Implementing a Survivorship Screening Tool in Breast Cancer Survivors: An Evidence-Based Quality Improvement Project

With advancements in cancer therapies, more patients are achieving remission. Following treatment, many of these patients struggle with ongoing physical, psychosocial, and practical concerns (Hussey et al., 2024). Providers face challenges in identifying and meeting these specialized needs while managing capacity (Love et al., 2022). The National Comprehensive Cancer Network (NCCN) recommends using standardized screening tools to identify unmet physical and psychosocial needs in cancer survivors (Sanft et al., 2023). Providers at an outpatient breast oncology clinic in Salt Lake City, UT, do not utilize a standardized tool to assess for unmet needs post-treatment, leading to potential missed identification of patients' needs and missed opportunities for referrals to survivorship resources. This project aimed to implement a standardized screening protocol to improve need identification and increase referrals. A quality improvement project was designed to improve the quality and quantity of screening for unmet needs in breast cancer survivors. The NCCN Survivor Assessment Survey was adapted to fit clinic needs and implemented with four providers over six weeks. Pre- and post-implementation surveys assessed provider screening practices, attitudes, and knowledge of survivorship resources. Education sessions with involved staff reviewed the screening tool, workflow, and available resources. Weekly provider feedback provided opportunities for adjustments to the protocol as needed. Screening and referral rates were analyzed and collected from the electronic health record (EHR). Data from survey responses were compiled and analyzed. Implementing a standardized screening protocol increased screening rates, identification of needs, and referrals to survivorship resources. 92% (n=123) of patients screened reported at least one unmet need, and 71% (n=88) of those patients were referred to survivorship resources, compared to 43% (n=77) before implementation. All providers (n=4) found the tool easy to use and integrate into their clinical workflow. 75% (n=3) of providers were satisfied with the tool, with 25% (n=1) neutral. Providers noted improved need identification and patient provider communication. Implementation of a standardized screening tool to assess for unmet needs in breast cancer survivors is effective and increases referrals to survivorship resources. The next steps include integrating the tool into the EHR for streamlined delivery and expanding it to other clinics and diagnosis groups within the organization.

1 Implementing a Survivorship Screening Tool in Breast Cancer Survivors: An EvidenceBased Quality Improvement Project Kate E. Blake, Jennifer Clifton, & Shelley White College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III April 18, 2025 2 Abstract Background: With advancements in cancer therapies, more patients are achieving remission. Following treatment, many of these patients struggle with ongoing physical, psychosocial, and practical concerns (Hussey et al., 2024). Providers face challenges in identifying and meeting these specialized needs while managing capacity (Love et al., 2022). The National Comprehensive Cancer Network (NCCN) recommends using standardized screening tools to identify unmet physical and psychosocial needs in cancer survivors (Sanft et al., 2023). Local Problem: Providers at an outpatient breast oncology clinic in Salt Lake City, UT, do not utilize a standardized tool to assess for unmet needs post-treatment, leading to potential missed identification of patients’ needs and missed opportunities for referrals to survivorship resources. This project aimed to implement a standardized screening protocol to improve need identification and increase referrals. Methods: A quality improvement project was designed to improve the quality and quantity of screening for unmet needs in breast cancer survivors. The NCCN Survivor Assessment Survey was adapted to fit clinic needs and implemented with four providers over six weeks. Interventions: Pre- and post-implementation surveys assessed provider screening practices, attitudes, and knowledge of survivorship resources. Education sessions with involved staff reviewed the screening tool, workflow, and available resources. Weekly provider feedback provided opportunities for adjustments to the protocol as needed. Screening and referral rates were analyzed and collected from the electronic health record (EHR). Data from survey responses were compiled and analyzed. Results: Implementing a standardized screening protocol increased screening rates, identification of needs, and referrals to survivorship resources. 92% (n=123) of patients screened 3 reported at least one unmet need, and 71% (n=88) of those patients were referred to survivorship resources, compared to 43% (n=77) before implementation. All providers (n=4) found the tool easy to use and integrate into their clinical workflow. 