Breast Cancer Screening

Part 1: Introduction

Part 2: Characteristics for Success: Breast Cancer Screening

Part 3: Implementation of Quality Measure: Breast Cancer Screening

Part 4: Improvement Strategies: Breast Cancer Screening

Part 5: Holding the Gains and Spreading Improvement

Part 6: Supporting Information

Part 4: Improvement Strategies: Breast Cancer Screening 

The actual improvement process is composed of three steps that respond to the following questions:

1. What changes can an organization make?
2. How can an organization make those changes?
3. How can an organization know the changes caused an improvement?

It is important to understand that improvement requires change, but not all change results in improvement. Considering all of the possible changes that can be made to health care systems, considerable effort has been dedicated to creating various quality improvement strategies providing a framework that organizes possible changes into logical categories. Frameworks for change in health care quality improvement are known as quality models and have been tested to guide change. In fact, considering that there are limited resources to dedicate to improvement, most organizations adopt one or more quality models to guide their improvement efforts. There is not a right or wrong approach, and there are many areas of overlap in quality models. Experienced quality improvement teams often use multiple strategies to overcome challenges as they progress. Two approaches often used by teams that are working to improve performance on Breast Cancer Screening include the Care Model approach and the Critical Pathway approach.

The case study continues....

The Case Study: The Improvement Journey

1. Care Model Approach: Implementing the changes described in the Care Model is a proven method to improve care delivery. The Care Model is an organizational framework for change and is organized into six domains:
   1. Organization of Health Care
   2. Clinical Information Systems
   3. Delivery System Design
   4. Decision Support
   5. Community
   6. Self-Management Support

   Changes within these domains can effectively leverage transformation of a current reactive care system to one that better supports proactive or preventive care. If an organization does not have general experience with the Care Model, reading about the Care Model before proceeding is recommended. The Care Model recognizes that preventive care is ongoing and requires more proactive care than the health care system often provides. The Care Model is implemented to improve care by working in six domains, defined below, that transform the way care is delivered:

   Community-To improve the health of the population, a health care organization reaches out to form powerful alliances and partnerships with State programs, local agencies, schools, faith organizations, businesses, and clubs.

   Organization of Health Care-A health care system can create an environment in which organized efforts to improve the preventive care of people take hold and flourish.

   Self Management-Effective self management is very different from telling patients what to do. Patients have a central role in determining their care and one that fosters a sense of responsibility for their own health.

   Delivery System Design-Delivery of patient care requires not only to determine what care is needed, but to clarify roles and tasks to ensure the patient receives the care; that all of the clinicians, who take care of a patient, have centralized, up-to-date information about the patient's status, and make follow-up a part of their standard procedures.

   Decision Support-Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. A health care organization integrates these guidelines into the day-to-day practice of primary care providers in an accessible and easy-to-use manner.

   Clinical Information System-A registry, that is, an information system that can track individual patients and populations of patients, is a necessity when managing chronic illness or preventive care.

   Definitions above adapted from the Institute for Healthcare Improvement Web site ⁽³⁸⁾

   
   Figure 4.1: The Care Model
   
   In Table 4.1: Care Model Key Changes, key changes are presented that have been used successfully to improve breast cancer screening within the Care Model framework  

    

