“Pap Corner Blues” Abnormal Pap Smear Notification Process

NAME OF HEALTH DEPARTMENT: Yadkin County Health Department

PROJECT TITLE: “Pap Corner Blues” Abnormal Pap Smear Notification Process

Lisa M. Ivester 
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Project Overview

Project Aim:
Yadkin County Health Department aims to improve the health of clients receiving PAP smears by successfully notifying the clients of abnormal PAP smear results, thus enabling our clients to make informed decisions on obtaining follow up as recommended by the agency physicians, and mid-level providers.  Cervical cancer can best be treated with early detection and treatment.  Staff awareness of improvement, goal oriented, plan/implementation, and utilization of policy is ongoing.   We will do this by June 2011 by utilizing the Method of Improvement and Lean Methodology.


  • >90% of our clients with abnormal PAP smears will receive timely notifications per ‘Abnormal PAP smear follow-up policy.’
  • A survey will be provided to clients regarding their satisfaction with the educational materials that were provided; a timely notification was relayed, and ensures clients understand the results of the testing process.  Staff to explain and clients to verbalize the dangers of the disease process if left untreated or continued ongoing monitoring is ignored.
  • Yadkin County Health Department policy regarding abnormal PAP smears may be revised at any time to allow improvement of abnormal PAP smear steps and to ensure correct steps are taken.
  • Staff will obtain increased knowledge of clients needs; adherence to ensure no client with an abnormal PAP smear is missed, and will strive for continued compliance with policy and procedure.  Staff will identify quality assurance/improvements are ongoing and will inspire to make changes in policy and procedure as needs arise.
  • 50% of the client population with abnormal PAP smears will seek referral process, and continued recommendation of following through with next step of process.
  • Yadkin County Health Department will track the percentage of returned notification letters mailed to clients regarding abnormal PAP smears.
  • Yadkin County Health Department will attempt to avoid increased agency cost for PAP smear follow up procedures. 

Project timeframe:
November 2010 to June 30, 2011

How was the need for the project determined?
YCHD reviewed client’s medical records that received pap smears and documented the time frame when clients were notified.  There was not a standardized time frame and the current Abnormal Pap Smear Policy was vague about notification times.  We felt that we needed to update policy, streamline the process and eliminate the multiple staff and multiple steps that were involved in the process. 

Does this quality improvement project link to accreditation?
Yes, Accreditation focuses on a set of minimal standards that must be provided to ensure the protection of the health of the public, but does not limit the services or activities an agency may provide to address specific local needs.  YCHD actually went above minimal standards and accomplished best practice for the health and well being of the residents of Yadkin County.

Areas for Improvement and Change Ideas Implemented

Improvement  1
Obtaining the correct address and telephone numbers of clients to be able to notify them of results.  We were able to get registration involved in obtaining correct information, but also helping client understand the importance of giving correct information. 

Improvement 2
Collected too much data/measures that were not helpful. 

Improvement 3 
Outdated pap smear policy

Improvement 4
Staff dedicating a lot of time to pap smear review

Improvement 4
Patient satisfaction 


Return on Investment Results

For every $1 invested on improvement, Yadkin County Health Department gained in financial improvement as shown below.

ROI = (Savings – Cost) / Cost

$2.27 = ($79,140 - $24,224.65)/$24,224.65 for year 1

$5.27 = ($79,140 – $12,631.08) / $12,631.08 for future years

Overall Improvements

  • Establishing Standing Orders freed up FNP to see more clients instead of reviewing Pap Smear results
  • By decreasing notification time to clients, we have increased client satisfaction.
  • Eliminated duplicated work.
  • Centralized locations of documentation of Abnormal Pap follow up to “notes” section of chart.
  • Streamlined notification policy to decrease amount of time Abnormal Pap Coordinator spent in process
  • Aid YCHD to meet our legal or regulatory obligations
  • Decreased time spent looking for correct address and phone numbers to contact clients
  • Saved money on paper needs based on standardized lab log and eliminated pap log documentation in chart
  • Intangible improvement with staff morale, FNP and client satisfaction.


Lessons Learned:

  • Kaizen Event was ‘feared’ prior to the event, but was an awesome experience for the team.  So much work accomplished.  Such an important step to the entire process.
  • Spread ability of changes need to be continually shared with other staff and QI Team should have a plan to share with staff.
  • Clueless member of the team brings fresh ideals that can change the most important item because they are not “invested” in current process.

Programs supported by:

BlueCross BlueShield of NC FoundatoinThe Duke Endowment

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