75% (n=3) of providers were satisfied with the tool, with 25% (n=1) neutral. Providers noted improved need identification and patientprovider communication. Conclusion: Implementation of a standardized screening tool to assess for unmet needs in breast cancer survivors is effective and increases referrals to survivorship resources. The next steps include integrating the tool into the EHR for streamlined delivery and expanding it to other clinics and diagnosis groups within the organization. Keywords: Breast cancer survivors, standardized screening tool, unmet physical needs, unmet psychosocial needs, cancer survivors 4 Implementing a Survivorship Screening Tool in Breast Cancer Survivors: An EvidenceBased Quality Improvement Project Problem Description Approximately 16.9 million Americans are cancer survivors (Gallicchio et al., 2021). This number is expected to increase to 22.2 million by 2030 (Gallicchio et al., 2021). Cancer survivors require specialized care and attention to address the multi-system and psychological impact of adult-onset cancer and its treatment (Hussey et al., 2024). Providers face significant challenges in identifying and meeting these specialized needs while managing capacity and transitioning patients to appropriate post-treatment care. These challenges negatively impact patients, with 83% of cancer survivors reporting at least one unmet need (Andreu et al., 2022). To ensure needs are appropriately identified and addressed in this population, the National Comprehensive Cancer Network (NCCN) Guidelines recommend screening for unmet physical and psychosocial needs in cancer patients who have completed treatment (Sanft et al., 2024). Currently, no standardized survivor-specific screening tool is utilized in the outpatient breast oncology clinic in Salt Lake City, Utah. There is a critical need for further assessment of patient needs post-treatment, as well as streamlined processes and enhanced education to support patients and providers in bridging this gap. Additional work is needed to implement a screening process to identify patients with unmet needs and facilitate referrals to appropriate survivorship resources. Available Knowledge Cancer survivors have specialized needs that are often not identified or adequately addressed at visits with their oncologist or primary care provider. These needs go unnoticed due to a lack of standardized screening tools, patients’ reluctance to disclose concerns, uncoordinated 5 care, or visit time limitations (Gallicchio et al., 2021; Hydeman et al., 2021). Survivors across all diagnosis groups consistently endorse fatigue, financial concerns, worry about the future, sexual health, exercise, healthy eating, and fear of recurrence as concerns (Carreira et al., 2021; Hussey et al., 2024; Hydeman et al., 2021; Maio et al., 2022; McDonough et al., 2021; Sanft et al., 2023; Vuksanovic et al., 2021). Breast cancer patients specifically identify fear of recurrence, problems with sleep, anxiety, aches, and memory impairment as concerns (McDonough et al., 2021). 86% of patients report at least one unmet need, with many reporting needs in multiple domains (Andreu et al., 2022). Survivorship resources that address these needs are often underutilized (Vuksanovic et al., 2021). Tools utilizing patient-reported outcome measures (PROMs) effectively identify patients with unmet needs and connect them to appropriate resources (Hydeman et al., 2021). The European Society for Medical Oncology and NCCN clinical guidelines recommend PROMs and standardized screening tools to identify and monitor new or persisting symptoms in cancer survivors (Maio et al., 2022; Sanft et al., 2023). The NCCN Survivor Assessment Survey is one such tool that utilizes PROMs for this purpose (Hydeman et al., 2021; McDonough et al., 2021). These tools consistently identify patients with unmet needs and are well-accepted by providers, as they facilitate discussion on otherwise unaddressed issues (DeGuzman et al., 2021; Hyams et al., 2023; McDonough et al., 2021). Studies indicate that providers consider the tools useful and not burdensome (McDonough et al., 2021). Standardized screening tools are favorably received by patients, with 95% finding the questionnaire topics relevant and reporting high satisfaction (Hydeman et al., 2021; McDonough et al., 2021). PROM implementation is associated with improved quality of life, perception of care, and overall patient health (Lau et al., 2024; Singhal et al., 2024). 