Cervical Cancer Screening and HPV Vaccination Rates Riggs Community Health Clinic Lafayette and Lebanon, IN Janine Lowery, RN Director of Quality and Risk Management

Pick a focus and keep it a focus… We have found too often that we will take on a project to improve a measure or clean up a workflow, then the minute we take the spotlight off people revert back to old habits. For 2018 we put the spotlight on Cervical Cancer Screening and kept it there by emphasizing pre-visit planning; providing education to providers and staff on where and how to chart within our EHR; training staff on workflows for closing the loop; having the unit manager report out monthly at our Quality Council meeting for all clinic and our PNWH unit, posting Quality Posters on our units with all clinic and individual provider numbers for 2 key measures for each unit; building custom dashboards within Azara for key measures.

TY 12/2018 Cervical Cancer Screening Year Percentage 2014 47.2% 2015 40.2% 2016 51.2% 2017 53.9% 2018* 61.8%

Cervical Cancer Screening Who, what, where, when, how Care Team Responsibilities: Pre-visit planning – identifying pts in need of screening Documenting health history – hysterectomies – verifying with reports whenever possible Completing the screen (Pap) and recommending future screenings based on results (Care Guidelines within NextGen) Alert Quality and IT when errors are encountered within NextGen or Azara Senior Leadership and Management Responsibilities: Staff training Competency check-off for staff Reporting out on the measure at the monthly Quality Council meeting and to their staff at least monthly Medical Records and Ward Clerk Responsibilities: Assist with obtaining records for screenings completed outside of the clinic Closing the loop by making sure orders are closed out once providers have signed off on results Quality and IT Responsibilities: Maintain data mapping within Azara and NextGen Identify gaps in care/services Troubleshoot any issues with interface for labs Assist with PDSAs to improve workflows when gaps are identified Building and maintaining custom dashboards within Azara

HPV immunization HPV Vaccine (Hedis HPV) at least 2 doses by 13th birthday Just shy of 15,000 VFC immunizations given in 2017 Pro-immunization clinic culture – it’s just part of doing our job We have discussed HPV immunization and ways to make our compliance better, but it has not been a focus for the clinic