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

2. 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.

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

4. 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

5. 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