6 While many studies report positive perceptions of PROMs, barriers to implementation prevent widespread usage. These barriers include doubts about clinical usefulness, limited provider capacity to respond to PROMs, inadequate support for implementation, and conflicts with the clinical workflow (Easpaig et al., 2020; Singhal et al., 2024). Additionally, previous screening tools were not evaluated for reliability, validity, cross-cultural validity, and responsiveness (Tian et al., 2019). Newer screening tools, including the one implemented in this study, have been evaluated, demonstrating strong internal consistency with a Cronbach’s alpha of 0.89, making them a suitable option for use (Hydeman et al., 2021). Rationale The Johns Hopkins Evidence-Based Practice (JHEBP) model provided a theoretical framework for translating evidence into practice in this evidence-based quality improvement (QI) initiative. The JHEBP model utilizes a three-phase PET process: practice question, evidence, and translation (Dang et al., 2021). In the first stage, practice question, the problem was defined, and a research question was formulated (Dang et al., 2021). This phase revealed a significant gap in screening practices for breast cancer survivors at the project site. The research question was structured in the PICO (population/patient/problem, intervention, comparison, outcome) format. The following research question helped guide this initiative: In outpatient breast oncology providers, does the implementation of a brief screening tool to identify survivors with unmet needs, compared to no screening, increase the quality and quantity of screening? The final step of this phase involved identifying key stakeholders. A comprehensive literature search was conducted in the evidence phase to identify and critically appraise existing research. Twenty articles were systematically evaluated for strength 7 and quality, revealing high-quality evidence to support the practice question. This phase is essential for any quality improvement initiative as it ensures initiatives are grounded in strong evidence. In the final phase, translation, findings from the evidence phase were synthesized and guided the development of an intervention. This included identifying a standardized screening tool, integrating the tool into the clinical workflow, creating educational materials, and developing patient-centered educational resources. The PICO interventions section further details each component of this quality improvement evidence-based initiative and measures used to evaluate the success of this intervention. Specific Aims The purpose of this Doctor of Nursing Practice (DNP) evidence-based quality improvement project is to implement a brief screening process to identify breast cancer survivors with unmet physical or psychosocial needs, improving both the quality and quantity of screening. A secondary purpose is to increase the number of referrals to and, therefore, utilization of survivorship resources at Huntsman Cancer Institute. Methods Context This evidence-based quality improvement project was implemented at a single outpatient breast oncology clinic within a non-profit cancer center. Given the specialized nature of care, this clinic provides care to patients throughout the Mountain West, including Utah and parts of Idaho, Montana, Nevada, and Wyoming. The clinic primarily serves adult female patients from diverse ethnic backgrounds, including those from both rural and urban areas. Participating providers included two physicians and two nurse practitioners. This project was performed with the 8 Wellness and Integrative Health Center, a resource offered by the non-profit cancer center. This center offers classes and services to promote well-being in individuals affected by cancer. Many of these resources address common unmet needs in the survivor population. Organization stakeholders believe survivors underutilized resources such as the Wellness and Integrative Health Center due to a lack of standardized screening and awareness of these resources among patients and providers (B. Smith, personal communication, June 12, 2024). Intervention(s) Implementation of this project occurred over four phases. The first phase of this project involved gathering key stakeholders to identify areas of improvement in survivorship care. Involved stakeholders were identified, consisting of three members: a) the specialty clinic manager, b) the Wellness and Integrative Health Center director, and c) involved clinic providers. All stakeholders identified the lack of standardized screening to identify needs in patients who have completed treatment as a care gap within this clinic. Involved stakeholders agreed that using a standardized screening tool would (a) improve the detection of needs and overall care within this population and (b) assist in the secondary goal of increasing the utilization of survivorship resources. A thorough literature search was conducted to identify an appropriate standardized screening tool and locate evidence for its successful integration into practice. The evidence was critically appraised and synthesized to identify best practices for translation. NCCN clinical guidelines that supported this practice were identified. Phase two of this DNP project focused on developing a plan to implement this screening tool within the breast cancer clinic sustainably. Clinic workflows were assessed to determine the most effective way to integrate the screening tool into existing practices. A pre-implementation 9 survey was created (Appendix A) using Qualtrics, designed to gather data on current screening practices and to assess perceived barriers to and benefits of standardized screening. The survey also explored provider awareness of