Increasing cervical screening rates at your practice (Part 2)

What is the aim of this QI activity 

The aim of this QI activity is to increase:

• education and awareness of CST  

• Improve the rates of CST within your practice. 

By participating in this self-paced QI activity, your practice will be contributing to the national goal of eradicating cervical cancer as a public health problem in Australia by 2035 (ACPCC, 2023).

What will I need to do?

Follow the below 7 steps to improve your CST rates at your practice.

How will I complete this activity?

Before completing this activity, ensure you have completed “Part 1 – Managing your patients’ cervical screening records”.

• Step 1: Form a quality improvement team

• Step 2: Review the National Cervical Screening Program

• Step 3: Order Resources & promote on social media (optional)

• Step 4: Identify eligible and overdue patients

• Step 5: Remind patients using a targeted and opportunistic approach

• Step 6: Track your improvements

• Step 7: Reflect on your efforts & consider future activities

Where do I document my results?

You can choose to track your results in a variety of ways including: 

• Cervical screening target poster 

• Quality Improvement register 

• Manually recording your numbers at the start and end of the activity

• Use the PIP QI report - 10 measures report in Primary Sense (step 6)

You may also choose to create your own way to track your results to best suit your practice if more suitable.

Who can I contact for support?

For support with this activity please contact the General Practice Quality Improvement team on Ph. 38647540 or email [email protected].

1. Form a quality improvement team

All staff can be involved and contribute in some way to this activity. Consider involving the Practice Manager, Administration Team, Nursing Team, General Practitioners. You might like to have a team meeting to brainstorm and decide on roles and responsibilities.

2. Ensure your clinical staff are familiar with the National Cervical Screening Program

Review the National Cervical Screening Program by reading the Healthcare Provider Toolkit: National Cervical Screening Program – Healthcare provider toolkit | Australian Government Department of Health and Aged Care

3. Order Resources & promote on social media (optional)

The Communications Toolkit  Cervical Screening Communications Toolkit | Australian Government Department of Health and Aged Care contains links to order resources such as posters, infographics as well as brochures to hand to patients. Consider your patient population when ordering resources, such as languages other than English. There are also plenty of ideas for social media posts. 

The new ‘Own It’ campaign includes resources targeting under screened groups. The kit includes social media tiles, newsletter content, email signatures and scripts if you wanted to create your own content! 

4. Identify eligible and overdue patients

By following the steps in “Part 1 – Managing your patients’ cervical screening records”, you will already have a list of patients that are eligible or overdue for cervical screening.

Additionally, you can review the ‘Patients booked in with missing PIP QI measures.’ Ensure you have cross checked the patients who will be presenting to the practice with the NCSR Hub, as discussed in step 3 of the part 1 activity.

Start by using either of the below reports in Primary Sense to assist with identifying eligible and overdue patients.

1) Patients missing PIP QI or accreditation Measures.

This report allows you to view active patients with upcoming appointments in the next 2 weeks who do not have a cervical screening result on file for the previous 5 years. 

2) Patients booked in with missing PIP QI measures.

This report allows you to view active patients with upcoming appointments in the next 2 weeks who do not have a cervical screening result on file for the previous 5 years. 

5. Remind patients using a targeted and opportunistic approach

You can choose to send screening reminders to the patients identified in the reports above, if they are due or overdue. Consider sending an SMS or phoning the patient (In line with your privacy policy & handling of patient information) Example:

1) Overdue/Never Screened:

‘Hi ____A Cervical Screening Test every five years is the best way to prevent cervical cancer. Our records indicate that you are overdue. The test can be completed by the Doctor/Nurse or by self-collection here at the Practice. To book.... Dr XXX’

2) Invitation for 25-year-olds:

‘Hi ____Turning 25 means you’re due for cervical screening. A Cervical Screening Test every five years is the best way to prevent cervical cancer. The test can be completed by the Doctor/Nurse or by self-collection here at the Practice. To book.... Dr XXX’

For patients with an upcoming appointment in the next two weeks, consider placing a note in the appointment calendar as a prompt for the Nurse or Doctor to discuss Cervical Screening with the person. 

6. Track your improvements 

To measure your progress throughout this self-paced activity and determine whether your changes have resulted in an improvement, you can  use Primary Sense to monitor the number of patients who are eligible or overdue for cervical screening.

Use the below Primary Sense report:

PIP QI report - 10 measures report

This will show the number of eligible active patients that have an up-to-date cervical screening result in file as a percentage (%). As you progress through your activity, this number should increase due to increased numbers of patients with an up-to-date cervical screening test, or through the improvement of accurate patient records due to your use of the NCSR hub.

Write your percentage on your target poster at the start of the activity and review it at the end of the month. 

Start of project = 

End of project =

7. Reflect on your efforts & consider future activities

At the end of the month reflect on the activity as a team. Some questions to prompt team reflections are: 

1. Did you increase the percentage of active patients that have an up-to-date cervical screening result on file?

2. What have you learnt from the QI activity?

3. Have you developed any new processes? 

4. What were the challenges?

5. Celebrate your achievements! 

6. What would you like to do in the future? (See below!)

After this activity, you might like to work on something different. The HPV Vaccine and the Cervical Screening Test work together to prevent cervical cancer. You could focus on identifying patients who may have not completed their HPV vaccine schedule and inviting them to receive the vaccine. 

Learn more about the HPV vaccine here: HPV (human papillomavirus) vaccine | Australian Government Department of Health and Aged Care

Use this blank template to get started with Quality Improvement Activities: Brisbane South Primary Health Network: QI Tools and resources | Brisbane South PHN

Here is an example of a prefilled Cervical Screening PDSA Cycle: QI Toolkit Introduction