Potential members include:
    • Adult and family primary care providers (e.g., medical doctor (MD), doctor of osteopathic medicine (DO), advanced practice registered nurse (APRN), or a physician assistant (PA)).
    • Registered nurse (RN).
    • Medical assistant (MA) or licensed vocational nurse (LVN).
    • Social worker.
    • Care coordinator.
    • Community health worker.
    • A member of the information technology (IT) or EHR team, (as part of the expanded team).
    • QI lead.
    • Billing manager or similar (as part of the expanded team).
    • A frontline staff member who interfaces with patients by phone and at check-in.
  • Invite identified people to become part of the implementation team and ensure that they have designated time for their participation and/or are compensated equitably for their time.

Teams should engage representation from information technology (IT) to support the work of pulling data from the electronic health record (EHR) and embedding updated data into tracking and evaluation.


4. Launch the implementation team and set it up for success.

Suggested team member(s) responsible: Clinical coordinator, chief operating officer (COO), or chief medical officer (CMO).

This work includes:

  • Ensuring that the team understands their charge or scope of work.
  • Developing a team charter outlining this work.
  • Defining roles and responsibilities including the anticipated commitment (in hours) on a monthly basis. Create a compensation plan for nonemployee members of your team (e.g., patients or community members).
  • Establishing a meeting structure, file structure and communications structure to support effective, efficient work.
  • Dedicating time and effort to forming, storming, norming and performing as a team. The Team Communication and Working Styles Template is one tool that team members can complete and share with other teammates to accelerate this process.
  • Understanding baseline data related to outcomes of interest (e.g., timely postpartum visits and baseline prenatal depression screening), along with data related to known and perceived barriers to these outcomes. Assess stratified outcomes data to identify quality performance disparities in particular subpopulations.
  • Prioritizing elements within the scope of work, informed by baseline data and identified population needs

We recommend that practices consider planning and attempting to implement the activities in the sequence provided in this guide, focusing first on the key activities before focusing on the activities suggested under “Going Deeper” or “On the Horizon.” However, different practices may follow different paths toward implementation


5. Develop a simple yet robust measurement strategy and learning system to guide your improvement efforts.

Suggested team member(s) responsible: QI lead or equivalent.

A learning system enables a group of people to come together to share and learn about a particular topic, to build knowledge and speed up improved outcomes. A simple yet robust measurement strategy and learning system:

  • Contains a balanced set of measures looking at outcomes, processes and possibly unintended secondary effects (e.g., increased cycle time and impact on team well-being).
  • Incorporates the patient perspective and the perspective of staff (front desk and others), care team members, and management.
  • Allows the team to determine if the process or system has improved, stayed the same, or gotten worse.
  • Helps guide improvement efforts and informs practice operations. See Appendix A: Sample Idealized System Diagram: Weaving Your Measurement Strategy and Learning System into Practice Operations for a sample system diagram for how your measurement strategy can be used to support practice operations.

Your practice should track the core and supplemental measures for colorectal cancer, breast cancer and cervical cancer screening. These can be considered outcome measures because there is ample evidence that improved timely screening rates will improve overall population health outcomes for cancer survival.

In addition to the core and supplemental measures, practices should track process measures and balancing measures. Appendix C: Developing a Robust Measurement Strategy describes and defines the key milestones in the development of a robust measurement strategy, including definitions for each of these terms.

Suggested process measures:

  • Percentage of adults who are sent a reminder regarding colorectal cancer screening who initiate screening activity.
  • Percentage of adults who are sent a reminder regarding breast cancer screening who initiate screening activity.
  • Percentage of adults who are sent a reminder regarding cervical cancer screening who initiate screening activity.

Suggested balancing measures:

  • One or more measures related to patient satisfaction.
  • One or more measures related to staff satisfaction.

Practices can also look at other metrics to understand the progress of specific improvement initiatives over time. These may include:

  • Progress on the Population Health Management Capabilities Assessment Tool (PhmCAT).
  • Progress towards foundational competencies listed in this implementation guide. For example, “Yes or No: Did your practice achieve the following foundational competency ‘Develop a process for screening pregnant and postpartum people for depression, using evidence-based tools’?”
  • Any other care gaps, clinical guidelines or measures your practice feels are important to prioritize.