survivorship resources and perceived utilization of said resources. Surveys were distributed to involved providers via email links. Additionally, a comprehensive chart review was conducted to identify the number of referrals to survivorship resources made by involved providers six weeks before implementation. This data assisted in establishing a baseline for utilization of survivorship resources. The screening tool was adapted to meet the needs of providers and the clinic (Appendix B). Questions addressing topics covered in other site screening measures were deleted to avoid repetitive and unnecessary screening. All stakeholders reviewed the adapted tool before implementation to ensure satisfaction with it. Education was distributed to involved clinicians via a PowerPoint presentation (Appendix C). Education outlined the screening tool, updated clinic workflows, screening criteria, implications of the tool, and survivorship resources, including how to place referrals to said resources. Education was also provided to medical assistants (MAs) who assisted in delivering the tool (Appendix D). This material was distributed in a PowerPoint presentation delivered via email. Education provided to MAs outlined the screening tool and updated clinic workflows for tool delivery and documentation. The workflow for implementing the screening tool was as follows: During the rooming process, MAs provided patients with a paper copy of the tool. Patients completed the tool before being seen by a provider. An interpreter assisted patients who spoke a language other than English in completing the tool. The provider reviewed the completed tool during the patient’s visit and addressed any identified needs. Following the visit, the MA scanned the completed tool 10 into the patient’s electronic medical chart. Once uploaded into the chart, the paper copies were securely disposed of. A single-page document summarizing the new clinic flow was printed and posted at MA stations for further review (Appendix E). Opportunities to further discuss the project in person were made available to both groups. Education on survivorship resources was developed in collaboration with the Wellness and Integrative Health Center. Tools created for this purpose included “dot phrases,” or pre-built content blocks, that can be used to insert text into clinical notes. These phrases contained information on survivorship resources and could be added to after-visit summaries. Additionally, brochures on available services were available to providers to be given to patients. Phase three of the DNP project consisted of implementing the screening tool within the clinic for six weeks, starting in the third week of October. During this time, MAs at the clinic administered the screening tool to all patients presenting for a surveillance visit. Surveillance visits are provider appointments with patients who have completed their primary form of treatment (chemotherapy, radiation therapy, or surgery). These visits typically occur at six or twelve-month intervals and are often the only time patients meet with their oncology provider after treatment. Clinic workflows for tool delivery and documentation were implemented as detailed above. Positive screens prompted providers to address concerns themselves or place a referral to survivorship resources, including the Wellness and Integrative Health Center. Phase four of this project focused on evaluating the implementation of this screening tool within the breast cancer clinic. A second chart audit was conducted to determine the total number of patients screened. This number was compared to the total number of patients who qualified for screening to determine the number of missed screens. Electronic Health Record (EHR) data was 11 also collected to determine the number of referrals to survivorship resources during implementation. Post-implementation surveys (Appendix F) were administered to providers via Qualtrics and distributed through email links. This survey assessed provider satisfaction with the tool, its usability, and its feasibility. It also explored provider awareness of survivorship resources, their perceived utilization, and barriers to implementation. A separate postimplementation survey (Appendix G) was sent out to involved MAs to assess satisfaction, feasibility, and integration into the workflow. Lastly, an executive summary was created (Appendix H) for all project partners. Study of the Intervention(s) Surveys administered to involved providers before implementation gathered data regarding current screening practices, perceived barriers to and benefits of standardized screening, awareness of survivorship resources, and perceived utilization of resources. Postimplementation surveys assessed provider satisfaction, awareness of survivorship resources, perceived utilization of said resources, and usability and feasibility of the tool. A separate survey was administered to involved MAs post-implementation. This survey assessed satisfaction, feasibility, and ease of tool integration into the workflow. During implementation, weekly site visits and emails were conducted to assess the initiative’s satisfaction and identify any needed changes. This allowed rapid cycle changes to be made as deemed appropriate by involved members. EHR chart audits assessed clinic referral rates to survivorship resources before and after implementation. Screening rates were assessed pre- and post-implementation to determine the number of eligible patients screened. 