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Abnormal Pap Smear Notification Improvement
Summary
Impact Statement:
Yadkin-County Health department used QI tools and methods decrease the time for notifying clients of abnormal Pap smear results, enabling clients to make informed decisions about follow-up care.
Summary:
The Yadkin County Health Department (YCHD) reviewed the medical records of clients who had received Pap smears and documented the timeframe when clients were notified. There was not a standardized timeframe, and the current Abnormal Pap Smear Policy was vague about notification times. YCHD felt that it needed to update policy, streamline the process, and eliminate the multiple staff and multiple steps that were involved in the process. The average wait from having a Pap smear to the time it takes the North Carolina State Laboratory to return the result to YCHD was 29 days. If the results of the Pap smear are high-grade lesion or greater, the State Laboratory contacts YCHD prior to sending the written results. In June 2010, YCHD made changes to its Abnormal Pap Smear Policy and developed a policy that specifically addresses priority notification of clients with abnormal Pap smears. From September 2010 to January 2011, YCHD had a 100% notification rate.
Organization that conducted the QI initiative:
Yadkin County Health Department
Citation:
Ivester, L. Public Health Quality Improvement Exchange. Abnormal Pap Smear Notification Improvement. Thu, 12/14/2017 - 11:18. Available at https://phqix.org/content/abnormal-pap-smear-notification-improvement. Accessed May 28, 2023.
Background and Aim
Aim statement:
YCHD aims to improve the health of clients receiving Pap smears by successfully notifying the clients of abnormal Pap smear results, thus enabling them to make informed decisions on obtaining follow-up, as recommended by the agency physicians and mid-level providers. Cervical cancer can best be treated with early detection and treatment. Staff awareness of improvement, goal-oriented plan/implementation, and utilization of policy is ongoing. YCHD will do this by June 2011 by utilizing the Method of Improvement and Lean Methodology.
Need For The QI Initiative:
YCHD had some process issues with notifying clients of abnormal Pap smears and with the follow-up process, so it was decided to use the QI program to show how to fix the client notification process. Some of the issues were that addresses for clients were not correct, phone numbers for clients were not correct, abnormal Pap smear policy did not give a clear follow-up procedure, and developing standardized notification letters to send to clients, along with written education in English and Spanish.
Michael Reavis, former Health Director, and Martha Powell, Nursing Supervisor, decided to use the abnormal Pap smear process as the QI 101 project on which to work.
Area for Improvement:
YCHD reviewed the medical records of clients who had received Pap smears and documented the timeframe when clients were notified. There was not a standardized timeframe, and the current Abnormal Pap Smear Policy was vague about notification times. YCHD felt that it needed to update policy, streamline the process, and eliminate the multiple staff and multiple steps that were involved in the process.
YCHD uses the North Carolina State Laboratory to process its Pap smears. The North Carolina State Laboratory uses the liquid-based cytology which is preferred by the American Congress of Obstetricians and Gynecologists (ACOG). The average wait from having a Pap smear to the time it takes the North Carolina State Laboratory to return the result to YCHD is 29 days. If the results of the Pap smear are high-grade lesion or greater, the State Laboratory contacts YCHD prior to sending the written results.
From May 2010 through January 2011, all clients with abnormal Pap smears have been notified. The average number of clients with abnormal Pap smears from month to month is four. The Quality Assurance Coordinator for YCHD audits charts twice a year to ensure that all clients with abnormal Pap smears are notified in a timely manner.
In June 2010, YCHD made changes to its Abnormal Pap Smear Policy and developed a policy that specifically addresses priority notification of clients with abnormal Pap smears. Specific changes are the following:
• Any high-grade lesion or greater notification is to be initiated within 7 to 10 working days.
• Any Pap smear result that does not include high-grade lesion will receive notified within 14 to 21 days.
• Any client who fails to respond to the first attempt to contact them will receive a certified letter within 2 to 4 weeks of initial notification.
From September 2010 to January 2011, YCHD had a 100% notification rate.
YCHD is proud to be involved in the North Carolina Center for Public Health QI Initiative to improve the abnormal Pap smear client notification process. YCHD aims to improve the health of clients receiving Pap smears by successfully notifying the clients of abnormal Pap smear results. This will enable our clients to make informed decisions obtaining follow-up, as recommended by the agency physicians, mid-level providers, and the North Carolina Department of Health and Human Services, Division of Public Health, Cervical Screening Manual. Cervical cancer can best be treated with early detection and treatment. Staff awareness of improvement, goal-oriented plan/implementation, and utilization of policy is ongoing. We will do this by June 2011 by utilizing the Method of Improvement and Lean Methodology.
The YCHD QI team is delighted to announce we will be participating in a Kaizen event from April 4 through April 7, 2011, which is part of the QI process. “Kaizen” means to change for the better or to break something down into its components to improve it. A Kaizen event is a short, focused project aimed at eliminating production waste in a particular area.
