Download 2011 Mammography Facility Survey - Metropolitan Chicago Breast

2011 Mammography Facility Survey
The Metropolitan Chicago Breast Cancer Task Force is collecting this information on behalf of the Illinois
Department of Healthcare and Family Services. Please have someone knowledgeable within your institution
complete and return this form based on practices in calendar year 2011 to Jennifer Orsi at [email protected] or
fax it to Jennifer at 312-563-2448 within 30 days of signing the provider agreement.
Instructions: Please fill out ONE form for EACH mammography facility at your institution.
MQSA Number: _______________
Facility name: ____________________________________________________________________________________
Address:
_______________________________________________________________________________________
City:
ZIP ___________ Institution affiliation (if any): ______________________
Name of person(s) completing questionnaire:
Phone: ______________________
Position or title(s): __________________________________________________________________________________
Lead Contact for your Facility: __________________________________________Phone: _______________________
Position or title(s): ____________________________________________________Email: ________________________
Current Capacity:
1. How many hours is you facility performing breast imaging from Monday-Friday? _________
2. How many hours is your facility performing breast imaging on the weekend? _________
3. How many analog (film screen) mammography machines are in operation? _________
4. How many digital mammography machines are in operation? _________
a. How many of these are Fuji CRM units? _________
b. How many of these are flat panel (stand-alone) units? _________
5. How many imaging techs dedicated to mammography (>75% of time)? _________
6. How many imaging techs who spend <75% of their time on mammography? _________
7. How many radiologists who are dedicated to breast imaging (>75% of time)? _________
8. How many general radiologists who read mammograms? _________
9. How many screening mammograms does this facility perform? ______ per month
10. How many diagnostic mammograms does this facility perform? ______ per month
11. During operating hours, for what percentage of the time is there at least one attending radiologist on site
<10%
10-25%
26-40%
41-59%
What percentage of your patients:
12 Are African-American
13 Are Hispanic
14 Have no private or public insurance
15 Have Medicaid
16 Are IBCCP patients
17 Are funded through other grant
sources (i.e. SAC, Silver Lining)
18 Are self-pay (i.e. not covered by a
grant/state program; out of their
own pocket)
60-75%
<10%
76-90%
10-25%
1
>90%
26-40%
41-59%
60-75%
76-90%
>90%
Computer-Aided Detection
19. Does your facility use Computer-Aided Detection (CAD) when interpreting mammograms?
1 Yes
2 No
20. If yes, please select which mammograms are routinely read with CAD (CHECK ALL THAT APPLY):
All screening mammograms
All diagnostic mammograms
Double-reading of mammograms
21. Does your facility routinely (as usual practice) employ double-reading of mammograms (i.e. a second radiologist
reads the film)?
1 Yes
2 No
22. If yes, please select which mammograms are routinely double read by a second radiologist (CHECK ALL THAT
APPLY):
All screening mammograms
Screening mammograms with an abnormal interpretation
All diagnostic mammograms
Diagnostic mammograms with an abnormal interpretation
Performance feedback
23. What types of feedback are provided to radiologists on interpretive performance for screening mammography?
Monthly
Quarterly
Annually
Less than Annually
Never
Recall rate
Biopsy rate
Cancer detection rate
% minimal/early stage
24. What types of feedback are provided to radiology technologists for screening mammography?
More than Weekly
Weekly
Monthly
Quarterly
Annually
Less than Annually
Never
Positioning
Compression
Other (specify): _______ ______
What percentage of:
<10%
25.
Mammograms are read on site at your facility?
26.
Screening mammograms are read same day as exam?
27.
Normal screening results provided before she leaves?
28.
Abnormal screening results provided before she leaves?
29.
Diagnostic mammograms are read same day as exam?
30.
Diagnostic results provided before she leaves?
Does your facility offer:
31. Diagnostic mammography?
32. Breast ultrasound?
33. Breast MRI?
34. Radiology guided breast biopsies?
1
1
1
1
Yes
Yes
Yes
Yes
2
2
2
2
10-25%
26-40%
41-59%
60-75%
No
No
No
No
35. For how many months were you unable to fill a position for a: mammography technician?
breast imaging specialist?
general radiologists mammographer?
36. As of today, how many days is the wait for: a screening appointment?
a diagnostic appointment?
a biopsy appointment? _______________
2
76-90%
>90%
37. Typically, what percentage of mammogram appointments are no-shows?
38. How many minutes are set aside for:
screening appointments?
diagnostic appointments?
39. In order to assess capacity, please provide us with a Microsoft excel spreadsheet that lists a count of screening
mammograms by patient zip code that your facility provided in calendar year 2011.
NOTE: Do not include diagnostic mammograms.
Example:
Screening Mammograms Provided at Facility X in Calendar Year 2011 by Patient Zip Code
Patient
Zip Code
60601
60602
60603
Count of Screening
Mammograms
5
10
11
3