   Table 4.1: Care Model Key Changes

   Community	Organization of Health Care	Self Management	Delivery System Design	Decision Support	Clinical Information System
   Partner with local specialists to provide free screenings	Integrate Care Model and Model for Improvement into organization's infrastructure	Short education sessions with patients to explain the purpose and procedure of screening	Empower MAs to prepare and complete relevant screening referral paperwork, put referral in chart for signage, and make appointments for patients to have screenings done before PCP sees patient	Ensure that providers and other staff receive education regarding ethnic/cultural diversity	Use database or information system to identify special needs of ethnic/cultural patients in various areas, such as, interpreter services, preferred language for written materials, and primary language spoken
   Partner with local mammography center to hold Saturday screenings for patients during a “Breast Health Awareness” event	Conduct initial and ongoing organizational cultural competency self assessments	Ensure that patients get relevant information and education; make appointments for screenings, and ensure follow-up on results is done on site	MAs discuss cancer screening with patients, if appropriate, followed by nursing staff who reinforces education before PCP sees patient	Use a cancer screening card that lists screening tests and dates performed; this prompts PCP to discuss during patient visit	Track and review measures regularly and provide systematic feedback
   Partner with AmeriCorps to do outreach to patients, such as, calls to remind them of their appointments for screenings; patient education on various screening tests, and follow–ups if patients missed or rescheduled appointments	Integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcome-based evaluations	Easy-to-read instructions and patient education tools with pictures concerning cancer screening, procedures, and follow-up	Transportation is provided to off-site screening centers	Provider report cards serve as important and useful tools for providing feedback on quality of care being provided	Use the registry to generate reminders and care-planning tools for individual patients
   Create links to referral sites and screening centers to encourage a consistent continuum of care for patients	Senior leadership makes quality improvement and Care Model a priority within organization and cultivates an organization of excellence	Develop or adopt instruction pamphlets and patient education tools to facilitate discussions and patient self management	Use 'standing orders' for guideline-based screening tests for breast cancer	Adopt evidence-based guidelines and practices for testing and screening throughout organization	Continuous monitoring of data to help create and facilitate excitement about the work
   Recruit interns (paid or voluntary) from local schools, community organizations, and volunteer centers	Determine most appropriate process for screening at all levels and operationalize it into the entire system, including competency testing, audits, job descriptions, annual reviews and performance appraisals, workflows, policies, procedures, scheduling, and budgetary impact for overall system reengineering	Send personalized letters to patients that alert them of need for screening--especially for patients who do not come in often for care	Develop or adopt patient release forms for patients referred to screening service centers and specialists to ensure that test results are provided to the organization	Prompts and reminders for providers, including chart-based and computerized reminders, audits, and feedback to improve cancer screening	Perform quality assurance checks to ensure that data is being captured and entered appropriately

   This toolkit is meant as a guide to help organize ideas, but is also designed to allow flexibility for creative planning.

    

   Note: An organization may choose to adapt and refine a tool to assist improvement for the measure, Breast Cancer Screening. Testing the measure before fully implementing it offers a way to try something new and modify it before additional resources are spent.

   The case study continues....

   The Case Study: The QI Team

2. Critical Pathway Approach: As with all critical pathways, good performance relies on many different systems and processes working together efficiently. An organization is encouraged to map its own critical pathway for Breast Cancer Screening or refer to the schematic in Figure 4.2. Often when a QI team maps its pathways, it readily can see how complex each step is. It is common for different team members to do the same step differently. Workflow inefficiencies become clear when an organization visualizes how each step is completed and the interdependencies among the steps. Some teams are overwhelmed by the possibilities of changes that can be made in their systems; others focus only on a specific group of factors.

   One way to organize the factors that have an impact on the systems is to consider that some are controlled by the patient, others are primarily controlled by the care team, and still others are inherent in the system of care delivery. All three sets of changes must be considered to improve systems of care. In general, these categories can be defined as follows:

   • Patient changes-efforts to support self management, patient engagement, and navigation of the care system
   • Care team changes-changes in job duties or workflows that assist to retain patients in care and ensure timely evidence-based breast cancer screening
   • Health system changes-changes that have an impact on how care is delivered, independent of who delivers it

   A team should use the steps along the critical pathway to target improvements. For this measure, Breast Cancer Screening, influences on performance begin by ensuring female patients are screened appropriately for risk factors for breast cancer beginning in their twenties.

   An organization should ensure patients are appropriately educated regarding the importance of regularly updating the health care team about their risks and have enough knowledge to participate in shared decision making as they grow older. Providing education to patients also affords an organization the opportunity to assess patient barriers to testing, such as, lack of insurance or cost. Successful organizations have often aligned resources in the community for mammography screening at a reduced cost for patients creating a true partnership in patient care.

   An organization can think through each part of the critical pathway in turn, teasing out what happens and what could be improved. In Table 4.2, changes that have worked for other QI teams are matched with the part of the system on which they have the most impact. These ideas are not meant to be inclusive, but to start a dialogue of what may improve each part of the critical pathway in an organization, and thus improve it overall.