Root Cause:
1. Not having correct addresses and telephone numbers for clients to notify them.
2. Using an outside laboratory for processing of Pap smears played an important role in the time it took to receive actual results for client.
3. Agency lab process showed a lag in time to send the specimens in for processing.
4. Staff buy-in.
5. Abnormal Pap Smear Notification Policy needed updating.
6. Need standardized notification letters and standardized education in English and Spanish to give to the clients.
YCHD reviewed medical records of clients who had received Pap smears and documented the timeframe when clients were notified. There was not a standardized timeframe, and the current Abnormal Pap Smear Policy was vague about notification times. We felt that we needed to update policy, streamline the process, and eliminate the multiple staff and multiple steps that were involved in the process.
Planning and Execution Details
QI Implementation:
Newspapers were used to keep a timeframe of when activities were due to each team member. Value Stream Mapping was used to show the current process and to identify where the concern in the process was. The Five Whys were used to identify why the process change was needed. Plan-Do-Study-Act (PDSA) cycles allowed us to change, test, study, and act on individual changes within the process.
YCHD had some process issues with notifying clients of abnormal Pap smears and the follow-up process, so it was decided to use the quality improvement (QI) program to show us how to fix the client notification process. Some of the issues were that addresses for clients were not correct, phone numbers for clients were not correct, Abnormal Pap Smear Policy did not give a clear follow-up procedure, and developing standardized notification letters to send to clients, along with written education in English and Spanish.
Michael Reavis, former Health Director, and Martha Powell, Nursing Supervisor, decided to use the abnormal Pap smear process as the QI 101 project on which to work.
YCHD utilized the QI 101 program to implement the changes. It started in November 2010 and was completed in June 2012. YCHD also took part in a Kaizen event in April 2011.
The entire YCHD staff, Core QI Team, Board Of Health, Women’s Health Branch, and community were notified through newspaper articles.
QI Tools:
Other QI tools:
Value Stream Mapping
Newspaper
QI Tool Documentation:
Initiative Dates:
11/1/10 to 6/30/11
Initiative Duration:
Between 6-12 months
Supplemental Materials:
Sample of materials produced
Storyboard
Supplemental Files:
| Attachment | Size |
|---|---|
 Yadkin County Storyboard May 2011.ppt | 1.26 MB |
 QI Follow through chart.xls | 66 KB |
| Days between Pap completed and Pt notified chart.xls | 55 KB |
| Days between Pap RTN and Pt notified chart.xls | 76.5 KB |
 Chart 1 staff satisf.docx | 17.38 KB |
| chart 2 staff satisf.docx | 17.29 KB |
Results
Measurable QI Outcomes:
Benefits Obtained/Outcomes Improved:
• Number of days between Pap smear and client notification goal is 30 days per policy. Actual average number of days is 24 (decrease of 17 days).
• Number of days between Pap smear results returned from state lab and client notification goal is 14 days. Actual average number of days is 3.3 (decrease of 6.2 days).
• Streamlined notification policy to decrease amount of time Abnormal Pap Smear Coordinator spent in process.
• Established only one clinic staff member as Abnormal Pap Smear Coordinator for all programs, which freed up two staff members.
• Eliminated three ticklers systems (duplicated work).
• Established new standing orders on Abnormal Pap Smear Protocol and infections noted on Pap Smear Protocol.
• Abnormal Pap Smear Coordinator reviews all Pap smears, which freed up the family nurse practitioner (FNP) (provider) to see more clients.
• Gained more patient touch time for provider and clinic staff.
• Improved staff morale (65% reported less stress with new process).
• By decreasing notification time to clients, clients who follow through with follow-up recommendations have increased by 19%.
• Aid YCHD to meet legal or regulatory obligations.
• Standardized lab log, which saved money on paper needs (went from 11 x 17 to standard size of 8.5 x 11).
• Removed abnormal Pap log found in chart. Documentation of Pap smear results already in chart, so there is no need to duplicate on another form.
• Clients complete one-half of sheet (address and phone number form) at each visit for current contact information, which has decreased the amount of time spent looking for correct addresses and phone numbers to contact clients.
• Chart takes five different steps within the new Pap smear process (decrease of four steps).
• 96% client satisfaction with new education (increase of 3%).
Tangible Financial Benefits (Yearly Basis):
• FNP (239 visits in June vs. 304 visits in August). Sixty-five more clients/month. Generating $78,000 revenue/year.
• Reduced paper costs by using standardized paper and eliminating duplicated work, saving $1,140.