12 Before the implementation of this project, standardized survivorship screening was not practiced in this clinic. Any increase in survivor-specific screening rates post-implementation can be attributed to the project’s focus on implementing standardized screening practices in this population. Measures Provider Pre-Implementation Questionnaire The pre-implementation questionnaire comprised 11 questions, including three demographic questions (Appendix A). The current time spent in surveillance visits was assessed with a multiple-choice question. Current screening practices and the perceived utility of a screening tool were evaluated in two questions: “Yes” or “No” answers. Five multiple-choice select all that apply questions assessed perceived barriers to implementation, familiarity with survivorship resources, and current utilization of resources. Provider confidence in educating patients on survivorship resources was evaluated in one Likert-type question. Provider Post-Implementation Questionnaire The same three demographic questions were included in the 15-question postimplementation questionnaire (Appendix F). The same multiple-choice question assessed time spent in surveillance visits. Three Likert-scale questions assessed tool integration in the current workflow, impact on quality of care, and provider satisfaction. Each of these questions provided a space for open-ended comments as well. Five multiple-choice select all that apply questions assessed specific areas of care that were improved, challenges encountered, familiarity with survivorship resources, and utilization of resources. Two multiple-choice “Yes/No/Unsure” questions assessed the feasibility and usability of the tool. These questions again provided a 13 space for providers to leave open-ended comments. A final open-ended question provided an opportunity to raise concerns or provide additional recommendations for the project. Medical Assistant Post-Implementation Questionnaire The 11-question post-implementation questionnaire (Appendix G) included two demographic questions. Two Likert-scale questions assessed the ease of integration and satisfaction with incorporating the tool into the clinic workflow, and an additional two Likertscale questions evaluated understanding of the tool and comfort with its administration. One yes/no/unsure question assessed the feasibility and allowed respondents to provide free-text comments. A “select all that apply” question asked MAs to identify any specific challenges they encountered with the tool. Finally, three open-ended questions provided opportunities to describe the tool’s benefits, offer suggestions, and share additional comments about the initiative. EHR Chart Audits A retrospective chart audit was completed on charts of all patients presenting for a surveillance visit with involved providers at the implementation site between September 16, 2024, and October 25, 2024. A second EHR chart audit from October 28, 2024, to December 6, 2024, was performed weekly. Data collected included the number of screens conducted, the number of positive screens, the number of positive screens addressed by providers, and the number of referrals to survivorship resources. Missed opportunities for screening were identified as well. The data collected from these chart audits was compared pre- and post-implementation. This chart comparison allowed the quality improvement team to determine whether screening rates and referrals to survivorship resources increased during implementation. 14 Analysis Data from the pre- and post-implementation surveys was evaluated to determine the success of the intervention. Given the small sample size, descriptive statistics were utilized for the comparative analysis of all data fields, including participant data, time spent with patients at their visits, and familiarity with and utilization of survivorship resources. Responses on feasibility, usability, and satisfaction with the protocol post-implementation were similarly analyzed. Qualitative data was also collected. An analysis of the summarized information was conducted on these open-ended survey questions. Responses were read word for word and categorized, organized, and summarized. Common themes were noted and compiled. Descriptive statistics were employed to analyze data collected in the pre- and postimplementation chart audits. Increases in screening and referral rates were calculated and converted to a percentage. Ethical Considerations This intervention was considered a quality improvement project and, therefore, was not subject to Institutional Review Board (IRB) oversight, as determined by the University of Utah. No conflicts of interest or competing interests were identified in this project. Participation in this initiative was voluntary and could be terminated at any time. Demographic information was collected in the pre- and post-implementation survey. However, no direct identifying information was collected. Results Data collected included responses from the provider pre-implementation questionnaires, provider post-implementation questionnaires, MA post-implementation questionnaires, and chart audits pre/post-implementation. 