D.16 CERVICAL CANCER SCREENING2.pdf

D.16 CERVICAL CANCER SCREENING

36C25922R0102

Ambulatory Care Standard Operating Procedure (SOP) for Cervical Cancer Screening

Oklahoma VA Health Care System

SOP 01

Oklahoma City, OK 73159

Signatory Authority:

Chief of Ambulatory Care Chief Nurse of Ambulatory Care

Responsible Owner:

Chief Ambulatory Care Women Veteran Program Manager

1. PURPOSE AND AUTHORITY

Service Line(s):

Ambulatory Care

Effective Date:

DEC 9, 2022

Recertification Date:

DEC. 9, 2027

The purpose of this standard operating procedure (SOP) is to establish procedures in Ambulatory Care services for cervical cancer screening and availability to all eligible female Veterans as clinically indicated through a primary care physician or gynecological referral. The primary care provider or designated women's health providers will follow the current VHA guidelines for cervical cancer screening and the process defined for Cervical Cancer Screening in VHA Handbook 1330.01, Health Care Services for Women Veterans.

2. RESPONSIBILITIES

a. Providers (Physician/Nurse Practitioner/ Physician Assistant) are responsible for:

(1) Obtaining Pap smears and Human papillomavirus (HPV) tests. Providers will also review Pap smear and HPV test results and notify patients in a timely manner (per guidelines defined in VHA Handbook 1330.01) by letter, in person or by telephone on recommended follow-up.

(2) Ensuring that the results of normal (NEM-No Evidence of Malignancy) cervical pathology are reported to the ordering provider by the lab within 30 calendar days of the pathology report being issued. The interpreting physician must ensure the ordering provider is contacted with abnormal results within 5 business days.

b. PACT Nurses are responsible for:

(1) Providing Chaperoning support and will ensure that specimens are properly labeled and sent to the lab on the same day.

(2) PACT nurses with assistance from the Women’s Health Program Support Assistant will provide monthly review of VSSC for upcoming cervical cancer screens as well as those past due (within 3 months). If the patient is not able to be reached by phone a letter will be sent requesting them to contact care team to schedule screen.

c. Women’s Health Nurse Navigator is responsible for:

(1) Tracking results of all cervical cancer screening and monitoring compliance with notification to the Veteran with in the designated time frame.

(2) Ensuring provider is notified of all results.

(3) Informing the Women Veteran Program Manager (WVPM) of an abnormal cervical cancer screening &/or Human Papillomavirus (HPV) that have not been communicated to the patient within the timeframes specified. The WVPM will give this information to the Chief of Primary Care for further action.

(4) Changing the frequency of the cervical cancer screening clinical reminder to reflect when the next pap smear is due per provider guidance.

d. The Women Veterans Program Manager (WVPM) is responsible for:

(1) Coordinating activities of the Women Veterans Health Program and managing the development, implementation and monitoring of policies regarding women veterans and their care.

3. PROCEDURES

(a) Pap and Pelvic Examinations: All eligible female Veterans will be offered pap smears, pelvic exam and STD screening (if indicated) exams through their primary provider or through the Gynecology Clinic.

On a monthly basis providers will be given a report by their PACT team (with assistance from the Women’s Health Program Support Assistant) containing all patients assigned to their specific panel that have a reminder due now for a pap smear. Pact teams will review the list and document the date of the last Pap/HPV and results for providers to ensure Pap smear is clinically indicated. If indicated, Provider will request PACT team schedule the Pap smear. PACT teams will regularly review VSSC for upcoming cervical cancer screens that are coming due as well as those past due. A letter will be sent requesting them to contact team for scheduling of appointment.

(b) Instructions for Pap Smears: Providers who perform gender specific exams like pap, pelvic and breast exams will have a chaperone present.

RN/LPN will appropriately label Thin Prep bottle with Veteran’s full name, Veteran’s full social security number.

PACT Team will place electronic order in CPRS for the Pap smear, HPV, and STI testing as indicated.

(c) Notifications and Follow Up for Positive/Negative Results: The lab will notify the provider and Women’s Health Nurse Navigator via a view alert when the results of pap and HPV are available.

The provider performing pap smears is responsible for follow-up on normal and abnormal exams, ensure patients get their result, follow-up exams, treat any pathology detected and/or to refer to gynecology if needed.

Patients referred to gynecology for abnormal exams will be followed by gynecology until they are released to be followed by primary care providers. GYN clinic will notify the provider of all recommendations.

The provider performing the pap smear is also responsible and must ensure that any abnormal pap (abnormal cervical pathology report) results is communicated to the patient in terms easily understood by a layperson within 5 business days of the report being issued. Provider will enter documenting notification of results and follow-up in their progress notes.

The cervical pathology report of Normal (NEM-No Evidence of Malignancy) results must be communicated to the patient in terms easily understood by a layperson within 14 calendar days from the date of the pathology report becoming available. Provider will enter documenting notification of results and follow-up in their progress notes.

PACT teams will place a self-alert and/or return to clinic order for follow up pap smear as indicated by provider in the patient’s electronic record.

(d) Patient Education: Education regarding periodic health examinations/female health issues is made available to female Veterans through pamphlets, educational programs, and one-to-one educational sessions.

(e) Quality Control: Monitoring of all abnormal mammograms will be conducted on an ongoing and as needed basis using a team approach to include Providers, Women’s Health Navigator, WVPM and Quality and Safety Nurses. Gaps in quality control will be addressed as identified.

4. ASSIGNMENT OF RESPONSIBILITIES

a. Ambulatory Care Leadership and Staff. This SOP assigns the responsibility to Ambulatory Care leadership and staff.

5. DEFINITIONS

a. None

6. REFERENCES

a. VHA Directive 1330.01 (03), Health Care Services for Women Veterans

b. VHA Directive 1330.02, Women Veteran Program Manager

7. REVIEW

This SOP must be reviewed at minimum at recertification and including when there are changes to the process outlined therein or where is there is a mandate for change. This DISTRIBUTION: Email to OKC Nurse Managers <OKCNurseManagers@va.gov>; OKC Chief Nurses <OKCAssociateChiefNurses@va.gov>; OKC Clinical AO <OKCclinao@med.va.gov>; OKC Clinical Service Chiefs OKCclisrvchfs@med.va.gov

RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of DEC 31, 2027 – 5 years from effective date. In the event of contradiction with national policy, national policy supersedes and controls.

8. SIGNATORY AUTHORITY

George Malatinszky, MD Chief of Ambulatory Care Signature:

George

Malatinszky

191377

Digitally signed by George

Malatinszky 191377

Date: 2022.12.13 14:30:49

-06'00'

Date:

Patricia Henderson Chief Nurse of Ambulatory Care Signature: Date:

12/13/22

Stephanie McCabe Women Veteran Program Manager

Signature: _______________________________________ Date: _12/09/22

NOTE: The signatures remains valid until rescinded by an appropriate administrative action.

mailto:OKCNurseManagers@va.gov mailto:OKCAssociateChiefNurses@va.gov mailto:OKCAssociateChiefNurses@va.gov mailto:OKCclinao@med.va.gov mailto:OKCclisrvchfs@med.va.gov