Date of Award

Fall 2023

Project Type

Clinical Doctorate

College or School




Program or Major


Degree Name


First Advisor

Melinda Miller-Thrasher

Second Advisor

Cathleen Colleran



Breast cancer remains a challenging health issue in the United States, representing the second leading cause of cancer deaths for women. The key approach to tackle this issue is the early detection of breast cancer through annual mammography screening in asymptomatic women. This quality improvement project sought to improve the proportion of breast cancer screening documentation in a private obstetrics and gynecology practice that serves primarily Black women. In addition, the project is thought to improve the current utilization of office mammogram services and its mammogram completion rate. Comprehensive interventions implemented included establishing clear guidelines, staff education, using paper checklists and Electronic Health Records (EHR) tools, enhancing the scheduling workflow process, and providing phone call reminders to patients before mammogram appointments. The project site's EHR and the CMS breast cancer screening report from the electronic clinical quality measure were used to collect data. The interventions were assessed by analyzing data extracted before and after the project. Data indicated that the proportion of eligible patients up-to-date with mammograms or receiving recommendations for breast cancer screening went from 50% pre-implementation to 76% post-implementation (chi-square 97.72, p < .001). There was a 16 percent increase in the CMS breast cancer screening quality measures. The mammogram department saw a 12 percent increase in mammogram performance, and the rate of patient adherence to appointments increased by 19 percent (z = 2.89, p = .03). Project results indicate that an evidence-based, comprehensive process enhances the cancer screening process and improves patient appointment adherence. Recommendations include sustaining the project and improving breast cancer screening referrals and tracking in the EHR.

Keywords: breast cancer, mammogram, screening.