For years, the radiology community has faced a problem: Less than 70% of mammograms offer a clear view of breast tissue, according to the American College of Radiology—a fact that can have deadly consequences for women.
So last year, the Stanford Department of Radiology’s vice chair of education and clinical operations, David Larson, set out to find a solution. He started the Mammography Position Improvement Collaborative with the ACR in June 2021 with the goal of working with hospitals to identify new mammography best practices.
It turned out, demand for such a program was high. A total of 101 medical centers applied to be in the collaborative’s first eight-month cohort, but only six were selected—and one of them was the MemorialCare Breast Center in Long Beach.
In the program, which launched March 14 and runs through November 14, the center within Long Beach Memorial’s Todd Cancer Institute is working with five other major hospitals, including Stanford’s own, to create a more effective and universal set of guidelines for taking mammograms.
Rather than trying to find a one-size-fits-all solution, the aim of the collaborative is to establish new processes that can result in more accurate mammograms regardless of the specific challenges posed by any given patient or hospital.
“We have difficulty really adopting solutions from one institution to another,” Larson said, “especially when it involves a lot of organizational and workflow changes.”
So, over the collaborative’s 10 learning sessions, participating hospitals are asked to consider different challenges—like a patient who might not be comfortable while maintaining the proper position, or skin folds or other abnormalities that could hide cancerous cells—and determine the steps that will lead to appropriate solutions.
Things like setting up a team, effectively defining a problem and its scope, setting specific goals and analyzing the workplace and workflow to identify obstacles are all part of the curriculum the ACR is bringing to the table.
“All improvement is not easy to do. It’s not intuitive,” Larson said. “To do it reliably requires having project management, it requires improving methods, having the organization support, having access to data, all those things.”
In fact, as a requirement to join the collaborative, institutions needed to have a dedicated “quality improvement coach,” or someone with quality improvement experience.
“Anyone who has done quality improvement recognizes that there’s many ways a quality improvement project can fail,” Larson said. “It has to do with the methodology, with the interactions between the team members having access to the data, the support from the local leadership, or the collaboration between different parts of the organization.”
While this type of focus on problem-solving would be beneficial in any field, it’s clearly needed in the world of mammography.
The inability to meet mammography standards is one of the biggest reasons that sites fail accreditation with the ACR, Larson said, and having that accreditation is an important part of demonstrating legitimacy for a hospital’s radiology procedures.
The inconsistency is also a problem acknowledged by major health organizations.
“It’s [an area] that the FDA has specifically looked at, because they recognize the challenge,” Larson said. “It’s very important in the diagnosis of breast cancer, the way the breast is positioned on an image can make the difference between whether a cancer is detectable or not.”
But the six institutions currently working in the collaborative are well-positioned to help address the problem.
“We already were very data driven; we already had implemented many quality improvement processes and items and software,” the Todd Cancer Institute’s executive director and collaborative sponsor, Lisa Poorman, said. “We were already trying to get there.”
Still, MemorialCare Breast Center’s imaging director Angela Sie said she has been pleasantly surprised by the collaborative’s approach.
“For some reason, I thought it was just going to be, ‘Oh, this is what you have to do to optimize positioning,’” Sie said. “It’s much more process-based, and it has really taught us how to attack a problem, how to improve the solution and how to measure how you are doing.”
The collaborative also has checks in place to ensure the new processes are achieving the intended results. Every week, the team audits about 60 breast cancer scans that have resulted from the collaborative’s process, according to MemorialCare Breast Center supervisor Bree Hysjulien, who serves as the project leader for the collaborative.
The results of these exams are gathered and shared with the other hospitals to compare with other systems as a way to test the effectiveness of the new methods.
While the new practices and standards that come out of this collaborative are key, a broader goal of the collaborative is to establish leaders in the field to spread that knowledge.
“That’s what we hope will differentiate it from being just a course you take or a project you undertake one time,” Larson said. “It becomes not only something that you ingrain within your own organization, but that you then share and learn from others.”
The team at the MemorialCare Breast Center, for its part, is ready to take on that task.
“Nowadays with Zoom, you can have a conversation with anyone anywhere in the world,” Sie said. “We can discuss what we went through, how it affected us and if we had lasting improvement, because the goal is to have lasting improvement in our positioning.”