Date Available


Year of Publication


Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Elizabeth Tovar

Clinical Mentor

Jessica Sass

Committee Member

Dr. Julianne Ossege

Committee Member

Dr. Cassilly Besten


Background: Sustainability is a domain or characteristic of quality in healthcare that is not just about what may be delivered to patients today, but what can continue to be delivered to patients in the long term. Evidenced based interventions and quality improvement (QI) initiatives have led to major advancements in health care and have become expected in every clinical setting. Despite the amount of QI work taking place, there is limited evaluation of the sustainability of initially successful quality improvement efforts and a lack of evidence supporting best strategies and measures to ensure that improvement of goals and outcomes are sustained.

Purpose: The purpose of the current study was to 1) evaluate the sustained impact of a quality improvement intervention initiated in November 2018 to improve colorectal cancer (CRC) screening rates and Cologuard® ordering rates in a single center, primary care setting and 2) explore current sustainability characteristics and strategies employed in this practice setting.

Methods: This was a multi-method descriptive study. A retrospective chart review following the same procedure as the original study was conducted from August 2020 through October 2020 to assess CRC screening and ordering rates in a primary care clinic. A sustainability culture survey, using the AHRQ Sustainability Tool, was completed by the clinic’s Director of Population Health and Practice Facilitation followed by a focused discussion about current sustainability characteristics, feasibility and utility of the AHRQ Sustainability Tool, and opportunities for improvement in sustainability practices. A survey was developed for providers in the clinic (Physicians and Advanced Practice Providers) to identify barriers and facilitators related to sustainability of CRC screening and ordering rates at the clinic.

Results: A total of 161 patient charts were reviewed and compared to the 200 patients reviewed in the original 2019 study. There was a significant decrease in up-to-date CRC screening from 71% (original study) to 59% (p=.017). Of the 41% not up to date, fewer patients in the current study had CRC screening ordered during the visit (19.7%), compared to 55.2% in the original study (p

Conclusions: Though results of CRC screening and ordering rates were found to be significantly decreased from the original QI study, Cologuard® ordering rates were significantly increased, and the primary care clinic’s CRC screening rate calculations have shown sustained improvement since 2019. Discussion and decisions about inclusion criteria for the calculation on which to base practice decisions is recommended. This study identified barriers, facilitators and sustainability characteristics in place at this clinic to sustain effective QI initiatives. Practice recommendations include modification of the AHRQ Sustainability Tool for primary care and the use of the AHRQ sustainability module to guide improvement efforts and ensure long-term sustainability.