D.32 Women's Health Pap coordinator - SOP, 36C25522R0052.pdf

Department of Veterans Affairs Truman VA Medical Center Columbia, MO

March 23, 2022

Women’s Health Pap Navigator

Standard Operating Procedure

1. PURPOSE: To establish care guidelines for the safe, ethical, respectful and appropriate management of cervical care.

2. POLICY: To provide eligible women veterans with all clinical and administrative services necessary for their care as outpatients and inpatients in Gynecology clinic.

3. BACKGROUND: All Veterans who are enrolled and assigned in VA’s health care system. (ChampVA is not eligible for Specialty, Surgical services or any OCC services due to regulations.)

4. DEFINITIONS:

• Community Care consults: Consults made to an outside facility

• HIMS: Health Information Management Section. This department handles the scanning in of records.

• OCC: Office of Community Care, the department within the VA Hospital who handles outside referral consults. Formally known as Fee Basis Department, Non-VA Community Care, Care in the Community.

• PACT: Patient Aligned Care Team. This is the patient’s PCP and members of the team.

• Provider: MD, NP

• WHCN: Women’s Health Gyn/Pap Clinical Navigator

• WVPM: Women Veterans Program Manager

• WHMD: Women’s Health Medical Director

D.32 Women's Health Pap coordinator - SOP, 36C25522R0052

5. RESPONSIBILITIES:

• Women’s Health Medical Director: Guidance and support of Women’s

Health Program. Supervision is by the Nurse Manager of Surgical Dept / Team Care.

• Women Veteran Program Manager: Guidance and support of the Women’s Health Program- administrative.

• Surgical Dept Nurse Manager: Supervision, guidance and support of

WHCN.

• Women’s Health Clinical Navigator – Clinical expert and support to the Gynecology Service and Women’s Health Program.

• Providers and Nursing staff: Work collaboratively with WHCN in effort to provide seamless care in a mutually respectful manor. Ordering providers are responsible to review cervical cancer screening results upon receipt, formulate a plan of care within the chart and communicate results appropriately to the patient per VHA directive 1330.01, which states upon receipt of results within 7 days for abnormal results or 14 days for normal results.

6. PROCEDURE:

A. Cervical Screening

• Well woman exams should be performed within the patients PACT.

GYN consults should be entered for services beyond those available in Primary Care. All normal and abnormal paps will be added to a tracking system. WHCN periodically reviews this tracking system to ensure recommended follow up in community and eventual return to services within the VA.

• WHCN receives cervical cytology reports for paps done within the VA by electronic alert from pathology. Referrals outside the VA consults cytology reports are alerted to the WHCN when scanned into

CPRS by the OCC team. Reports are reviewed daily and an addendum is added to the provider note to update the reminder. The provider should be notifying the patient of results and updating the cervical cancer screening reminder. All abnormal results are alerted to the provider to determine plan of care and discuss with patient. All normal and abnormal pap results are tracked by the WHCN.

B. Collaboration

• WHCN will work collaboratively with WVPM to ensure women veterans receive quality and ethical care. Clinical coverage for WHCN will be provided by cross coverage of surgical navigators assigned by the Nurse Manager.

• WHCN will work in Gynecology clinic in effort to provide seamless care in a mutually respectful manor, including:

o Notify PCP or GYN when new consult is needed for services and why o WHCN will review incoming consults for appropriate, enter new order or forward to OCC based on service available and guidelines.

o OCC will alert WHCN when records of abnormal cervical cancer screening faxes are received.

• If at anytime that a resolution to a Women’s health care concern is not resolved by 3 business days, it will be elevated to the Nurse Manager and to WVPM for resolution.

C. Audits

• An audit will be performed during the External Peer Review Program

(EPRP) monthly by the WHCN using the cervical screening auditing tool to monitor for compliance of cervical screening tracking. Any non-compliance will be reported to the WHMD and WVPM to address with Primary Care Chief.