   Changes That Work  

   Table 4.2: Sample Changes That Work Are Linked to the Critical Pathway for Breast Cancer Screening

   Table 4.2: Sample Changes That Work

   Area of Critical Pathway	Patient Changes	Care Team Changes	Health System Changes
   Female patients aged 20 years and older present for care	Educate patients with resources that describe breast cancer and age- appropriate screening Assess barriers to breast cancer screening; address barriers in partnership with patients	Promote breast cancer screenings (mammograms) for patients 40 and older at every patient encounter Ensure messaging from the care team regarding importance of periodic screening Query electronic medical records or billing system monthly (patients 50 and older)	Prompts for breast cancer screening (mammograms for patients 40 and older) due at point of care – registry and flow sheets Implement standing orders for HbA1c per protocol Implement standing orders for screening per protocol
   Breast cancer screening and risk assessment	Education for patients on importance of breast cancer screening (mammograms) including guidelines Assess patient beliefs for screenings Assist with appropriate self-management goal setting and strategies to overcome barriers Consider health literacy screening Provide evidence-based guidelines for breast cancer screening including risk assessments	Designate care team member to outreach to patients due for breast cancer screening (mammograms) Culturally-competent education for patients to support breast cancer screening (mammograms) Continued education for age- appropriate screening and risk assessment Providers should agree on guidelines so that care among providers is congruent	CME's for providers that support culturally-competent screening and education supporting appropriate breast cancer screening Display culturally-appropriate posters and brochures in patient areas to encourage patients to talk to providers about breast cancer screening and mammograms Clinical guidelines for breast cancer risk assessment and age appropriate screenings
   Shared decision making based on risk	Education for patients on importance of breast cancer screening, including guidelines in a culturally-competent manner	Share clinical guidelines in patient-friendly format Share screening procedure Ensure screening is ordered when it is due, regardless of reason for visit Document current care plan and share copy with the patient Ensure access for patients who need additional support	Provide list of free or low-cost mammography services Develop routine mammogram referrals for female patients 40 and older
   Screening mammogram ordered	Provide evidence-based guidelines for breast cancer screening including risk assessments Consider health literacy screening	Continued education for age- appropriate screening and risk assessment Providers should agree on guidelines so that care among providers is congruent	Clinical guidelines for breast cancer risk assessment and age-appropriate screenings Providers have continuing educational opportunities to stay current with appropriate interventions Prompts for screening are not turned off when test is ordered, but rather when results received
   Mammography not indicated or patient declined	Education for patients on importance of breast cancer screening including guidelines and risk factors Assist with appropriate self management	Continued education for age- appropriate screening and risk assessment Providers should agree on guidelines so that care among providers is congruent	Patient routinely given documentation of current care plan Tools to support breast cancer screening Providers have continuing educational opportunities to stay current with appropriate interventions Display culturally-appropriate posters and brochures in patient areas to encourage patients to talk to providers about screening
   Mammography completed	Education on follow-up and importance of receiving test results once complete	Document current care/treatment plan and share copy with the patient Recall system/log to ensure screening complete	Implement patient follow-up and recall system to ensure screening follow- through Clear procedures for how screening results are routed once received – usually to a provider or another health professional who can act on the results by protocol
   Results received and routed to appropriate staff	Education for patients on importance of receiving test results	Ensure outreach to patient with test results and achieving targets per guidelines; no news is good news strategy for notifying patients about mammogram results is not aligned with good care Set clear expectations for follow-up	Monitor patient contacted with results Set data tracking and evaluation systems for timely patient contact Implement a tracking system that monitors screening results and prompts if results not logged as expected
   Positive findings?	Education on the importance of treatment of positive findings Resources for patient support	General referral for treatment Help patients to make follow-up appointments Assess current care plan, barriers to following care plan, and collaborate with patient on care plan modifications	Partnerships with specialist for low-cost interventions Culturally-competent education materials readily available for specialist referral
   Referral for appropriate care and treatment	Schedule self-management support between visits as indicated. Ensure patients get the relevant information, education, and make appointments for follow-up care	Set clear expectations for follow-up Assess current care plan, barriers to following care plan, and collaborate with patient on care plan modifications Patient satisfaction survey on navigating system	Ensure patient receives guidance about access to the practice with interim concerns Financial considerations and referral source for low-cost interventions Implement Patient Satisfaction Survey for Breast Health Navigation

   This toolkit is meant as a guide to help organize ideas, but is also designed to allow flexibility for creative planning.

    

   Note: An organization may choose to adapt and refine a tool to assist improvement for the measure, Breast Cancer Screening. Testing the measure before fully implementing it offers a way to try something new and modify it before additional resources are spent.

