Date of Graduation

Summer 8-18-2022

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

Dr. Sara Horton-Deutsch

Second Advisor

Dr. Cathy Coleman



Problem: The recent Covid-19 Pandemic led to delays in necessary cancer screening procedures, such as Breast Cancer Mammography Screening (BCS). Suboptimal mammography screening rates persisted at 11% compared to the regional goal of 30% of eligible women in a primary care setting.

Context: Covid-19 Vaccination Clinics are part of a private HMO health plan that participates in quality accreditation and data benchmarking utilizing Healthcare Effectiveness Data and Information Set Measures (HEDIS). In this managed care health system, primary care clinics offer appointments and referrals for screening tests similar to mammography.

Interventions: Change ideas such as standardized scheduling scripting, standard work process for clinic registration staff, and team education related to population health management were incorporated to foster a Quality Improvement (QI) culture to increase breast cancer screening scheduling for eligible women 40-74 years of age.

Measures: The primary outcome measure addressed increasing breast cancer screening mammography scheduling, following organizational guidelines for the population of average risk eligible women aged 40-74. From a baseline of 11% to a target quarterly goal of 25% or more excellent by July 15, 2022. One process measure aimed for 90% of clinic staff to receive breast cancer screening scheduling training by June 8, 20222.

Results: For two months, 90% of clinic staff (N=15) received 1 to 1 real-time hands-on training related to scripting, scheduling, and same-day mammography scheduling.

Conclusion: Healthcare restrictions resulting from Covid-19 had unintended consequences that resulted in late cancer diagnoses and missed opportunities for life-saving cancer screening mammography. Clinical nurse leaders are encouraged to employ evidence-based practices in the microsystem setting.