ATT D9 Cervical Tracking SOP.pdf

Cervical Tracking Standard Operating Procedure

SOP

G.V. (Sonny) Montgomery VAMC Jackson, Mississippi 39216

Signatory Authority:

GVSMVAMC Chief of Staff GVSMVAMC Deputy Associate Chief of Staff Primary Care

Responsible Owner:

GVSMVAMC Chief of Quality Management

1. PURPOSE AND AUTHORITY

Service Line(s):

Primary Care

Effective Date:

March 30, 2021

Recertification Date:

March 30, 2024 a.This standard operating procedure (SOP) sets forth to establish and provide guidance to staff for tracking Cervical Screenings (PAPS) in Women's health and ensure compliance to VHA Directive 1330.01 (4) Health Care services to women Veterans, dated February 15, 2017;amended January 8, 2021.

b.The purpose of this SOP is to establish procedures and responsibility for tracking Cervical (PAP) Screens. This SOP must be followed by all G.V. (Sonny) Montgomery VA Medical Center (GVSMVAMC) and Community based Outpatient Clinics (CBOC) designated personnel. The Women's Health Coordinators (WHC) along with the Women Veterans Program (WVPM) and/or Women's Health Medical Director (WHMD) is responsible for developing, implementing the tracking procedures for compliance of the Cervical Screens. It is the responsibility of the WHCs to track Cervical Screens upon receipt. The Women Health Program Support Assistant (PSA) is also designated to assist.

2. PROCEDURES

a.The Women Health Coordinators/Program Support Assistant and CBOCs designees (liaisons) will track PAPs upon receipt.

b.The GVSMVAMC Women Health Coordinators/Program Support Assistant and CBOC designees (liaisons) will utilize the attached guidelines to track and ensure appropriate follow up of Cervical Screens for completion (see attachment).

c.In the event of one of the Women Health Coordinators absences, the second coordinator along with the PSA will track and ensure appropriate follow up has been completed.

d.Included in the tracking process, the WHCs and PSA will validate/verify the report in the electronic record system as appropriate.

Link to Resources for Implementation of VHA Policy SharePoint site:

https://dvagov. sharepoint.com/sitesNACOVHACOS/1064/PI R P/1 0B4/SitePages/Home.aspx

3. ASSIGNMENT OF RESPONSIBILITIES

a.GVSMVAMC Chief of Quality Management. In accordance with the responsibility in VHA Directive 1330.01 (4) Health Care Services for Women Veterans, Chief of Quality Management/team for the GVSMVAMC, in collaboration with the WVPM, WHMD, Chief of Pathology and Primary Care Service will oversee the tracking and timeliness of follow-up of findings from Cervical screenings in accordance with procedures in this SOP.

b.GVSMVAMC Associate Chief of Primary Care. The GVSMVAMC Associate Chief of primary Care in collaboration with the Quality Management Chief/team in collaboration with the WVPM, WHMD, Chief Lab/Pathology and Primary Care Service will oversee the tracking and timeliness of follow-up of findings from cervical screening in accordance with procedures in this SOP and requirements in VHA Directive 1330.01

(4) Healthcare Services for Women Veterans.

4. DEFINITIONS

None.

5. REFERENCES

VHA Directive 1330.01 (4) Health Care Services for Women Veterans, dated February 15, 2017/amended January 8, 2021.

6. REVIEW

This SOP must be reviewed at minimum at recertification and including when there are changes to the governing document, VHA Directive 1330.01(04) This review is documented on the GVSMVAMC Facility SharePoint site Medical Center Policies and Memoranda see:https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbvname.aspx ?viewpath=°/02Fsites%2Fvhajae/02Fpoliciesmemos%2FForme/o2Fsortbyname.aspx (see). NOTE: This is an internal VA Web site that is not available to the public.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of February 2026. In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

https://dvagov.sharepoint.com/sitesNACOVHACOS/10B4/PIR P/1 0B4/SitePages/Home.ashx

Rachel Peery, MD,FACP GVSMVAMC Chief of Staff Date Approved: March 30, 2022

Andree' A. Burnett, MD GVSMVAMC Deputy Associate Chief of Staff Primary Care Date Approved: March 30, 2022

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

DISTRIBUTION: Emailed to the GVSMVAMC Quality Management Employees Email Distribution List, Primary Care Employees Email Distribution List, Chief of Lab/Pathology Email Distribution List and the GVSMVAMC Chief of Staff Women health Employees Email Distribution List on March 30, 2022. SOPs are available at:

GVSMVAMC Facility SharePoint site Medical Center Policies and Memoranda https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?vie wpath=°/02FsitescY02Fvhajae/02Fpoliciesmemos'Yo2FForme/02Fsortbyname.aspx http://vaww.va.gov/Anytown Publications/. NOTE: This is an internal VA Web site that is not available to the public.

https://dvagov.sharepoint.com/sitesNACOVHACOS/10B4/PIR P/1 0B4/SitePages/Home.aspx

Cervical (PAP) Tracking Guidelines

1. Receive order with Veteran information (name, last four of social, & date) through printer.

2. Enter the information listed above, cervical screenings result, and actions taken on results (if indicated) into the cervical screening data spreadsheet located on the Women's Health drive (Cervical Screening Folder) under cervical screening Log.

3. Verify (CPRS) timely letter notifications to Veterans; no evidence of malignancy (NEM) 14 calendar days and for any abnormal cervical pathology report, 7 calendar days of the report.

4. Tracking of cervical cancer screening, including notification of Veterans who are due for screening's, tracking of completion of screening, results reporting, and follow-up care.

https://dvagov.sharepoint.com/sitesNACOVHACOS/10B4/PI R P/1 0B4/SitePages/Home.aspx