15 Provider Pre-Implementation Questionnaire Responses Four providers were invited to participate in this project and received the initial questionnaire. Three (75%) completed the pre-implementation survey. Three email attempts and one site visit were made to obtain the fourth response; however, these attempts were unsuccessful. The demographics of respondents are summarized in Table 1. Current practices and opinions on a standardized screening tool were evaluated, and before implementation, the time spent in a surveillance visit ranged from 10-20 minutes (n=1) to 20+ minutes (n=2). 100% (n=3) of responding providers denied the use of a standardized screening tool to assess for unmet needs in cancer survivors. 100% (n=3) of providers believed implementing a standardized screening tool to evaluate for unmet needs in survivors would be beneficial. Potential barriers to implementation were identified, including the learning curve associated with using the tool (n=1), challenges with integration into the current workflow (n=1), and increased time required for each visit (n=2). Familiarity with survivorship and wellness center resources was assessed. This data is summarized in Figure 1 and Figure 2, respectively. Provider Post Implementation Questionnaire Responses All four involved providers, including two NPs and two physicians, completed the postimplementation survey. Respondent demographics are summarized in Table 2. Practices during implementation were evaluated. During implementation, providers reported that the time spent in a surveillance visit ranged from 10-20 minutes (n=1) to 20+ minutes (n=3). Usability, feasibility, and satisfaction with the tool were assessed. 75% (n=3) reported the tool was “extremely easy to use,” and 25% (n=1) found the tool “somewhat easy to use.” 75% (n=3) of providers found the tool “extremely easy” to integrate into their current workflow, and 25% (n=1) found the tool “somewhat easy” to integrate. Three providers (75%) 16 found the tool feasible in clinical settings, and one provider (25%) was neutral. 50% (n=2) of providers were “extremely satisfied,” with the other 50% “somewhat satisfied” (n=1) and “neither satisfied nor dissatisfied” (n=1) with the tool. The provider's experience with the tool was further assessed. 50% (n=2) believed the tool “moderately improved” the quality of survivorship care, while the other 50% (n=2) reported “no change.” Specific aspects of patient care that improved with the tool were identified as improved identification of patient needs (n=3) and improved patient-provider communication (n=2). One “select all that apply” question evaluated for specific challenges encountered during implementation. No provider identified technical issues, lack of time, or patient resistance as a challenge. 75% (n=3) of providers reported encountering “other” challenges while using the screening tool. Selecting “other” allowed the provider to provide an open-ended response to expand upon their answer; however, no open-ended responses were provided. Familiarity with survivorship and wellness center resources was again assessed. This data is summarized in Figure 1 and Figure 2, respectively. Providers had the opportunity to provide open-ended feedback after the survey. Two responses were recorded. One response noted familiarity with the survivorship resources before implementation (n=1). Another response suggested clarifying the frequency with which patients experience symptoms by adding a “sometimes” option (n=1). One unanticipated outcome was the identifying unmet needs unrelated to the cancer diagnosis or treatment. Despite the statement, “As a result of my cancer diagnosis and treatments,” at the top of the screening questionnaire, providers (n=3) reported that patients often marked yes to “symptoms due to other known and chronic problems.” Due to time constraints, care in this setting primarily focuses on the patient’s cancer diagnosis and treatment; however, 17 identifying these issues prompted referrals to other specialties or the patient’s primary care provider. An unanticipated barrier to the utilization of resources was the location. Many survivorship resources are offered at the campus in Salt Lake City. Providers (n=2) reported that many patients do not live in Salt Lake City, and some live multiple hours away. No unanticipated costs were identified. MA Post-Implementation Questionnaire Five MAs were involved in the initiative. All five received the post-implementation questionnaire. Two (40%) responses were received. Three staff members could not be reached after three email