Cervical Cancer Screening
In this Audit
Approximately 160 women are diagnosed with cervical cancer in New Zealand each year, and 60 die from this largely preventable
disease.1 It is now universally accepted that the main underlying cause of cervical cancer is persistent infection with
certain high-risk types of human papillomavirus (HPV) and that these viruses are sexually transmitted. Most HPV infections
resolve spontaneously, but persistent infections can result in the development of precancerous lesions and, if untreated,
can progress to cervical cancer.
Cervical cancer has a 10 – 20 year latency and regular cervical smears can effectively identify the majority of women
with these pre-cancerous lesions and reduce a woman’s risk of developing cervical cancer by 90%.1, 2
The National Cervical Screening Programme (NCSP) recommends that women have three-yearly cervical smears from age 20
years until they are 70 years. Women having their first smear or those who have not had a test for five years or more
should have a repeat smear within one year.1 Women with an abnormal result should have more frequent smears as outlined
in the New Zealand guidelines for cervical screening.1 If the cervical smear has been reported by the laboratory as unsatisfactory,
e.g. due to an inadequate sample or excessive mucus or blood, the smear should be repeated within three months. The use
of liquid-based cytology, however, is likely to have reduced the number of samples reported as unsatisfactory.
The NCSP provides an important “backstop” to ensure that women who have an abnormal smear result are informed and that
appropriate follow up is planned, however, the responsibility for notifying women that they are due for a cervical smear,
providing results and placing a recall on a Practice Management System (PMS) belongs to the primary care team.
The current target for cervical screening is for 80% of all eligible women to have had a cervical smear. 3 This increased
target was introduced with the new Integrated Performance and Incentive Framework (IPIF) on July 1, 2014 and replaces
the previous PHO Performance Programme (PPP) target of 75%. This audit, however, is designed to assess whether the systems
in your practice are effective, not only to document women who are up to date with cervical smears, but also to check
that for all eligible women there is a record in their notes if they are overdue, have declined smears or have a clinical
reason that a cervical smear is not required.
For additional information see: “How to increase the uptake of cervical screening:
a profile of success”, BPJ 55 (Oct, 2013)
Audit action plan
The recommended steps for completing this audit are to:
Take a random sample of your female patients aged 20 to 69 years.
Identify what percentage of these patients:
- Are up to date with their smears and have a recall in place
- Are overdue for a cervical smear, but have had multiple reminders
- Have a clinical reason why a smear is not required, e.g. the woman has had a total hysterectomy and there was no record
of malignancy on histology
- Have declined to have smears
Criteria for a positive result
For a patient to be considered a positive result for this audit the following information should be documented in the
patient’s clinical record:
- That they are up to date with their cervical smears and an appropriate recall is in place OR
- That they are overdue for a cervical smear, however, they have had multiple reminders regarding this OR
- That there is a clinical reason why they have not had a cervical smear OR
- They have declined to have cervical smears
This audit is designed to assess the effectiveness of the procedures for cervical screening within your practice. At
least 80% of women should have undergone screening in the last three years and have a recall in place (Column A). The
overall target for this audit is for 100% of eligible woman to have evidence in their notes that cervical screening is
up to date, screening is not up to date but repeated reminders have been given, screening has been declined, or screening
is not required (Columns A, B, C or D).
All women aged 20-69 years are eligible for this audit.
You will need to have a system in place for identifying eligible patients. Many practices will be able to identify patients
by running a “query” through their patient management system (PMS).
It is likely that you will have a large number of eligible patients for this audit, therefore take a random sample of
30 patients whose notes you will audit (the first 30 identified is sufficiently random for the purposes of this audit,
provided that this includes women of varying age and ethnicity – this will vary depending on how you build your query).
Use the data sheet provided to record your data and calculate
Assess the percentage of positive results obtained overall for the four clinical situations. The results should be discussed
within the practice and this discussion used to identify ways to improve these results. In particular, for patients who
are overdue for a cervical smear, check if an alert has been placed on the patient record so this can be discussed when
the patient next presents.
Identifying opportunities for CQI (or other)
The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual
performance and then to decide how to change practice.
Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.
The plan should assign responsibility for any actions to specific members of the practice team and should include realistic
It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).
Problem solving process
- What is the problem or underlying problem(s)?
- Change it to an aim
- What are the solutions or options?
- What are the barriers?
- How can you overcome them?
Overcoming barriers to promote change
- What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them
in the practice setting
- Identify the barriers
- Develop a priority list
- Choose one or two achievable goals
- No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to
bring about lasting change
- Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance
Monitoring change and progress
It is important to review the action plan at regular intervals. It may be helpful to review the following questions:
- Is the process working?
- Are the goals for improvement being achieved?
- Are the goals still appropriate?
- Do you need to develop new tools to achieve the goals you have set?
Following the completion of the first cycle, it is recommended that practitioners complete the first part of the
activity summary sheet (Appendix 1).
Undertaking a second cycle
In addition to regular reviews of progress, a second audit cycle should be completed in order to quantify progress on
closing the gaps in performance.
It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle
should begin at the data collection stage. Following the completion of the second cycle it is recommended that practitioners
complete the remainder of the CQI activity summary sheet.
Claiming MOPS credits
This audit has been endorsed by the RNZCGP as an Audit of Medical Practice activity (previously known as Continuous
Quality Improvement - CQI) for allocation of MOPS credits; 10 credits for
a first cycle and 10 credits for a second cycle. General practitioners taking part in this audit can
claim credits in accordance with the current MOPS programme.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
Record your completion of the audit on the MOPS Online credit summary, under the
Audit of Medical Practice section.
From the drop down menu, select the audit from the list or select “Approved practice/PHO audit” and record the audit name in “Notes”, the audit date and 10 credits.
General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.
As the RNZCGP frequently audit claims you should retain the following documentation, in order to provide adequate evidence of participation in this audit:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).