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This article was originally published in May 2011.

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How Sea Mar Community Health Centers successfully separated mammography from other office workflows and dramatically increased screening rates

By reorganizing their workflow, clarifying team member roles, and making better use of their electronic health record (EHR) system, the Sea Mar Community Health Centers (20 clinics located along Washington's I-5 corridor) have achieved remarkable successes in ensuring that their patients get screening mammograms.

For example, they recently received a report from the Community Health Plan of Washington showing that 100% of the female Medicaid patients, age 52-69, seen at Sea Mar's Seattle clinic during the second quarter of 2010 had received their mammograms. "We almost didn't believe it," Sea Mar's Virginia Ramos, RN, ASN, BSBM said. "We had to go back and re-check it ourselves." That impressive number was accurate—and after all their work on this ongoing project, it was a cause for celebration.

An important turning point in Sea Mar's success was learning how to apply Lean principles to their work. Guided by Qualis Health's facilitators, the Sea Mar team mapped the process of how patients were referred for a mammogram and how the later results were tracked (or not) in the EHR. "There were a lot of gray areas," Ramos said. "It wasn't always clear who was supposed to do what, and there were just too many options and variables." And on top of this uncertainty, the referrals and tracking were supposed to be done during the patient visit—when both the providers and the patients were more focused on the health problem at hand than preventive services.

As the team discussed possible solutions, Ramos admitted that it was overwhelming to look at their entire patient population, not to mention all the potential changes that might need to be implemented by the various staff members and computer systems. Team member Phillip Reilly, MD, suggested that they start small, by focusing just on those women who had already scheduled an appointment. "That suddenly made it seem manageable," Ramos recalled. "The team could then break things down to do-able tasks."

The process they implemented is straightforward—but quite a leap from the way that things are typically done in primary care practices. While the new workflow is triggered by a patient's appointment, all the mammography-related tasks are actually completed outside of the provider visit.

Each day, a report is run that finds all the women with an appointment for the following day who are due for a mammogram. One staff person reviews each of those charts, cleaning up the related data as needed (for instance, linking mammogram results to the original order), and/or ordering the mammogram in the EHR under the patient's primary care provider. The employee also researches whether the patient might be eligible to receive preventive care through the Washington Department of Health's Breast, Cervical and Colon Health Program (BCCHP). If eligible for BCCHP, the patient is scheduled to complete a Well Women's Exam prior to the mammogram appointment.

The new workflow improved Sea Mar's mammography rate significantly—and produced side benefits, as well. For one, the process of closely examining patients' charts related to mammography ordering and results "uncovered some issues for our IT folks to figure out," Ramos said. It also prompted Sea Mar to start increasing the number of days they contracted for onsite imaging. By expanding their capacity to perform onsite mammograms, Sea Mar is better able to track no-shows, properly link results to orders, and decrease barriers for patients (such as finding transportation to, or interpreters for, another location). Finally, the new workflow integrated Sea Mar's BCCHP coordinator into the care team. Instead of being focused on administrative paperwork, the coordinator is now closely connected to patients—who know her by name, since she schedules the mammogram, assists with patient flow the day of the mammogram, and follows up if they miss their appointment.

The Sea Mar team's initial focus allowed them to systemically make changes to workflow, EHR capabilities, service level, and patient satisfaction. "Now we have a lot more control and clarity over the entire process," Ramos said.