attempts and a site visit. The two respondents reported 2-5 years and 10+ years of oncology & breast oncology experience. Usability, feasibility, and satisfaction were assessed. All respondents (n=2) found the tool “very easy” to use and integrate into their workflow. No barriers to implementation were identified (n=0). One participant found the tool feasible in the clinic setting, while one respondent was “unsure” about its feasibility. Respondents were “very satisfied” (n=1) and “neither satisfied nor dissatisfied” (n=1) with the initiative. Comfort with the tool was assessed. Respondents (n=2) were “very comfortable” explaining and administering the tool to patients. The final question provided an opportunity to provide open-ended feedback. Neither participant responded to this question. EHR Chart Audits Data from the six weeks before implementation, 9/16/24 – 10/4/24, was collected. One hundred eight-one eligible patients were seen during this period. No standardized screening was conducted. 43% (n=77) of these patients were referred to survivorship resources. 18 During the six weeks of implementation, 10/28/24 – 12/6/24, 144 eligible patients were seen. 93% (n=134) of patients were screened. Of patients screened, 92% (n=123) reported at least one unmet need. A provider addressed 98% (n=120) of positive screens. 71% (n=88) of patients with a positive screen were referred to survivorship resources. Figure 3 summarizes the data collected in the EHR chart audit. Discussion Summary The results of this QI initiative demonstrate that implementing a standardized screening protocol to identify breast cancer survivors with unmet needs a) improved the quality and quantity of screening and b) increased the number of referrals to survivorship resources. Overall, clinic providers and staff found the tool easy to use and feasible in the everyday clinical setting. Key findings from this QI initiative indicate that screening improved patient-provider communication and identification of patient needs. The specific strengths of this project included the ability to implement this initiative in a setting with a high number of cancer survivors, the well-established survivorship resources, and the support of stakeholders in executing this project. Interpretation The initiative’s results were consistent with the expected findings and previous research. Prior studies have reported a high prevalence of unmet physical and psychosocial needs among cancer survivors (Carreira et al., 2021; Hussey et al., 2024; Hydeman et al., 2021; McDonough et al., 2021; Sanft et al., 2023; Vuksanovic et al., 2021). Research supports using standardized screening tools to identify these unmet needs and connect patients with appropriate resources (Hydeman et al., 2021; Maio et al., 2022; McDonough et al., 2021). 19 Consistent with these findings, 92% (n=123) of patients screened in this initiative reported at least one unmet need, with many reporting multiple needs. Screening enhanced patient-provider communication and allowed providers to address unmet needs. Additionally, screening increased access to survivorship resources, with referral rates rising from 43% to 71%. Provider experience with the tool varied; however, no provider found the tool to be burdensome, difficult to use, or reported dissatisfaction. Overall, providers were satisfied and found the tool easy to use and feasible to implement. Similarly, clinic staff found the tool easy to use and did not identify barriers to implementation. Although clinic staff had mixed views regarding satisfaction and feasibility, no staff member found the tool unfeasible or reported dissatisfaction. As detailed in the PICO interventions section, education was provided on all survivorship resources, including Wellness Center resources. An increase in familiarity post-implementation was expected. Consistent with these expectations, providers reported increased familiarity with all general survivorship resources (Figure 1). However, when asked about specific services offered by the Wellness Center, a decrease in familiarity was observed (Figure 2). This finding was unexpected. Possible explanations for these findings include inadequate education on these resources, poorly worded questions, or respondent inattention when completing the postimplementation survey. The monetary cost of maintaining this project is minimal, limited to printing costs for the screening tool and a slight increase in time spent during patient visits (Appendix H). Given the high level of satisfaction and overall benefits of the tool, screening will continue with breast cancer survivors in this clinic. 