D. REFERENCES:

• VHA directive 1330.01 (Health Care Services for Women Veterans)

• VHA Directive 1232 (Consult Processes and Procedures)

• VHA Directive 1088 (Communicating Test Results to Providers and

Patients)

E. This Standard Operating Procedure has been reviewed and approved by the following officials:

X Shawn Ricketts RN BSN

WOMENS HEALTH PAP CLINICAL NAVIGATOR

Signed by: people

X

SURGICAL NURSE MANAGER

WOMENS HEALTH MEDICAL DIRECTOR

WOMEN VETERANS PROGRAM MANAGER

Approved by WH Committee YES or NO

Reviewed Date(s)

Revised Date(s)

Appendix A: Cervical Screening Auditing Tool

Step by Step instructions on Spreadsheet Tracking

In the public file for Women’s health Services has resources and the trackers for cervical cancer screening This PC\S:\Public\WHS-Womens Health Services

The National Cervical Cancer Tracking Tools

Women's Health - Cervical Cancer Tracking Tools - All Documents (sharepoint.com)

In the Abnormal PAP sheet, a tab is added to track episode of care for further evaluation. You will enter yes/no or N/A and consult will be tracked until completion. After all the follow-ups and request on the abnormal tab results have been completed, you will go and enter yes to complete.

Women’s Health Pap Coordinator Coverage

The National Women’s Health Cervical Cancer Tracking Tool on Share Drive: me https://dvagov.sharepoint.com/sites/VHAWomensHealth/Shared%20Field%20Documents/Forms/AllItems.aspx?RootFolder=%2Fsites%2FVHAWomensHealth%2FShared%20Field%20Documents%2FCervical%20Cancer%20Tracking%20Tools&FolderCTID=0x0120000DBF245C44E9664A94B6F1CF2D6E92C7

Women’s Health-Cervical Cancer Tracking Tools-All Documents(sharepoint.com)

1. Receive all cytology alerts on all services and only need to enter the data from the cervical scrapings and vaginal cytology requests.

2. Receive all cytology results for all services and only need to enter the data from the cervical scrapings and vaginal cytology results.

3. Enter the veteran’s name

4. Enter last 4

5. Enter Date the Pap was collected

6. Enter Date the Pap was reported

7. Enter the Results for PAP and HPV

8. Enter the Date Veteran was contacted

9. Enter how contacted

10. Enter the Provider

11. Enter Colposcopy date if needed

12. Enter when next Pap will need to be repeated

Abnormal PAP:

1. Click on Abnormal tab at bottom

2. Enter the veteran’s name

3. Enter last 4

4. Enter Pap results

5. Enter HPV results

6. Enter recommendations

7. Enter Colposcopy results

Screenings should be done in the PACT and or the Gyn clinic. Teams Dr. Welch and or R Cupp- PA-C when receive the cytology results done in the Gyn clinic so they do not get missed.

Any cytology results from screenings done in the community will be collected by OCC LPN and they will alert you per teams and or per CPRS note. Enter the results as per above.

Cervical Cancer Screening Reminders:

1. Call pap results to veteran and then set Cervical Cancer Screening Reminder in CPRS for all GYN cytology after reviewed by Providers. They will need to determine when the follow up screening is needed 1, 3, and or 5 years as per ACS guidelines.

2. If Abnormal may need to schedule for Colposcopy if ordered. Enter RTC.

3. Start a new note, may use Co- pap coordinator title.

4. Start Note with “Updating Cervical Cancer Screening Reminder.”

5. Then click the Reminder tabs and click onto Cervical Cancer Screening which may be under All Evaluated and it will populate into the note.

6. Follow the prompts/boxes:

a. PAP smear obtained at this encounter

b. Click both boxes for HPV and Screening

c. Click Record prior or outside PAP/HPV results

d. Click Normal or Abnormal (will need to click which one it is)

e. Location is HSTVA or CBOC (or CC if needed) type in box

f. Enter the Date completed

g. Click Cervical HPV negative or positive

h. Location is HSTVA or CBOC (or CC if needed) type in box

i. Enter the Date completed

j. Enter the frequency of screening

k. Click finish

l. Will add the Colposcopy date if done and the results

7. Add “alerting Primary Care Team for informational purposes only” and add them as a signer as a courtesy

8. Add Gyn Provider as signer

9. The new reminder will be set according to the frequency chosen

10. Will need to check back on the paps completed by other providers when the veteran was notified of the results and if the reminder has been set appropriately

a. If veteran has not been notified within the 10 days directive, I will teams the

RNCC and ask them to check with the provider

11. If the veteran has reached the age of 65, may need to change the frequency to stop screenings according to ACS guidelines but only if provider writes that in their note.