D.18 SOP for Cervical Cancer Screening at Salem VAMC.pdf

D.18 SOP for Cervical Cancer Screening at Salem VAMC 36C24621R0068

CERVICAL CANCER SCREENING

SOP 658-11-002

Salem VA Medical Center Service Line(s):

Salem, VA 24153 Deputy Chief of Staff, Primary Care, Lab

Signature Authority: Effective Date: October 28, 2020 Special Program Assistant to the Chief of Staff

Responsible Owner: Recertification Date: October 28, 2025 Women Veterans Program Manager

1. PURPOSE: To define the process of managing Cervical Cancer Screening at all sites of the Salem VA Medical Center. VHA and ACOG recommends cytology testing alone every 3 years for women aged 21 to 29 years and reflex HPV testing for abnormal pap smears. For women aged 30 to 65 years, co-testing with cytology and HPV testing every 5 years is preferred, and screening with cytology alone every 3 years is acceptable, according to the guidelines.

2. POLICY:

A. The Salem VAMC Center provides and tracks cervical cancer screening results and timeliness of follow-up of findings from cervical cancer from cervical cancer screening, per the requirements of VHA handbook 1330.01 Health Care Services for Women Veterans.

B. Cervical cancer screening/HPV co-testing is performed by Providers and Gynecologists at all sites of the Salem VA Medical Center, including Danville, Lynchburg, Tazewell, Staunton and Wytheville Community Based Outpatient Clinics using the 2016 American College of Obstetricians and Gynecologists (ACOG) standards.

C. Anal Pap smears/HPV co-testing is performed by the Gynecologist if clinically indicated.

D. All cervical cancer screening laboratory specimens are processed at the Salem VA Medical Center.

3. PROCEDURES:

A. The Pap smear clinical reminder due report will be run monthly for Salem and all 5 CBOCs monthly. Salem and all outpatient clinics will designate a women’s health nurse to review the due list and schedule patients according to clinical need (VA Pap results can be found under “Labs/Anatomic Pathology” and HPV can be found under “labs” in CPRS).

B. The designated women’s health nurses will call women Veterans who do not have Pap results in CPRS to see if exam was done in the community.

C. For patients who have had Pap exams done in the community, the designated women’s health nurses obtain records, scan them under “Outside Medical Records,” and document results referencing the outside report under the note title “Nursing note” in CPRS with the primary care provider co-signed. The Women’s Health provider or GYN adjusts the clinical reminder accordingly.

D. For patients who have not had a Pap done at Salem or the community, the designated women’s health RN documents appropriate clinical background information under the note title “Nursing Note,” then gives the list to the MSA in Salem or CBOC for scheduling.

E. Providers performing the Pap smear at all sites place the laboratory order in

CPRS.

F. The lab has 30 calendar days to return normal cytology reports and the interpreting pathologist has 5 business days to notify the ordering provider (or surrogate) by phone or in person of all abnormal reports.

G. The provider is notified of all results by view alert in CPRS at all sites.

H. Once both Pap and HPV results are returned from the lab, the ordering provider (or designee) notifies patients of normal results within 14 calendar days via printed letter generated from CPRS templated note “Pap Normal Result Notification.”

I. Once both Pap and HPV results are returned from the lab, the ordering provider (cannot be designated) notifies patients of abnormal results within 5 business days via phone call or face-to-face meeting and generates CPRS templated note “Pap Abnormal Result Notification.” If after 3 attempts of trying to contact the patient by phone and documenting the record of abnormal results in CPRS, the provider will send a certified letter to the patient (a copy of the letter and returned USPS signature) will be put in the patient’s record).

J. A laboratory representative sends weekly results to the designated women’s health nurses, as well as ordering providers.

K. The designated nurses monitor providers for compliance of CPRS documentation of normal and abnormal cytology results and abnormal follow-up.

L. The designated nurses report all Pap smear data on a quarterly basis to the

Women’s Health Committee (WHC) –total number of Paps, number of insufficients, number of abnormals, follow-up compliance on abnormals and patient notification compliance.

M. The WH nurse manager audits 10 charts a month to ensure compliance with all procedures outlined in this SOP.

N. The WVPM rolls up this data into bi-annual Medical Executive Council executive summaries.

4. REFERENCES: https://www.acog.org/Patients/FAQs/Cervical-Cancer-

Screening https://www.acog.org/Patients/FAQs/Cervical-Cancer-Screening https://www.acog.org/Patients/FAQs/Cervical-Cancer-Screening

5. REVIEW

Review of this SOP will be, at minimum at recertification, and including when there are changes to the governing document.

6. RECERTIFICATION

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

7. SIGNATORY AUTHORITY

Digitally signed by Tammy S. Snyder 181419 Date: 2020.11.05 08:31:04 -05'00'

Tammy Snyder, Special Program Assistant to the Chief of Staff

Digitally signed by SOHEIR S BOSHRA

SOHEIR S BOSHRA 1440776 1440776

Date: 2020.11.09 10:16:45 -05'00'

Dr. Soheir Boshra, WHMD

Eleanor Elizabeth Holt Wright, WVPM

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

DISTRIBUTION: SOPs are available at:

https://dvagov.sharepoint.com/sites/salem/Salem%20SOPs/Forms/AllItems.aspx

Digitally signed by Eleanor E. Wright

Eleanor E. Wright 181394 181394

Date: 2020.11.09 09:09:11 -05'00'

Tammy S. Snyder 181419 https://dvagov.sharepoint.com/sites/salem/Salem%20SOPs/Forms/AllItems.aspx