Improving cervical cancer screening rates at a Federally Qualified Health Center

Cervical cancer is the fourth most common cancer in women. Early detection with screening methods can help to prevent mortality.

Cervical cancer screening is below national standards at a Midwest Federally Qualified Health Center and may compromise future funding. A manual chart review of cervical cancer screening was compared with an electronic health record-generated report and found results from outside facilities accounted for 27% of the metric's underperformance. This quality improvement project aimed to improve the Uniform Data System performance for cervical cancer screening at a specific health center from 46.3% to 79.2% by July 2024.

Implementation, guided by the Improvement Model and Lewin's Change Theory, included (1) analysis of cervical cancer screening underperformance, (2) sharing data with key stakeholders, and (3) creating tip sheets for chart reconciliation.

Interventions consisted of (1) auditing and reconciling charts from Epic's generated reports, (2) modifying the frequency of or discontinuing Pap smears, (3) updating surgical history to reflect hysterectomy type, and (4) sending scheduling outreach messages.

As of March 2024, cervical cancer screening 2023 percentages increased by ≥9% for each quarter and by 8.7% for year-to-date at the Midwest health center. The quality metric's quarter 1 and 2, 2024 data increased by 4% and 3% as of July 2024.

Although the target goal was not reached in the designated time frame, the percentage increase proves that implementation of a chart reconciliation workflow can improve rates for cervical cancer screening at a Federally Qualified Health Center.