Improving Provider Performance

Photo of a secretary talking on the telephone

Telephone calls offer a personal touch when reinforcing the need for screening, confirming appointments, and addressing challenges.

Award recipients in CDC’s National Breast and Cervical Cancer Early Detection Program have found many innovative ways to help those in need of cancer screening get the tests they need. Below, we share highlights from some programs that motivated health care providers to refer patients for cancer screening by using a scorecard, creating standing orders for testing, and identifying women at high risk.

Clinic Makes Improvements and Increases Referrals

The Sisseton-Wahpeton Oyate community, located in the Great Plains Indian Health Service region, is greatly affected by cancer and had very low breast and cervical cancer screening numbers in 2015 compared to the national average. The Sisseton-Wahpeton Oyate Community Health Education Program worked with other groups from December 2018 through June 2019 to improve screening processes and make it easier for people in this community to get cancer screening tests.

A community health educator (CHE) was trained to collect and track data. The CHE worked on improving processes, including getting clinic staff to use the reminder tab in the computer system. Clinic staff started reminding patients when they were due for a cancer screening and telling doctors which patients needed to be screened. The program talked to women individually about the importance of cancer screening and developed small media messages. Partners in this effort included six departments at the Sisseton Indian Health Service, the Great Plains Tribal Leaders’ Health Board, the Robert County Department of Health, Sisseton Wahpeton College, and the health care organization that provided mammograms.

With these new processes in place at Sisseton Indian Health Service, 150 reminder letters and 99 reminder calls were completed for mammograms, 82 reminder calls were completed for cervical cancer screening, and 120 women received one-on-one education on breast and cervical cancer screening. Small media efforts reached 430 people, and 142 people registered for the Honor Every Woman Wellness Fair. The fair offered 18 different breast and cervical cancer educational opportunities, including opportunities to have individual talks with health care workers and community liaisons and to view digital stories, which are important in this community.

Quality Improvement Increases Screenings in South Carolina

South Carolina’s Pee Dee and Midlands regions had low breast and cervical cancer screening and rescreening numbers, as well as very high cancer death rates. Several clinics in these regions didn’t have standard cancer screening practices established to make sure that all steps, from first contact to follow-up, were completed.

In April 2018, the Best Chance Network program chose one health system from the Midlands and Pee Dee regions to join its BCN CAN SCREEN Quality Improvement Learning Collaborative Initiative. Using this collaborative approach, staff from these selected health systems worked with Cancer Division staff and a Lean Six Sigma Master Black Belt improvement coach to learn how to improve cancer screening procedures in all of their clinics. The health system staff created standing orders for testing and assigned a staff member from each region’s main office to call patients who needed to be screened. They enhanced their computer system to call, text, and e-mail patients to remind them to get screened. They encouraged doctors to recommend Best Chance Network services to patients.

By the end of January 2019, the health system in the Midlands region raised its breast and cervical cancer screening rate from 41% to 50%, and its rescreening rate from 36% to 45% across its 11 clinics. In the same time frame, the health system in the Pee Dee region raised its screening rate from 34% to 45% and its rescreening rate from 22% to 40% across its 13 clinics. The clinics in the Midlands regional health system now get screening reports monthly, quarterly, and yearly. Both health systems say they will keep tracking progress at their clinics to make sure that screening numbers continue to improve.

Idaho Program Increases Enrollment by Expanding Eligibility

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Programs can extend their screening program eligibility criteria to include younger women who may be eligible for services.

Idaho Women’s Health Check had trouble meeting its enrollment goals for the period of July 2014 to June 2015 because younger women who did not have symptoms were not eligible for screening. The program’s focus for breast cancer screening services was women who were 50 years old or older, and for cervical cancer screening services was women who were 40 or older. Women who were 30 or older could get screened through the program only if they had symptoms needing follow-up.

The program expanded its eligibility criteria for enrollment, allowing younger women to receive services. Women who are 21 years old or older can now get cervical cancer screening services. Women who are 40 or older can get screening mammograms if they are at high risk or have personal family history of breast cancer. Enrollment in Women’s Health Check went up 4.5% the next year, and 6.6% the year after.

Maine Partners with Dental Hygienists to Promote HPV Vaccination

In Maine in 2015, only about 57% of boys and 61% of girls had been vaccinated for human papillomavirus (HPV) as recommended. These numbers were well below the Healthy People 2020 goal of 80%.

Because the HPV vaccine helps prevent several kinds of cancer, including oral cancers, Maine’s Breast and Cervical Health Program wanted dental health providers to promote HPV vaccination. In 2017, the program worked with the state’s comprehensive cancer control and immunization programs and a regional affiliate of the American Cancer Society to adapt educational resources for dental health providers. With support from the Maine Dental Hygienists Association, the resources were mailed to more than 1,300 hygienists to use when they see adolescent patients and their parents or guardians.

The hygienists were asked to fill out a survey about the resources. Of the 124 hygienists who completed the survey, 44 (36%) said they reviewed the materials with the dentist and 42 dentists approved using the Tips for Talking About HPV fact sheet [PDF-150KB] when educating patients and parents. Seven hygienists said the dentist would like to establish standard practices to make sure all patients were told about how the vaccine prevents cancer, and the state’s comprehensive cancer control program will continue to work with these dentists.

Tools Help Doctors in New Mexico Identify Women with High Breast Cancer Risk

Doctors who worked with the New Mexico Breast and Cervical Cancer Early Detection Program didn’t know their patients’ risk of getting breast cancer, so they did not make sure patients got the screening tests they needed. In April 2019, the program changed its screening and referral form to add a question about the patient’s breast cancer risk and introduced two easy-to-use online risk assessment tools. The program also included information about reimbursable services for women at high risk for breast cancer to encourage doctors to recommend screening for their patients. At the beginning of the program year, the program added the requirement to use the new form to their provider agreements.

The percentage of doctors who completed the risk assessment went up from 8% in April 2019 to 74% by September 2019. The number of patients who are known to be at high risk for breast cancer more than tripled. Clinic staff are very careful to make sure these women get the cancer screening tests they need. The program is continuing to train and help its providers increase the use of risk assessment tools.

Virginia Clinic Improves Processes to Boost Breast Cancer Screening Numbers

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Reviewing charts ahead of time to determine who is due for screening improves the likelihood of patients being screened for cancer.

As of June 2018, only about half of the women patients at Clinch River Health Services had been screened for breast cancer as recommended. This screening percentage was low compared to the state average of about 80%. This federally qualified health center didn’t have an established process to inform staff which patients needed to be screened for breast cancer or to assign staff members to talk with patients about cancer screening and to schedule it. The clinic also needed a performance review process to help clinicians improve in this area.

The clinic started a quality improvement team that adopted standing orders for mammograms, which allowed women to be referred for breast cancer screening automatically. The team set up clinician alerts and patient reminders in the clinic’s computer system. Before patients come to the clinic for their appointments, staff talk about which patients need to be screened. The team also explained cancer screening guidelines to clinicians and clinic staff and began using a monthly scorecard to show how well doctors are doing. As a result, the screening rate went up from 54% in June 2018 to 62% by July 2019.