Develop Systems

Develop systems that support cancer screening

This is the space where we will be loading up useful tools and resources, case studies and example Model for Improvement (or “Plan, Do, Study, Act” as they are often known) cycles relating to the ‘Develop systems that support cancer screening’ change principle.

Don’t forget the checklist on page 27 of the MI Guide which is full of great ideas you can try!

Case Study –

Vicki Coombes, Practice Manager at Star Street Medical in Macksville has led the introduction of an SMS recall and reminder service, she talks to us about the benefits Start Street have seen from this quality improvement initiative:

What was the situation prior?

Prior to joining the collaborative all of our reminders were via letter, and our recalls were via phone call.  This approach was both costly and time consuming – people often won’t answer their phone during work hours so staff had to make multiple calls to finalise a recall.

What quality improvement changes did you make?

  • I firstly met with GPs in the Practice to ensure all GPs were inputting their recalls/reminders appropriately and understood the difference.
  • We asked patients through patient update forms and notes on reminder letters to opt out of SMS reminders.
  • I met with Administrative staff to develop a protocol for recalls and reminders.
  • We had an online training session with IT Medical to fine tune our understanding and procedures.
  • We set up SMS templates within Medical Director for each GP, so the process of sending an SMS takes only seconds for multiple patients.

What were the benefits to your practice of making this change?

The impact with recalls particularly was quite significant.  Instead of multiple telephone calls and/or leaving messages for patients, we are receiving almost instant response to text messages as most people appear to check for messages at breaks.  

With recalls, we send a second message, if this is not answered then we telephone and finally if this fails, we send a registered letter. (Unless the matter is critical, then we follow up with same day telephone).

This has made significant time and financial savings.  For reminders, I have reduced the number of monthly reminder letters from approximately 100 down to 30.  The remainder are going by SMS.

For recalls, we are finding we are receiving a response to the initial SMS within hours in most cases.  This has significantly reduced the time spent on the telephone by receptionists.  Although the patient receives a generic SMS, they mostly know why we are calling, and this saves reception time explaining the call and having to make multiple calls to home or mobiles.

We have only been using this new system for 2 months, however, in that time we have had very positive feedback from patients.

You can download this case study here

Case Study –

The team at Trial Bay Family Practice have done intensive work over the past 18 months to introduce a gold standard recall and reminder system across a range of conditions and preventative actions.

They did this by investing in the team undertaking advanced training with Medical Director. This incurred a cost, but the Practice has found that the income they now generate through more effective reminder of patients for their GP Management plans, Health Assessments, Asthma plans, Pap smears etc. has created a steady income generate primarily through the nursing team and is of real financial benefit to the Practice. 

The team also feels they are delivering better patient centred care as a result of their accurate and systematic recall system and ability to link non-income generating activities such as breast screen reminders with other services and reminders.

Practice Manager Sonia Perry talks us through their experience:

What was the situation/system before?
18 months ago (under a previous Practice Manager) we were on an old version of Medical director, and the process at that time was to delete recalls from the system once we had sent out a letter.   

Using Pap smears as an example, the staff only re-entered the recall if the patient presented for their next Pap smear after receiving the letter, otherwise they dropped off the system unless picked up by a doctor when re-presenting for some other reason.

What did you do to improve it?

Firstly, we upgraded to the latest version 3.16 which had an updated recall component, and we undertook advanced user training with Medical Director.

Version 3.16 is fabulous, you can track your progress, add notes of conversations with patient and automatically update the recall when an appointment is made.  If the appointment is cancelled the recall will revert back and not lost.

I extracted a current patient list from the Canning tool, and sorted/culled the list to meet the Pap smear criteria. 

We then printed out a list from Medical Director of all of our patients with current Pap smear recall and crossed these off the Patient list. 

Then I had the Registered Nurse access the remaining patient files, enter in appropriate recalls and remove anyone from a recall who had had a hysterectomy or if the patient had requested to opt out.

The Receptionist then proceeded to work through the recall list to bring patients that were overdue or due in for a Pap smear.

It was a real team based approach, and we have applied similar processes across other chronic conditions, breast cancer screening etc.

What is the situation now (what impact have you seen from the changes)?

We are doing more pap smears, which is great for our practice but more importantly for our patient’s health. 

The increased paps being done will impact our PIP payments from Medicare, our data is more accurate. 