Applying an equity lens

Your practice is likely achieving better outcomes with some patients than others. To understand who the practice is achieving poorer adult prevention outcomes for, practices should stratify their data based on race, ethnicity and language (REAL); sexual orientation and gender identity (SOGI); and other patient characteristics (e.g., social needs, etc.) within the Population of Focus. See more in Key Activity 4: Use a Systematic Approach to Address Inequities within the Population of Focus. The ability to segment data in such a manner can lead to profound insights about structural challenges driving some of the health outcomes. The Advancing Equity Through Data Quality and Reporting section of the PHMI Data Quality and Reporting Guide provides more guidance on this.

Putting it all together

We recommend that your practice record your measurement strategy in one place. This Measurement Strategy Tracker contains all the fields we believe are most useful; it can be customized to meet your practice’s needs.


6. Plan and implement regularly scheduled meetings of the implementation team.

Suggested team member(s) responsible: QI lead or equivalent.

  •  Hold time on team members' calendars for standing meetings. Consider biweekly (twice monthly) meetings to start with. The frequency, duration and focus of these meetings may change as you consider additional populations or subpopulations, additional sites or locations, and the changing nature of the work.
  • Develop a system to efficiently report on all work streams and track follow-up items. The Action Plan Template is one tool that can be used to focus your team around the foundational competencies and define responsibility for actions steps to be taken for each project your team has prioritized to work on.


7. Make adjustments based on data from the team’s measurement strategy and feedback loops.

Suggested team member(s) responsible: Multidisciplinary team.

  •  Review data and feedback at least monthly and adapt efforts as needed. Adaptation could include any or all of the following:
    • Amending the charge or scope of work.
    • Modifying meetings or meeting structures.
    • Changing the team composition (adding or removing members).
    • Refining key activities to better meet the needs of patients and practice staff and to improve outcomes or reduce inequities.
    • Modifying the measurement strategy and/or feedback loops to better understand what is and isn’t happening.
  • On an annual basis, the team’s charter and core membership should be reviewed. As the implementation team's goals are met, the team could disband, meet less frequently (e.g., twice per year), or fold this meeting into a similar standing meeting that occurs separately.

See also Appendix D: Peer Examples and Stories from the Field to learn about how others are implementing this activity.

Evidence base for this activity

Pandhi N, Kraft S, Berkson S, Davis S, Kamnetz S, Koslov S, Trowbridge E, Caplan W. Developing primary care teams prepared to improve quality: a mixed-methods evaluation and lessons learned from implementing a microsystems approach. BMC Health Serv Res. 2018 Nov 9;18(1):847. doi: 10.1186/s12913-018-3650-4. PMID: 30413205; PMCID: PMC6230270.

Sarfaty M, Wender R. How to Increase Colorectal Cancer Screening Rates in Practice. CA: A Cancer Journal for Clinicians. 2007 Nov 1;57(6):354–66.

Percac-Lima S, Grant RW, Green AR, Ashburner JM, Gamba G, Oo S, et al. A Culturally Tailored Navigator Program for Colorectal Cancer Screening in a Community Health Center: A Randomized, Controlled Trial. Journal of General Internal Medicine. 2008 Dec 6;24(2):211–7.

Dougherty MK, Brenner AT, Crockett SD, Gupta S, Wheeler SB, Coker-Schwimmer M, et al. Evaluation of Interventions Intended to Increase Colorectal Cancer Screening Rates in the United States. JAMA Internal Medicine. 2018 Dec 1;178(12):1645.

Adams SA, Rohweder CL, Leeman J, Friedman DB, Gizlice Z, Vanderpool RC, et al. Use of Evidence-Based Interventions and Implementation Strategies to Increase Colorectal Cancer Screening in Federally Qualified Health Centers. Journal of Community Health. 2018 May 16;43(6):1044–52.