S02 ATTACHMENT D.19 - SOP 011-132 MAMMOGRAM POLICY.pdf

Mammography Process

MCP 11-132

Veterans Health Care System of the Ozarks Fayetteville, AR 72703

Signatory Authority:

Medical Center Director

Responsible Owner:

Women Veteran Program Manager

Rescinded Document:

See paragraph 7.

Effective Date:

June 8, 2022

Recertification Date:

June 8, 2027

1. POLICY

This Medical Center Policy establishes compliance standards for the Veterans Health Care System of the Ozarks (VHSO) Mammography Process. The mammography process will be used with each patient receiving a mammogram throughout VHSO and staff involved in the care coordination process shall be listed in paragraph (3) with responsibilities to ensure tracking, monitoring, and timely follow-up care.

2. JUSTIFICATION

This policy exists to meet the mandate in Veterans Health Administration (VHA) Directive 1330.01(4), Health Care Services for Women Veterans, dated February 15, 2017, amended January 8, 2021 and VHA Directive 1105.3, Mammography Program Procedures and Standards, dated May 21, 2018.

3. RESPONSIBILITIES

a. Medical Center Director. The Medical Center Director is responsible for ensuring overall VA medical facility compliance with this policy, and appropriate corrective action is taken if non-compliance is identified.

b. Women Veteran Program Manager (WVPM). The Responsible Owner is responsible for oversight and guidance responsibilities for this policy to include:

(1) Conducting training with staff involved in the mammography process including new staff orientation, annual training and as needed with VHA directive updates per staff needs.

(2) Auditing the mammography process to include ordering and tracking. Review a 100% of “Suspicious” or “Highly Suggestive of Malignancy” Breast Imaging Reporting and Database System Score (BI-RADS) codes 4 and 5. Conduct a 10% audit on BI- RADS codes 0, 1, 2, 3.

June 8, 2022 MCP 11-132

(3) Reporting mammography performance metrics in the Women Veteran Health Committee (WVHC) at least quarterly.

(4) Reporting identified compliance gaps to Quality, Safety, and Value (QSV) committee, submitting a patient safety report upon discovery of non-compliance and collaboratively developing action plans for mitigation through the WVHC membership, in accordance with the WVHC Charter.

c. Chief of Staff (COS). The COS is responsible for:

(1) Delegating QSV staff to trend timeliness of Veteran notification of Community Care (CC) mammography test results by the ordering provider and implement follow up actions for any noted trends more than the Veteran Affairs (VA) seven day timeliness standard.

(2) VHSO Office of Community Care does not administratively close mammography consults. Data for compliance will be reported as a standing agenda item at CC oversight council meetings.

(3) Ensuring that the designated facility QSV staff review data for compliance quarterly and submit to the CC oversight council on a quarterly basis with a goal of 100% compliance. Review questions will cover but not limited to the following:

(a) Provision of mammography results/reports in the patients Electronic Health Record (EHR) are timely and include required information.

(b) Timeliness of reporting of mammography results from community providers to VA ordering providers.

(c) Communication of mammography results to patients.

d. Mammogram Coordinator. The mammogram coordinator is responsible for:

(1) Identifying patients due for screening using the Breast Care Registry (BCR) “mammogram Due” report or pull clinic, and notify providers on a monthly basis.

(2) Entering consult information on the mammogram tracking spreadsheet, based on alerts in the EHR.

(3) Monitoring the mammogram tracking spreadsheet regularly to ensure mammography care is confirmed and CC staff takes action on any reports expected but not received by requesting reports from community facilities.

(4) Tracking scheduled appointments on the mammogram tracking spreadsheet and alerting appropriate staff to facilitate timely follow up of findings.

(5) Documenting the mammography report findings on all mammography reports received and providing reports to Health Information Management Service (HIMS) for scanning consideration into the medical record in accordance with local policies.

Documentation includes:

(a) Sending patient notification, entering patient notification date and date documented on the mammogram tracking spreadsheet.

(b) Entering System for Mammography Results Tracking (SMART) note notification for next/follow-up mammogram.

(c) Communicate the results of normal mammograms completed to the patient within 14-calendar days of receiving the results for BI-RADS codes 1 and 2.

(d) Alerts the women’s health care coordinator Registered Nurse (RN) for BI-RADS codes 4, 5, and 6.

(6) Reporting issues or concerns via appropriate established guidelines.

e. Community Facilities or Community Care Network Provider (CCN).

Community Facilities are responsible for compliance with contractual and regulatory guidelines for communicating results to the ordering provider per consult specifications.

f. Community Care Staff. The Community Care Staff are responsible for:

(1) Verifying administrative and Mission Act eligibility for care in the community per the Office of Community Care Field Guidebook. Note: Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) patients will only have a radiology order and are followed by the women’s health care coordinator RN.

(2) Monitoring the level of compliance with the 30-day standard for the return of medical documentation from community providers and escalating issues to the CCN/local patient safety reporting process.

(3) Reporting quality or safety issues in the community care oversight council.

g. Radiology. Radiology is responsible for:

(1) Completing orders management that coincide with the community care consult order.

(2) Entering and associating the mammography results (BI-RADS codes) to a radiology order in the EHR within the radiology package.

(3) Sending all received mammography reports directly to HIMS for priority scanning and alert the mammogram coordinator.

(4) Receiving report from HIMS after it is uploaded in Vista Imaging.

(5) Competing radiology order and attaching the BI-RADS codes, which triggers an automatic alert to the ordering provider and Breast Care Registry. The Mammography report will be located in Vista Imaging. The mammography result information is located in the SMART note.

