Pap Smear Quality Improvement Project

Context: Cervical cancer screening is a key quality metric for primary care, all providers at this primary care clinic were below the cervical cancer screening goal of 82% of eligible patients.

Objective: To improve the percentage from 78% to > 82% of female patients aged 21 to 64 who were screened for cervical cancer using either of the following:

• • Women aged 21-64 who had cervical cytology performed every 3 years

• • Women aged 30-64 who had cervical cytology/HPV co-testing performed every 5 years

Study Design and Analysis: Using My Panel Metrics in Epic Dashboard a single provider’s panel was accessed. The list of patients overdue for cervical cancer screening was 103 out of an eligible population of 471. The record of each of the 103 patients was audited over a 4 month period by the primary care provider and nurse team, spending approximately 30 minutes per week.

Dataset/population studied: Single provider’s panel of 471female patients age 21-64 eligible for cervical cancer screening

Intervention: Chart audit

Outcome Measures: The percentage of eligible patients who have been screened for cervical cancer.

Results: Cervical cancer screening increased from 78% to 89%. (p .0001)

-55 of 103 patients were overdue for screening.

-48 patients fell into 3 categories: incorrect data entry (not captured by in Epic’s My Panel Metrics dashboard), incorrect screening intervals (prompted by a EMR change 3 years prior), or patients who had moved on from the practice and were removed from the provider’s panel.

Conclusions:

1. 1. With the help of a quality analyst and “Digging into the Data”, we were able to improve our understanding of healthcare maintenance and EMR metric calculation. Data entry process is now done correctly and all provider/nursing teams were educated on this process. If providers do not understand how the metric is measured and accounted for, it is difficult to achieve good results.

2. 2. EMR transitions can cause glitches in metric reporting, until we closely reviewed the data and discovered this issue the metric wasn’t being properly measured.

3. 3. Maintaining accurate provider panels is key for accurate metrics

4. 4. Targeting a single metric will often improve other metrics. Incidentally, when patients were being invited for cervical screening, it also provided an opportunity to target other preventative measures

5. 5. The provider/nurse team found the rapid improvement of this metric was very gratifying.