PDSA #1 Mammograms Alerts were added to charts for all women between the ages of 40-85 who had not had a mammogram documented within the last two years. If the mammogram report is not present in the chart, the alert remains red, calling the patient’s provider’s attention to address the importance of mammography with the patient at all points of contact. Even with chart alerts, the overall percentage of women with a mammogram documented in the chart was historically not improving. Reports from radiology departments were not being sent back to our primary care office. A TWC physician led PDSA #1 and engaged two large, local hospital systems to secure remote access to their EHR so our nursing staff could retrieve mammography reports for patients without relying on the hospital to fax the information to our data management department. After TWC’s nursing staff gained access, the percentage of women within the practice with documented mammograms increased from November 2013 until February 2014 (below). The graph (right) demonstrates that TWC’s registries are fluid, meaning patients are not excluded from reporting if they are a new patient in the reporting period. As our population of women in the age range to receive a mammogram continuously grows, our trending mammogram performance may concordantly drop or plateau (below). We transparently acknowledge the challenges of fluid registry functionality with all providers, stressing intentional focus on controllable factors and continuous improvement. The green arrow shows where PDSA #1, described above, began and the yellow arrow shows progress plateauing due to practice influx of new female patients in that timeframe.
Practice 50th Percentile Measure Target KEY: The blue line depicts TWC practice screening mammography performance; the red line depicts the HEDIS 50 percentile; the yellow line depicts the target set by the collaborative in which TWC participates.
Number of Female Patients Between Ages 40-85 Changing the scale helps justify our speculation that as more women between the ages of 40-85 come into the practice without a mammography report, our mammogram measures would plateau.
22 | The Wright Center | HIMSS Ambulatory Davies Award: Independent Ambulatory Practice
Partnership with Lackawanna Mobile X-ray Almost a year later, a community-based service agency, Lackawanna Mobile X-ray approached TWC to see if we would be interested in offering mammograms onsite at the office. A PDSA was developed to describe how we trained one of their staff members to proactively run the exception report of all women due for mammograms (left). The staff member was trained to call and schedule interested patients for onsite mammography within our EHR. We saw a spike in the number of completed mammograms within a month and successfully completed a total of 169 on site mammograms for TWC patients.