20 Limitations There are several limitations to consider when evaluating this initiative. This initiative was conducted in a single clinic setting with few providers. Of the four involved providers, only three completed the pre-implementation survey. This limits the ability to compare pre/postimplementation survey responses accurately. A low response rate was also observed in medical assistants, with only 40% of involved medical assistants participating in the post-implementation survey. As noted earlier, three attempts were made to gain additional responses; however, these were unsuccessful. The low response rates from both groups are thought to be due to a lack of time. Several providers were on leave at the time of this initiative, significantly increasing the workload for other team members. The small sample size and low survey response limit the generalizability of findings to different settings. The short implementation period may also have affected overall results. This initiative was implemented in the clinic for six weeks, which may not have been an adequate time frame to assess the screening tool’s long-term feasibility, sustainability, or impact. Additionally, as stated above, providers and staff were working with higher-than-normal volumes at the time of implementation, potentially limiting the effectiveness of the intervention. Finally, the validity of the post-implementation survey responses may be limited. The decreased familiarity with specific Wellness Center services post-implementation suggests potential survey fatigue, poor survey design, or inattention during survey completion, which could negatively impact the reliability of all the self-reported data collected. Conclusions The findings of this quality improvement initiative suggest that utilizing a standardized screening tool to identify breast cancer survivors with unmet needs is effective and increases the 21 number of referrals to survivorship resources. Project participants reported that the tool improved patient-provider communication while being feasible, easy to use, and satisfactory. By identifying patients with unmet needs, providers could effectively manage patient concerns or refer patients to survivorship resources offered by the institution. Given the proven benefits, this tool is expected to continue with the survivorship group within the clinic. This group is led by a nurse practitioner involved in this initiative, who will maintain screening efforts. Future steps include converting the tool into a digital format for seamless integration into the patient’s EHR. Other applications of this project include expansion to survivor populations in other oncology diagnosis groups. Overall, this quality improvement initiative demonstrates the value of a standardized screening tool in enhancing survivorship care, with promising opportunities for a broader application. 22 Acknowledgments I would like to extend my sincere thanks and appreciation to my Project Chair, Jennifer Clifton, DNP, FNP-BC, CCHP-A, FAANP, for her support and guidance. I would also like to thank Ashley Burke, BSN, RN, OCN, Cassidy Campanella, DNP, APRN, ACHPN, FNP-C, and the entire Huntsman Clinic 2K for their support and dedication to this initiative and the patients they serve. 23 References Andreu, Y., Martinez, P., Soto-Rubio, A., Fernandez, S., Bosch, C., & Cervantes, A. (2022). Colorectal cancer survival: Prevalence of psychosocial distress and unmet supportive care needs. Supportive Care in Cancer, 30, 1483–1491. https://doi.org/10.1007/s00520-02106513-1 Carreira, H., Williams, R., Dempsey, H., Stanway, S., Smeeth, L., & Bhaskaran, K. (2021). 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Breast Cancer, 28, 289–297. https://doi.org/10.1007/s12282-020-01156-2 26 Tables and Figures Table 1 Demographics of Providers Pre-Implementation Questionnaire Characteristic N % Nurse Practitioner (NP) 2 67% Physician 1 33% 0-1 years 0 0% 2-5 years 0 0% 6-9 years 1 33% 10 years 2 67% 0-1 years 1 33 % 2-5 years 1 33% 6-9 years 0 0 10+ years 1 0% Role Experience in Oncology (# of years) Experience in Breast Oncology (# of years) 27 Table 2 Demographics of Providers Post-Implementation Questionnaire Characteristic N % Nurse Practitioner (NP) 2 50% Physician 2 50% 0-1 years 0 0% 2-5 years 0 0% 6-9 years 1 25% 10 years 3 75% 0-1 years 1 25% 2-5 years 1 25% 6-9 years 1 25% 10+ years 1 25% Role Experience in Oncology (# of years) Experience in Breast Oncology (# of years) 28 Figure 1 Provider familiarity with survivorship resources pre- and post-implementation. 100% 100% 100% 100% 100% 75% 67% Social Work The Wellness Center Pre-Implementation 67% SOS Post-Implementation Financial Services 29 Figure 2 Provider familiarity with Wellness Center Resources pre- and post-implementation. 100% 100% 100% 100% 100% 100% 100% 100% 100% 67% 50% Acupuncture Massage Fitness Creative Arts Pre-Implementation 50% Nutrition Post-Implementaiton Osteopathic Manipulation 30 Figure 3 Data collected during post-implementation chart audit. Number of patients Patients eligible for screening 144 Patients screened 134 Patients who reported at least one unmet need 123 Positive screens addressed by a provider 120 Postive screens referred to survivorship resources 88 31 Appendix A Pre-Implementation Survey 32 Appendix B Screening Tool 33 Appendix C Provider Education 34 35 Appendix D Medical Assistant Education 36 Appendix E MA Reference Sheet 37 Appendix F Provider Post-Implementation Survey 38 39 Appendix G MA Post-Implementation Survey 40 41 Appendix H Executive Summary