The Solution

1. Establish Centralized Performance Monitoring & Data Governance

CMAG partnered with information technology and quality leadership to implement a centralized, cloud-based performance dashboard that incorporated data from the five practices’ electronic health records. The dashboard provided visibility into mammography care gaps at the organizational, practice, provider, and patient levels. Weekly performance huddles were established to review results, assign responsibilities, escalate barriers, and monitor progress toward the screening target.

2. Redesign Clinical Workflows & Standing Orders

CMAG worked with clinical leadership to establish standardized standing orders and screening protocols across participating practices. Electronic alerts were configured to identify eligible patients due for mammography at the point of care. Workflow templates clarified the responsibilities of physicians, nurses, medical assistants, front-office staff, and population health teams. These changes reduced unnecessary appointments, limited variation between practices, and created a more direct pathway from care-gap identification to screening completion.

3. Implement Systematic Patient Outreach & Engagement

CMAG developed a coordinated outreach strategy that provided multiple opportunities to connect with eligible patients and address barriers.

• EHR-generated patient letters

• Secure patient portal messages

• Telephone outreach campaigns

• Community awareness events

• Point-of-Care education addressing pain concerns, screening expectations, and the importance of early detection

4. Strengthen Cross-Practice Learning & Best Practice Adoption

CMAG facilitated cross-practice performance reviews that allowed teams to compare results, identify high-performing workflows, and share lessons across locations. Successful practices shared outreach techniques, scheduling processes, and patient-education strategies with lower-performing sites. This peer-learning model helped accelerate the adoption of effective practices while creating shared accountability for organizational performance.

5. Build Internal QI Capability & Sustainability

CMAG partnered with information technology to resolve reporting delays and strengthen ongoing performance monitoring. Rather than creating long-term dependence on external consultants, CMAG trained practice quality improvement coordinators in:

• PDSA methodology

• Rapid-cycle workflow testing

• Care-gap analysis

• Performance tracking

• Root-cause identification

The Impact

Operational Impact

The initiative established standardized screening workflows across five practices, improved visibility into care gaps, clarified staff responsibilities, and created a consistent process for patient outreach and performance monitoring.

Organizational Impact

Cross-practice learning replaced isolated improvement efforts with a coordinated performance strategy. Practices gained the ability to compare results, share successful approaches, and work toward common organizational goals. Teams were equipped to monitor care gaps, conduct PDSA cycles, evaluate interventions, and sustain improvements beyond the engagement period.