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Upstream Change: Policy, systems and environmental change through CCC coalitions, Part One

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If your coalition is like most comprehensive cancer control coalitions, when you hear the words “policy, system and environmental change” or PSE, you might think:

Policy change? We can’t do that can we?

System change? That’s too hard!

Environmental change? That’s too costly.

If you have had these thoughts, you are not alone. We often think large scale change is too difficult, costly and not possible. But, look at these strategies from current CCC plans:

  • Decrease tobacco industry marketing to minors at point-of-sale checkout counters.
  • Ensure that adequate opportunities for safe physical activity are available (e.g. built environments, green spaces, community recreation facilities, walking trails and safe sidewalks).
  • Work with organizations such as 4-H, Boy Scouts, Girl Scouts, and Boys and Girls Clubs to include sun safety education within their programs and/or to develop policies or recommendations surrounding sun safety at their events.
  • Ensure that the implementation of the Patient Protection and Affordable Care Act in our state includes access to breast cancer screening, diagnostic, and treatment services.
  • Promote the use of survivor care plans by patients, healthcare providers and systems.
  • Collaborate with the Office of Public Instruction to advocate for best policies and practices for childhood cancer survivors and their siblings.

If you thought “these look familiar” or “our coalition could do that” then you are already working on PSE changes or could begin to work on them.

PSE changes are focused on “upstream” or early factors that use legislative, community or organizational change to positively affect the world we live in. PSE efforts result in long-lasting sustainable change that doesn’t just rely on individual behavior change, but also creates the environment to either make it easier (eat healthier, increase access to screening, exercise more) or harder (restrict smoking, remove soda machines in schools) to engage in an individual behavior. PSE change is upstream change that helps individuals do what they need to do to get and stay healthy.

So, as a CCC coalition, how do you choose which PSE changes to work on? As a starting point, look at the current priorities your coalition is working on or the strategies listed in your CCC plan. Ask yourself: are any of these policy, system or environmental change strategies? If you answer yes, that’s great. Make sure your coalition members understand that they are working on PSE changes and encourage your teams to access tools and resources to ensure quality implementation of PSE strategies, such as:

CDC’s Communities Putting Prevention to Work Program Resource Center

CDC’s CHANGE Tool: Community Health Assessment aNd Group Evaluation Tool

American Cancer Society Cancer Action Network Resources

Michigan Cancer Consortium’s PSE Web Page

If you answer no, that your coalition is not working on PSE changes, then look at your plan and see if any PSE strategies are already in your plan. Consider choosing these PSE strategies as you work on your cancer plan priority objectives. If you look at your cancer plan and realize there are no PSE strategies, talk with your coalition leadership to see if you should consider incorporating PSE change into your CCC plan implementation.

For an innovative view of upstream change, check out Rebecca Onie’s TED Talk, What if our healthcare system kept us healthy?

Join us for next month’s Coalition Corner conversation when we continue focusing on PSE change and highlight some examples of CCC coalitions successfully working on PSE change strategies. But, you don’t need to wait until then: Join the conversation now! What kinds of PSE change strategies is your coalition working on now?  



Related to this discssion are

Related to this discssion are the final revised/restated lobbying restrictions for CDC grantees. Re-posting from Trust for America's Health:

In 2005, the IOM released a

In 2005, the IOM released a report called "Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia." My understanding is that this was developed at the request of Georgia's comprehensive cancer control coalition. I think it would be very interesting to see how they have used this report, and how other states have looked into quality of care data, and then what they have done with that data. Do you know of any states that have taken this on? If so, what have they done?

Hi Kristi. Thanks for your

Hi Kristi. Thanks for your question and comment. Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia describes and recommends a set of 52 quality indicators with which the Georgia Cancer Coalition can measure Georgia's progress in improving cancer care and reducing the number of cancer cases and deaths. The report can be found on the IOM website at:  In fact the Georgia Cancer Coalition used the quality indicators to help shape their current CCC plan which can be found on Cancer Control P.L.A.N.E.T. The measures outlined in the IOM report are being used to assess progress in implementation of the cancer plan in the state.

We agree! The type of quality indicators used by the Georgia Cancer Coalition can be used by other CCC coalitions to measure progress and drive action around improving the quality of cancer care. Many CCC coalitions are partnering with Commission on Cancer (CoC) accredited cancer programs to use data from the National Cancer Data Base (NCDB) to better understand the quality of cancer care delivery in their communities. Also, many CCC coalitions have specific objectives in their CCC plans aimed at increasing the number of CoC-accredited cancer programs in their state or region.

Join the discussion! What is your CCC coalition doing to improve quality of cancer care? What kinds of data and measures are you using to gauge progress and drive action? 

That's really interesting

That's really interesting about the coalitions that partner with the CoC programs to use data from the National Cancer Data Base. I participated in the webinar on how CCC programs and the CoC in their state can work together, and looked into the CoC more. I saw that they do collect data, but didn't think about a potential partnership in this area. One of the concerns here over the quality indicators in the IOM report, was HOW to even go about collecting the data. We've been told that the cancer registry here is linking our SEER and Medicare data, but I didn't even think about asking the state CoC chair about getting access to their database. We'll have to stregthen our relationship with our CoC chair and look into this some more.