Our female patients files have been audited to ensure that they have a Pap smear recall at the correct recall date and those who do not require one or have requested to opt out have been removed from future recalls.  

We aim to make sure an annual audit is done.

Our Practice is also now generating a strong, ongoing income through our nursing staff’s delivery of services that are generated off of our recall and reminder system, including health assessments, asthma plans, Pap smears etc.

BreastScreen has provided a summary of their invitation process to help your practice to understand where you can best add value through provision of reminders.  BreastScreen suggests two key times where Practice reminders can really value add: 1. For women who have never screened   2. On a woman’s actual re-screen due data

The Mullumbimby Medical Team felt that a good way to start the screening conversation with their patients was to:

1. Have posters up telling women their practice was in the Collaborative

2. Have the Reception team give eligible women  a flyer asking them when they last screened – the women then take the flyer into their appointment with them, opening the door for a discussion with their Doctor or Nurse about screening.

Your Practice Support Officer will be bringing you two posters.

Click the image below to download a copy of the flyer that you can put your practice logo on, print and use!


If you use the posters or flyer, don’t forget to write it up in a PDSA!

There is often a lot of work that needs to be done to improve how practices use software to maintain effective recall and reminder systems.

Click on the image below to access some great hints and tips by Katrina Otto from Train IT Medical on establishing an effective recall and reminder system.

(Even if your practice doesn’t use Medical Director or Best Practice, you will still find many of the principles outlined in these slides really helpful!)

In addition to these slides, Train IT Medical recall and reminder manuals are available for both Best Practice and Medical Director Practices in the NCPHN footprint, contact your Practice Support Officer for more information.

One of the challenges in developing your breast screening register is that your BreastScreen results may be listed under ‘investigations’, meaning that you can’t search via ‘past history’. 

Train IT Medical has provided some excellent ‘recipes’ that allow you to search under investigations, you can find them here, along with a helpful explanatory document called ‘Saving BestPractice queries’.

Remember, practices participating in the Women’s Cancer Screening Collaborative can access a free hour of technical support from the Train IT Medical team, you can book this hour via your Practice Support Officer.

For more information about what support and training Train IT Medical can offer visit:


The Trial Bay Family Practice team report having found Medical Director webinars really helpful, they recommend the following webinars for recall and reminders systems: 

“We found both Recall Workflow & Recall Notification very useful:

Recall Workflow: Revamped within 3.16 Connect
Recorded: April 2016

Recall Notification
Recorded: September 2016″.

You can access these webinars here:

You can request data from the NSW Pap Test Register, including patient cervical screening history. Obtaining this patient data can be a helpful way to improve your recall and reminder lists:

The Trial Bay Family Practice team flagged that they had to submit multiple versions of their doctors names to recieve a complete list of women in their practice who had screened with BreastScreen e.g.:

Dr John Smith

Dr John B Smith

Dr JB Smith

Contact Sara or your Practice Support Officer if you would like to be re-sent the BreastScreen data release form.

There is a great self-examination guide from the Sydney Breast Cancer Foundation that can be ordered free of charge and hung in the shower.

When speaking to women about self-examination its important to always emphasise that mammography remains critical because it detects much smaller cancers.

Case Study: Healthwise Medical Centre using systematised Mammogram reminders for early detection

Let’s hear from a practice from the Tweed Valley involved in the Women’s Cancer Screening Collaborative about how they prioritised their reminder system and as a result a 60-year-old asymptomatic woman was diagnosed with breast cancer through early detection.


What was the situation prior?

Prior to participating in the WCSC our practice did not have a system in place for setting Mammogram Reminders.

Since the commencement of our involvement with WCSC our practice has identified 1 asymptomatic woman aged 67 diagnosed with breast cancer.

  • Female Asymptomatic patient aged 67.
  • Patient has never had a mammogram
  • Patient presented to NSW Breast Screen after receiving reminders from the practice


What quality improvement changes did you make?

  • We collected data of patients who have had a mammogram either from NSW breast Screening or individually checking each patient record
  • Recorded patients Mammograms into best practice and set a reminder in best practice software for their next due date
  • Set a reminder for all patient’s who had not had a mammogram or were overdue
  • 1st Reminder sent via SMS    
  • 2nd Reminder sent via standard reminder letter or phone call to follow up
  • 3rd Reminder sent via Template letter from NSW Breast Screen
  • (Template Downloaded from NSW Breast Screen and imported into best practice I also attached a NSW Breast Screen business card to each letter)


What were the benefits to your practice of making this change?

