The purpose of the initiative is to increase the percentage of eligible female veterans who receive biennial mammography to over 80% consistently at the Minneapolis VA (MVA) medical center.
The External Peer Review Program (EPRP) evaluates a number of charts each month to report quality of care on a variety of performance measures. Breast Cancer Screening is among those evaluated with the goal of a 77% completion rate. In 2012 the average EPRP showed MVA’s completion rate at 77%. It also highlighted that it was below target for 4 months. Clinical Reminders are relied upon for provider notification, however, the current process depends on clinicians going into individual charts to see and act on them. Oftentimes this is not done in an acceptable amount of time.
The Corporate Data Warehouse (CDW) stores clinical information from VistA. A pro-active process to address biennial mammography completion was reproduced using methods that query the CDW. Reports that evaluated all veterans, overdue or nearly due, for breast cancer screening were created. Lists of these patients were generated and sent to providers/PACT teams for evaluation and resolution. These “push” reports were distributed quarterly, starting in January 2014, and increased to monthly in 2015.
EPRP results are highly variable and depend on the sample selection for any given month. Therefore a rolling 12 month average, median, and standard deviation of the samples are reported along with actual monthly values.
The MVA breast cancer screening rate, as reported by EPRP, improved from a 12 month average of 80% to a 12 month average of 95% over 2 years. The variability/standard deviation was reduced by 50% as quality improved.
“Push” reports can help improve rates of early breast cancer detection by screening within the recommended period of time. This panel management tool can be created at any VA facility and can be extrapolated to other quality measures.