I also hadn't thought to look at Georgia's plan, which in hindsight should have been one of the first places I went. Thanks for your feedback! I was feeling like this was important data to consider, but had hit a wall which you have helped me move around! I feel like I have some new avenues to explore.

Thanks again!

 Kristi, We are very proud of

 Kristi, We are very proud of the "Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia" IOM report. In addition to using the report as the foundation for Georgia's current Comprehensive Cancer Control Plan, we have used the report in many other ways. Here are just a few:

We had several organizations participate in pilot programs to implement the measures. St. Joseph's Cander (SJ/C) in Savannah, GA was the first to conduct a pilot program. Once you begin to measure metrics, you experience process improvements. For example: Measure 5-1: Diagnosing Cancer - Timely Cancer Biopsy: this measure states that for a bi-rad 4 or 5 abnormal mammogram, the biopsy should be completed within 14 days. They were able to reduce the time to biopsy to less than 14 days by leveraging patient navigators. SJ/C developed a toolkit to assist others in collecting the data.

  • A short time later, SJ/C was selected as an NCI Community Cancer Center Program (NCCCP) site. The Georgia Cancer Coalition help facilitate a clinical alliance between SJ/C, Harbin Clinic in Rome, GA and John B. Amos Cancer Center in Columbus, GA.
  • The clinical alliance worked on a Breast Cancer Patient Navigation research program. All three sites were at various stages of their navigation efforts. They used navigators to address several of the 52 measures in the IOM report. ACCC selected them as a 2011 Innovator Awardee. .
  • Nancy N. and J.C. Lewis Cancer & Research Pavilion at St. Joseph's/Candler, Savannah, Ga.

    Harbin Clinic, Rome, Ga.

    The Medical Center, Inc., John B. Amos Cancer Center, Columbus, Ga.

    Navigating for Improved Outcomes

In 2008, the Georgia Pain Initiative was reconvened and developed a strategic plan. We leveraged the IOM measures 6-11: Treating Cancer - Cancer Paint Assessment; 6-12: Treating Cancer - Prevalance of Pain Among Cancer Patients; 6-14: Treating Cancer - Cancer Patients' Hospice Length of Stay to include in the strategic plan. No need to reinvent the wheel.


Angie -  Thank you so much

Angie - 

Thank you so much for your response! Out of curiousity, were the facilities (such as SJ/C) looking at this kind of data prior to the report? One thing I keep coming up against is, "aren't the facilities already looking at this?" and "Is that really our role? What would we do to impact those measures"? My instinct says that yes, as the CCC coalition we do have a reason to look at it, as it directly relates to a very important piece of the cancer continuum. What would we do about it? Some sort of professional education I would guess, but since we haven't looked at it, I'm not sure. I'm having a harder time expressing my thoughts on this though, in a way that seems to make sense without relying on my "intuition." Does anyone else have some thoughts on this, whether they agree that it is something CCC should look at, or whether it's not?

One other thing that I hear is that with the ACA and meaningful use, these types of treatment issues should work themselves out because the facilities will have to look at them. I never really know what to think about that, because I'm not very familiar with the ACA, other than the major (and basic) provisions.

The 14th edition of “How Do

Followers of this discussion might be particularly interested in the 14th edition of “How Do You Measure Up?” This report by the American Cancer Society Cancer Action Network rates states on the strength of policies including:

  • smoke-free workplace laws,
  • tobacco taxes,
  • funding for tobacco prevention and cessation programs and
  • cessation coverage under Medicaid, funding for cancer screening programs and
  • indoor tanning restrictions for minors.

The report also looks at whether or not states:

  • have accepted available federal funds to increase access to care through their Medicaid program,
  • passed policies to increase patient quality of life,
  • ensured patients who need oral chemotherapy drugs have the same access to them as to intravenous chemotherapy and
  • adopted balanced approaches to provide access to pain medications.

The following link will direct you to our landing page, where you can access state by state report cards as well as the full report:

The Comprehensive Cancer

The Comprehensive Cancer Control National Partnership had such a productive leadership meeting last week that I am still digging out and thinking about the insights I gleaned.

One of the topics we grappled with was building capacity for coalitions involved in "upstream", policy interventions.  Stay tuned! But in the meantime, I would like to share something that landed in my inbox.  

CDC, the Georgia Health Policy Center, and the National Network of Public Health Institutes have developed the 2016 Leading Through Health System Change Planning Tool.

The online tool guides public health leaders through a five-step planning process with information about the Affordable Care Act, common questions raised by health reform and health system transformation, and action steps to support strategic thinking and implementation. The updated tool can help health departments and their partners navigate the technical and adaptive challenges associated with health system transformation.

Is adaptive thinking a strategy you use in your work?  The toolbox creators believe that the steps in this process are key to helping leaders focus on the actions that lead to innovation and strategic thinking.  

How do you convene others around these difficult, yet important discussions? And do let me know what you think about this tool.....