Before an organization can begin to improve systems of care for a targeted population, the organization needs to understand and define the population in order to accurately measure and assess the impact of breast health improvement activities. Due to many different national breast cancer screening guidelines, setting up clinic-wide processes can be difficult. Deciding on a clinic-wide referral policy is the first step to help clinics optimize the capacity that they do have; and a clear referral policy helps to establish the demand for mammography services and measuring success.
Establishing the target population enables baseline measurement and goal-setting to assess and drive progress. Defining the population is closely linked with Element 2: Access to Screening Appointments and Building Capacity and Element 3: Data Collection Plan to Measure Progress.
Steps for Implementation
- Review national guidelines for breast cancer screening with your provider team.
- Agree upon an evidence-based breast cancer screening guideline for system-wide implementation within your clinic.
- Define the target population eligible for breast cancer screening according to the adopted guidelines.
- Determine the demand for mammography services for 100% access, by establishing the number of active, eligible patients seen per year.
Establishing Referral Guidelines for the Clinic: Greater Baden Medical Services, Inc., Prince George’s County, Maryland
In order to determine the system-wide breast cancer screening referral guidelines, the Greater Baden Medical Services (GBMS) provider team met and discussed each provider’s current practices. Some providers used the U.S. Preventive Services Task Force (USPSTF) guidelines, referring women 50 and over, every 1-2 years. Other providers always referred women annually beginning at age 40, and included younger women deemed high-risk according to family history. The GBMS provider team decided that the priority population for mammography screening remains women 50 and over. Therefore, the team decided to adopt the USPSTF guidelines for system-wide implementation and defined their population as women 50 and over to serve as the baseline for tracking and monitoring the referral process for the priority population. Providers still have the clinical discretion to refer women outside the parameters of the guideline, but data on these women are not tracked as part of process improvement activities.
Determining the Demand: Community Health Care Network, Fairfax County, Virginia
The team at Community Health Care Network (CHCN) established a system-wide guideline to refer all women 40 and over every year and defined an “active”, eligible patient as a woman, 40 and over, seen at least once over the past year. The clinic team decided to initiate focused breast health process improvement activities at one of their three sites and thus, established the demand at that site. Using data from their practice management system, the team determined that 1,340 active, eligible patients were seen in the previous year. Per their guidelines, that means that 1,340 mammograms are needed each year, or approximately 112 mammograms per month.
Frequently Asked Questions
Q1. With all of the different mammography screening guidelines out there, how do we pick just one for all providers to implement?
A1. Guidelines include recommendations, strategies, or information that assist healthcare professionals and patients to make appropriate clinical decisions, but providers exercise independent clinical judgment specific to individual patients. Providers may refer a patient for a mammogram, whether or not the patient characteristics are within the clinic referral guidelines, especially patients deemed as high-risk. However, the clinic must establish a system-wide guideline for adoption and implementation in order to streamline processes for all staff and enhance the delivery of care to the target population. It may take many meetings with the provider team to discuss the screening guidelines and reach consensus on the system-wide guideline.
Q2. How do you define active patient?
A2. You may define it however you like to best capture the number of women seen and establish your target service population. Some patients may only come in once and never return to the clinic, so you may not want to count those in your active patient population. However, some clinics may want to include patients who visit the clinic just once because you want to make any and all clinic visits an opportunity to refer a patient. The Initiative defines an active patient as “a patient who had two face-to-face encounters with different dates of service – one visit during the past year and the other visit in the measurement period or within two years prior to the end of the measurement period.”
Q3. What if our patient population is growing? Do we adjust the number of mammograms needed?
A3. Once you define the population served by your clinic, you may revisit the process to re-establish the target number and the mammography need (“demand”). It must be a data-driven process, which most likely will occur when monthly measures demonstrate significant differences between the true demand and the established monthly goals. (See Element 3: Data Collection Plan to Measure Progress).