Earlier in this module, examples are provided of changes (Critical Pathway and Care Model) that have led to improved organizational systems of care and better patient health outcomes. Because every change is not necessarily an improvement, changes must be tested and studied to determine whether the change improves the quality of care. This concept is addressed in detail in the Managing Data for Performance Improvement module.

It is important that these changes be tested in the context of an organization's staff, current processes, and patients. The goal is that the change results in lasting improvements within an organization.

Organizations commonly use tools to manage change as they work to improve their systems. For a further discussion of change management, refer to the Managing Data for Performance Improvement and Redesigning a System of Care to Promote QI modules. Here are a couple of tools that are worth mentioning in the context of this measure:

1. Small tests of change – Model for Improvement and PDSA (Plan-Do-Study-Act)
2. Process mapping

3. Model for Improvement

   The Model for Improvement ⁽³⁹⁾ identifies aim, measure, and change strategies by asking three questions:

   
   Figure: AIM Measure Change
   
   These questions are followed by the use of learning cycles to plan and test changes in systems and processes. These are referred to as PDSA (Plan-Do-Study-Act) cycles. The PDSA Cycle is a test-and-learning method for discovering effective and efficient ways to change a current process. In Figure 4.3: The PDSA Cycle, the graphic provides a visual of the PDSA process:
   
   Figure 4.3: The PDSA Cycle

   
   An organization focusing its improvement efforts on Breast Cancer Screening for its patients benefits from implementing PDSAs to test change processes that have an impact on access to preventive care. Those organizational processes tested may focus on outreach, operational procedures, or patient education interventions ensuring that patients have timely access to care. A few examples of such processes relating to Breast Cancer Screening are listed below:

   • What system is in place to provide patients with timely reminders regarding breast cancer screening?
   • What are the assigned roles, duties, and tasks for planned visits to a multidisciplinary care team? Are members of the team cross-trained?
   • Does the patient population understand its specific role in breast cancer screening or is there an opportunity for education?
   • Is there an opportunity to educate the community on the importance of cancer screening, including breast cancer, in a group visit setting?
   • Are there cultural, linguistic, and literacy barriers that the organization may need to address?

   • As an organization plans to test a change, it should specify who, what, where, and when so that all staff know their roles clearly. Careful planning results in successful tests of change. Documentation of what happened – the S or study part of the PDSA – is also important. This can help a team to understand the impact of changes to a process as unanticipated consequences may occur.

     Tips for Testing Changes

     • Keep the changes small and continue testing.
     • Involve care teams that have a strong interest in improving cancer screening.
     • Study the results after each change. All changes are not improvements; do not continue testing something that does not work!
     • If stuck, involve others who do the work even if they are not on the improvement team.
     • Make sure that overall aims are improving; changes in one part of a complex system sometimes have an adverse effect in another.

   • Process Mapping

     Process mapping is another valuable tool that an organization focused on improvement often uses. A process map provides a visual diagram of a sequence of events that result in a particular outcome. Many organizations use this tool to evaluate a current process and again when restructuring a process.

     The purpose of process mapping is to use diagramming to understand the current process; i.e., how a process currently works within the organization. By looking at the steps, their sequence, who performs each step, and how efficiently the process works, a team can often visualize opportunities for improvement.

     Process mapping can be used before or in conjunction with a PDSA cycle. Often, mapping out the current process uncovers unwanted variation. In other words, different staff may perform the process differently, or the process is changed on certain days or by specific providers. By looking at the process map, a team may be able to identify gaps and variation in the process that have an impact on breast cancer screening.

     The case study continues....

     The Case Study: PDSA Cycles in Action

     Process mapping, when used effectively, can identify opportunities for improvement, and support testing changes in the current system of care. Additional information, including tools and resources to assist an organization in adapting process mapping as an improvement strategy within its organization, can be found in the Redesigning a System of Care to Promote QI module.

Measures and data are necessary to answer this question. Data is needed to assess and understand the impact of changes designed to meet an organization's specified aim. Measurement is essential in order to be convinced that changes are leading to improvement. Organizations that have experienced successful improvement efforts found that data, when shared with staff and patients outside the core improvement team, led to the spread of improvement strategies, in turn generating interest and excitement in the overall quality improvement process.

Measures are collected prior to beginning the improvement process and continue on a regularly scheduled basis throughout the improvement program. Once an organization reaches its specified goal, frequency of data collection may be reduced. Additional information regarding frequency of data collection, tracking, and analyzing data can be found in the Managing Data for Performance Improvement module.