  • Quality improvement with patient care and possible early detection of Breast Cancer
  • Improving our data percentage of under screened patient
  • Best Practice data clean up to easily identify under screened mammogram patients using PENCAT instead of individually investigating


What is the situation now?

  • Patient has been referred to specialist for further investigations/treatment


“In my 18 years of working as a practice manager and being involved in many different studies, data collection etc. with my local PHN this would have to be the one of the most worthwhile, fulfilling programs I have had the pleasure of being involved in.

Although Healthwise Medical Centre would have preferred to not have any asymptomatic patients diagnosed with Breast Cancer this is clear evidence the WCSC can and will help save lives.

My hope for the outcome of the WCSC would be to eventually have all breast screening results be received electronically to be able to identify all under screened women easily and set bulk reminders and for it to one day be mandatory practice for all General Practices Australian wide to have this system in place for quality improvement.

Thank you NCPHN for inviting our practice to participate in the WCSC”

  • Practice Manager, Healthwise Medical Centre



This PDSA comes from Suzanne O’Donnell at Dr Lerm’s Surgery in Woolgoolga.

Goal: Establish reminders for breast screening for all woman aged 50-74
Idea:  When we receive the cervical smear reminder report from the registry, check the patients mammogram history
Plan:  From 15 May, when we receive cervical smear reminder report the Practice Manager will check whether they have a recall for a mammogram and if not, check when/whether they are due, and set one as appropriate.

Do:    We were able to implement this system from May 15
Study:We found it a helpful way to work through updating breast reminders without feeling like the job was too overwhelming. 
Act:    We will continue to use this system, along with other ideas for reminding women who are not having either cervical and breast screening (who won’t appear on the cervical smear register)

Erin Shannon, Practice Manager at Five Star Medical in Port Macquarie did a great job of breaking down the goal of creating a recall and reminder list into multiple, small, easy to implement ideas.

You might like to try some of these ideas yourself:

Goal: Create an accurate recall and reminder list by 30 April 2017

Idea #1: Appoint a staff member who is responsible for creating and maintaining a database, add this role to their job description

NCPHN suggestion: Building your teams capacity for recall and reminder systems can take time, understanding the value of committing the time in terms of financial and patient outcome is important.

Now that we have Katrina Otto’s training and manual available, Five Star could  add three ideas here about:

Idea: Review the recall and reminder manual from Train IT Medical for ideas 

Idea:Have a team meeting to brainstorm how recall and reminder systems could improve income generation and patient care (e.g. by linking multiple recalls such as cancer screening recall, GP Management Plans, Health Assessments etc together)

Idea: Create a list of questions about setting up recall and reminders in the system, and book in Katrina Otto (through our Practice Support Officer) for a 1 hour training session to answer these questions

Idea#2 Draft a written procedure for our recall and reminder system

Idea# 3 Get the procedure approved

Idea# 4 Add the procedure to our policy and approvals manual

Idea# 5 Search our BP database for

  • Women aged between 50-74
  • Clean data – inactive or merge where needed
  • Remove women who have a breast cancer diagnoses

Idea# 6 Create a recall /reminder system

Ideas#7 Inform staff about the recall/reminder system

Idea# 8 Review the recall/reminder system after 6 months       

Idea# 9 Obtain list from Cancer Institute NSW of patients who have been screened in the last 30 months – submit form by 24/03/2017

Idea# 10 Identify those patients who have been screened through Breast Screen NSW and those who are due/overdue

Idea#11 Use data to assist in creating an accurate recall/reminder list

This website is no longer active but is available to browse as a resource.

Women’s Cancer Screening Collaborative (WCSC) 2017-2018

Through the delivery of structured, clinician-led general practice quality improvement and health literacy interventions, general practices worked towards increasing access to and equity of women’s cancer screening programs across the North Coast.

From January 2017 to July 2018, general practices improved clinical systems and data auditing processes to better identify and remind never or under-screened at-risk populations of women. Focus groups were also held with at-risk women to understand the environmental and individual barriers and motivators to screening. 

This WCSC website acted as an information repository for all WCSC developed content providing access to and sharing of quality improvement tools, change strategy resources and ideas.

WCSC evaluation and resources can be found on the North Coast Primary Health Network. 

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