(6) Communicates quarterly to the VISN Imaging Chief notification timeframe from the outside provider to the VA provider for abnormal mammograms (BI-RADS codes 4, 5, 6).

h. Primary Care Provider. The Primary Care provider is responsible for:

(1) Ordering mammograms.

(a) Community Care eligible patients, providers will complete, sign, and submit a Community Care mammogram consult (automatically generating a mammogram order in the radiology package) and the Decision Support Tool.

(b) Non-Community care eligible patients, providers will complete, sign, and submit a radiology order for mammography.

(c) Patient Aligned Care Team (PACT) members receive monthly mammogram coordinator report, BCR, pull clinic, and/or EHR.

(2) Entering a SMART Note and/or fax to mammogram coordinator when the reports are received by the PACT. Sets SMART note notification for next mammogram. Review B-IRADS codes and take action based on results. If not faxed to mammogram coordinator, send to HIMS for priority scanning. Document must meet scanning criteria to be uploaded into Vista Imaging.

(a) If there are BI-RADS codes 1 and 2 the provider, or team member documents the mammogram findings in the EHR using a SMART note. Notification is sent to Veteran and the SMART note triggers reset of the clinical reminder per American Cancer Society (ACS) guidelines based on radiologist recommendation.

(b) If there are BI-RADS codes 0, 3 Inconclusive/Incomplete, or probable benign results the ordering provider reviews results and contacts Veteran or delegates task to team nurse to document mammogram findings in the medical record using designated mammogram completion note, sends notification to Veteran and resets the clinical reminder per ACS guidelines and radiologist recommendation.

(c) Inconclusive or Incomplete mammogram results (BI-RADS 0, 3) require follow up studies to include diagnostic mammogram, ultrasound, Magnetic Resonance Imaging (MRI), or biopsy. Patients should be notified by the PACT regarding need for follow up.

Veteran notification should occur within 5 business days (14 business days for BI-RADS code 3) of the provider receiving report notification.

(d) If there are BI-RADS codes 4, 5, 6 the provider contacts patient via phone call or face to face with results and discusses plan of care to include the meaning of the findings with the patient and the alternatives for further study, treatment, or referral.

Provider then documents in the medical record using designated mammogram completion note. Both phone call and documentation must be completed within 72 hours from the time the report is received.

i. Women’s Health Care Coordinator. The women’s health care coordinator RN or designee is responsible for:

(1) Leave coverage when the mammogram coordinator is on leave.

(2) Maintaining BI-RADS codes 4, 5, and 6 tab on the mammogram tracking spreadsheet to monitor and facilitate timely provider to patient communication and appropriate consults are completed timely for patients who undergo breast biopsy, and may require oncology and/or surgical consults.

(3) Reviewing and tracking all mammograms with BI-RADS codes 4, 5, 6 to ensure appropriate follow-up.

(4) Tracking and monitoring of non-CC eligible mammograms per the same process as the mammogram coordinator.

(5) Notifying clinical managers (Community Based Outpatient Clinic’s Women’s Health Liaisons) to assist with communicating results that require follow-up to the provider and quality assurance processes as needed.

j. Quality, Safety, & Value (QSV). The QSV staff are responsible for reviewing mammography data for compliance and submit to CC oversight committee and WVHC quarterly. Trend timeliness of Veteran notification by ordering provider.

4. DEFINITIONS

a. Date Mammogram Ordered. Date test ordered.

b. Date Mammogram Completed. Date test performed.

c. Date Provider Notified. Date provider received alert.

d. BI-RADS. Breast Imaging Reporting and Database System Codes Score 0, 1, 2, 3, 4, 5, 6.

e. Mammography Results. Normal requires no additional action and abnormal-requires additional action.

f. Days to Orderer Notification. Calculated by calendar days between date mammogram completed and date provider notified. Requirement is 30 days for normal (0, 1, 2, 3) and 5 business for Abnormal (4, 5, 6).

g. Patient Notification Date. Date patient notified of the results.

h. Patient Notification Method. Choose appropriate method. Secure message would be listed as a letter.

i. Days to Patient Notification. Calculated in calendar days from provider notification date to patient notification date for normal and abnormal.

j. Patient Notified Timely. Normal results within 14 days and abnormal results 7 days.

5. RECORDS

All records will be maintained and inventoried in accordance with Medical Center Memorandum (MCM) 04-03 and Records Control Schedule (RCS) 10-1. Records will be inventoried on the Women’s Health record file and inventory plan.

6. REFERENCES

a. 38 U.S.C. 7319(b), Mammography quality standards, October 9, 1996

b. VHA Directive 1330.01(4), Health Care Services for Women Veterans, dated January 8, 2021

c. VHA Directive 1088, Communicating Test Results to Providers and Patients, dated October 7, 2015.

d. VHA Directive 1105.03, Mammography Program Procedures and Standards dated, May 21, 2018.

e. VHA External Peer Review Program, Communication of Test Results, First Quarter, Fiscal Year 2022.

f. MCM 11-079 Reporting Diagnostic Test Results, dated March 10, 2017

g. FDA Mammography Standards Guidance

h. Community Care Field Guidebook, dated January 10, 2022

7. REVIEW

Required review will be completed at recertification, when there are changes to the governing document (for example, national policy or a health care accreditation body mandate).

8. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of June 2027. This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.

https://dvagov.sharepoint.com/sites/VHAfav/policyreview/PDF/11/11-079.pdf https://www.fda.gov/radiation-emitting-products/mammography-quality-standards-act-and-program https://dvagov.sharepoint.com/sites/VHAOCC/CNM/CI/OCCFGB/SitePages/FGB.aspx

9. SIGNATORY AUTHORITY

Christopher G. Myhaver, MHA, FACHE Interim Medical Center Director

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

DISTRIBUTION: Intranet