D.23 Management of Breast Cancer Screening.pdf

D.23 MANAGEMENT OF BREAST CANCER SCREENING

36C25923R0045

Ambulatory Care Standard Operating Procedure (SOP) for Management of Breast Cancer Screening

Oklahoma VA Health Care System

SOP 02

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 breast cancer screening and management in accordance with the requirements of VHA Handbook 1330.01, VHA Health Care Services for Women Veterans and VHA Directive 1105.03 Mammography Program Procedures and Standards. Sections including Primary Care, Non-VA care, and Radiology. Diagnostic and screening mammography will be available to eligible female and male Veterans as clinically indicated through Community Care office.

2. RESPONSIBILITIES

a. Community Care is responsible for:

(1) Creating referral packet to include authorization and radiology image order and sending to designated community provider.

(2) Scheduling and coordinating appointments for mammograms.

(3) Verifying completion of appointment and requesting imaging results from contracted facilities.

(4) Following Office of Community Care guidelines for consult completion.

(5) Scanning and indexing community mammography reports received into the medical record linked to associated consult.

(6) Notifying the Women’s Health Nurse Navigator when mammography reports are scanned and available for review. Notification is sent to Provider and Women’s Health Nurse Navigator when consult is closed.

(7) Notifying Radiology Service when community mammography report has been scanned and indexed to medical records.

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

(1) Tracking results of all mammography consults and notifying the patient of normal results within 14 days of receipt. The Women’s Health Nurse Navigator is identified by the facility as the designee for the ordering provider to notify veterans of all Breast Imaging, Reporting, & Data System (BI-RADS) 0, 1, 2, and 3 mammograms results.

(2) Ensuring provider is notified of any incomplete or abnormal results.

(3) Ensuring functionality of self-alert notifications for all short term follow-up diagnostic mammograms classified as high risk.

(4) Completing clinical reminder once results are received, prompting the smart alerts when future mammograms are due.

(5) Notifying the ordering provider when radiology ordered is discontinued due to cancellations or no shows.

(6) Sending letter to the patient letting them know the consult has been discontinued and to contact their PACT team for replacement of consult when they are able to have screening mammogram completed.

(7) Informing the Women Veteran Program Manager (WVPM) of an abnormal mammogram 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.

(8) Reviewing administratively closed Community Care mammography consults monthly to ensure receipt of medical documentation and that follow-up action was taken when need, providing appropriate information to Community Care for additional follow up as needed.

c. Provider is responsible for:

(1) Reviewing and following up on all mammogram results and ordering additional views/biopsy as indicated.

(2) Notifying patient of abnormal mammogram results (BI-RADS 4, 5, 6) as well as documenting notifications within five (5) business days of receipt of abnormal results.

(3) Ordering short-term (3-month, 6 month) follow-ups on all diagnostic mammograms.

The order must be placed within 30 days of desired imaging date.

d. PACT Nurses are responsible for:

(1) Coordinating with the Women’s Health Program Support Assistant to provide monthly review of the Breast Cancer Registry (BCR) or Veteran Integrated Registries Platform (VIRP) for upcoming mammogram due, 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 team for consult place

e. Radiology is responsible for:

(1) Timely (within 30 days) uploading of report to the radiology package to include the BIRAD result. Reports uploaded to the radiology package become available for tracking and future care management within the BCR/VIRP tracking system.

f. 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) Periodic Examination: All eligible female Veterans will be offered breast cancer screening and exams as needed through their primary provider or through the Gynecology Clinic in accordance with the VA guidelines. All mammograms are requested through a Community care consult request. Annual screening mammography will be offered to all average risk women veterans age 45 to 54. Women 55 years and older will be offered mammogram screening every two years or have the option to continue screening annually. For patients in their 40s, screening mammography will be offered. Standard screening mammogram will begin from age 45 to 54 utilizing the National Mammogram Clinical Reminder. Screening of high-risk patients will be done on an individual basis. The ordering healthcare provider will discuss the indications and limitations of mammography with individual patients. Staff are to document any patient refusals of breast cancer screening in a CPRS progress note or consult note.

(b) Instructions for CPRS Mammogram Orders: To order mammograms for female veterans, providers are to complete the mammogram request utilizing either the screening or diagnostic consult and clearly indicate the procedure(s) requested. This is to be done through the mammogram orders in the ambulatory care order menu in CPRS so there will also be a radiology order attached to the consult. Nurses are to order the screening mammograms using the mammogram screening clinical reminder.

To order mammograms for male veterans, providers are to complete the consult request utilizing the diagnostic mammogram consult/ultrasound in the ambulatory care orders menu and clearly indicate the procedure(s) requested. All mammograms consults must have associated radiology orders entered prior to Community Care processing the consult. Once requests are submitted, Community care reviews the request, sends the authorization to the patient/facility for scheduling, and ensures consults are closed with appropriate documentation.

(c) Follow-up for Positive/Negative Results Request: Copies of mammogram result reports will be faxed from contract mammography facilities to Community Care service.

The Women’s Health Nurse Navigator notifies patients of all normal results, all incomplete exams and the follow-up interval of next mammogram or ultrasound within 14 days from report received. The provider notifies patients of abnormal results within 5 business days or sooner as appropriate. These notifications are to be documented in

CPRS.

(d) Patient Education: Education regarding periodic health examinations/female health issues (to include, but not limited to self-breast examination) will be made available to female veterans through pamphlets or verbal education.

(e) Quality Control: Monitoring of all abnormal mammograms are conducted on an ongoing and as needed basis using a team approach to include Providers, Women’s Health Navigator, Community Care, WVPM and Quality Safety Nurses. Gaps in quality control are 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. Smart Alert: An alert that provides notification to an ordering provider when a mammography is due

b. Self- Alert: An alert that allows providers to prompt themselves to follow up on a given task

6. REFERENCES

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

b. VHA Directive 1105.02, Mammogram Program Procedures and Mammography Standards

c. 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

As expected in house mammography program is developed, this SOP will be reviewed to indicate changes in procedure as necessary

RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of DECEMBER 9, 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 Digitally signed by George

George Malatinszky Malatinszky 191377

Chief of Ambulatory Care Signature:

191377 Date: 2022.12.13 14:31:42

-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