Mammography Positioning Improvement Collaborative records dramatic gains in breast image quality
A newly established Mammography Positioning Improvement Collaborative has recorded dramatic gains in breast image quality, according to new research published June 29 in JACR [1].
The benefits of regular screening are well-established, with breast cancer mortality dropping by 49% since 1989. However, poor patient positioning can lead to undetected cancer cases and increased costs due to the need for repeat exams, experts noted. To address this, the American College of Radiology established a quality collaborative, with sites aiming to increase the percentage of mammograms meeting established positioning criteria.
Providers worked to develop target goals, gather data on their performance and identify root causes leading to inadequate breast images. Across six participating sites, the average percentage of screening mammograms meeting overall passing criteria each week leapt from 51% to 86%. In follow-up surveys, all respondents indicated that the program was a “positive experience.”
“The first cohort of the Mammography Positioning Improvement Collaborative demonstrated the effectiveness of the learning network model of sharing knowledge across multiple organizations working together towards a common goal in leading to improved mammography positioning at multiple sites simultaneously,” lead author Sarah M. Pittman, MD, with the Department of Radiology at Stanford University’s School of Medicine, and colleagues advised. “Using systematic methods for problem solving, the participating sites identified root problems and key drivers affecting mammography positioning and implemented targeted interventions to effectively address the noted barriers and achieve their improvement goal.”
ACR accepted applications for the ImPower Program through the end of 2021. It chose the initial sites based on the strength of local leadership support, intraorganizational relationships, access to data and analytic support, and previous experience with quality improvement initiatives. Those selected spanned four states (California, Delaware, Ohio and Texas) and included two academic institutions, one private practice, and three non-teaching health systems.
To measure performance, those involved created a positioning-criteria scoring system based on ACR’s mammography accreditation guidelines. This included all 11 potential positioning problems on the review sheet, Pittman and co-authors noted. Breast examinations were given an overall passing grade if all 14 major criteria were met and at least 9 of the 12 minor criteria were addressed. Participants regularly examined mammography positioning performance data, displaying the results for all in the department to see.
Every week, project teams reviewed a random sample of about 60 of their own routine screening mammograms. They collected baseline data spanning the first seven weeks of the program (May to June of 2022), while the final set represented exams audited between September and November 2022.
Common causes of poor positioning included variability in technologist training and experience, inconsistent communication between techs and patients, inconsistent image evaluation and variability in patient condition (such as physical limitations). Site teams identified key drivers behind these causes, such as “agreement on image quality,” having a standard and sustainable way to measure and report positioning performance, developing and maintaining technologists’ skills, and clear and concise radiologist-tech communication. From these, leaders then developed and tested interventions, which varied among sites.
Among the most common were:
- Posting positioning criteria in exam rooms.
- Holding weekly technologist huddles to review positioning criteria.
- Identifying coaches to provide tips, perform image review, assist in positioning and deliver ongoing training.
- Providing monthly education including articles, videos, a journal club and case of the month.
- Creating a mammography script for technologists to explain the exam to patients.
- Placing stickers on the floor to guide patients’ foot placement.
- Tasking radiologists with providing meaningful feedback to techs.
- Having technologists document the reasons for difficult exams that result in positioning criteria not being met.
By the end of the improvement project, 4 of the 6 sites met or exceeded the target average performance of 85%. In a follow-up survey, 100% (22/22) of respondents either agreed or strongly agreed that the program was a positive experience and contributed to their professional growth. Another 95% (21/22) agreed or strongly agreed that the initiative improved their daily work and empowered them to tackle future quality improvement projects. Lessons learned have helped to serve as a starting point for the second group, which launched in March 2023.
“As future cohorts join the collaborative and build upon the work of the first and subsequent cohorts, we expect this foundation of knowledge will continue to strengthen, with potential to help facilitate widespread improvement in mammography positioning nationally and internationally, across diverse clinical settings,” the authors wrote. “Practices of all types wishing to achieve a similar level of performance improvement in mammography positioning may benefit from joining future cohorts of the collaborative.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.