Project Cost:
• Kaizen event (food, supplies, lab book): $364.13
• Equipment: $415.44
• Hotel expense: $699.00
• Staff time for conferences/Kaizen event: $10,115.00
Current Project Cost: $11,593.57
Yearly Continued Cost:
• Postage/certified letters: $151.08/year
• Abnormal Pap Smear Coordinator time: $12,480.00
Yearly Cost: $12,631.08
Economic Impact of Project:
• Project saving: $78,000.00 + $1,140.00 = $79,140.00
• Year 1 impact = $79,140.00 − $24,224.65 = $54,915.35
• Year 2 and beyond = $66,508.92
Return on Investment (ROI) Results:
For every $1 invested on improvement, YCHD gained in financial improvement, as shown below:
ROI = (Savings − Cost)/Cost
$2.27 = ($79,140.0 − $24,224.65)/$24,224.65 for Year 1
$5.27 = ($79,140.00 − $12,631.08)/$12,631.08 for future years
Other QI Outcomes:
Staff satisfaction and new policy freed up the FNP to see more clients instead of reviewing Pap smear results, increased client satisfaction, eliminated duplicated work, aided YCHD to meet legal and regulatory obligation, decreased staff time looking for correct client contact information, and raised staff awareness of the QI model for improvement and its positive impact on the agency.
Lessons Learned, Observations and Insights:
• Kaizen event was “feared” prior to the event, but it was an awesome experience for the team. So much work was accomplished. This was such an important step to the entire process.
• Spread ability of changes needed to be continually shared with other staff, and QI team should have a plan to share with staff.
• Outside member of the team brings fresh ideas that can change the most important item because they are not “invested” in current process.
• QI model for improvement works and does bring about positive change.
• YCHD is a small agency, which leads to problems with staffing during QI projects and also makes it difficult to have a diverse team.
Future Plans:
YCHD started a spread plan to orient and train staff on the QI model for improvement by having small PowerPoint presentations at monthly staff meetings about certain aspects of the QI model for improvement (e.g., one staff meeting was about the Five Whys; one meeting was on aim statements).
Describe plans to replicate the QI in other units, service lines, or organizations. Describe plans to maintain the gains, and provide any insights on the likelihood that observed gains may weaken over time, and plans for monitoring and maintaining improvement.
The QI model was used to implement Bright Futures in the clinic in October 2011. One staff member went to the QI Advisory Program and completed another QI project on the business office. QI spread through educating staff on the QI model for improvement, which began January 2012 and was completed July 2012. Currently, the agency is in the accreditation process and is hoping to restart the QI model after that is completed in late November 2012.
Training and Preparation
Technical Assistance Received:
NC Center for Public Health Quality and other local health department QI leaders.
QI Related Training Received:
The entire team went to the NC Center for Public Health Quality QI 101 Program.
One member went to the QI Advisor Program and received many Webinar trainings, publication information, and project tools.
Information about the Community
Population Size:
Population Characteristics:
Yadkin County is located in the northwest Piedmont region of central North Carolina. The region consists of rolling farmlands that are frequently broken by hills or valleys formed by streams. Yadkin County marks the eastern end of the Brushy Mountains range, and, the Yadkin River forms the county's northern and eastern borders.
Although Yadkin County remains primarily rural in character, the county combines a farming economy with growing industrial development. Industrial growth was slow in coming to Yadkin due to decisions made in 1871, 1885, and again in 1908 not to allow the railroad into the county. Highway infrastructure later allowed growth to take place, and now Yadkin County has a healthy mix of manufacturing operations. Examples of this would be the Unifi, Phillips-Van Heusen, Lydall, and Chipita manufacturing plants that now reside in Yadkin County.
According to the 2010 U.S. Census data, Yadkin County has 38,406 residents. This is a 5.7% increase in population since the 2000 U.S. Census data were collected. Some notable population data points are that 23% of the population is under the age of 18, and 16% are over the age of 65. The two largest ethnic groups in the county are white at 88.5%, and persons of Hispanic or Latino origin at 9.8%. These differ from state data, which are 68.5% and 8.4%, respectively.
Information about the Health Department
Local/State Relationship:
Shared
PHAB Accreditation Status:
Planning to submit application for accreditation in the next year
State-based accreditation?:
No
Annual QI Initiative Frequency:
QI activity level:
Organization Type:
QI Staff Information
Total number of Staff on QI Team:
6
QI team members:
Role in the Initiative:
Lead
Role in Organization:
Public Health Nurse II
FTE:
0.70
Role in the Initiative:
Team Member
Role in Organization:
Nursing Supervisor
FTE:
0.10
Role in the Initiative:
Team Member
Role in Organization:
FNP
FTE:
0.10
Role in the Initiative:
Team Member
Role in Organization:
Lab Tech
FTE:
0.10
Role in Organization:
Environmental Specialist
FTE:
0.05
Accreditation Details
PHAB Standards:
Domain 9: Evaluate and continuously improve health department processes, programs, and interventions›Standard 9.1 Use a Performance Management System to Monitor Achievement of Organizational Objectives
Domain 9: Evaluate and continuously improve health department processes, programs, and interventions›Standard 9.2 Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions›Measure 9.2.1 A Establish a quality improvement program based on organizational policies and direction
Contact Information of the Submitter
First Name:
Lisa M.
Last Name:
Ivester
Organization:
YCHD
Submission Status:
Completed
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