Defense Date


Graduation Date

Fall 12-17-2021

Submission Type

DNP Manuscript

Degree Name

Doctor of Nursing Practice (DNP)


Doctor of Nursing Practice (DNP) Program


School of Nursing

Faculty Mentor

Dr. Catherine Johnson


cervical cancer screening, cervical cancer guidelines, HPV, cervical cancer tracking, EHR, HIT, HIT/cancer



Background and significance: Cervical cancer is the fourth most commonly occurring cancer in women and the eighth most commonly occurring cancer overall (WCRF, 2020). Papanicolaou (Pap) testing is the primary screening for cervical cancer. In the past 40 years the number of cases and deaths from cervical cancer has decreased significantly, resulting from cervical cancer screenings (CDC, 2021). Healthy People 2030 reports to increase the proportion of females ages 21-65 who receive a cervical cancer screening based on the most recent guidelines. The 2030 target is 84.3%. Human papillomavirus (HPV) is a virus that is transmitted through sexual contact and is the leading cause of cervical cancer. Purpose: The purpose of this quality improvement (QI) project is to support the implementation of the Women’s Health Cervical Cancer Screening Protocol (CCSP) in Primary Care Practices within a federal qualified health center (FQHC) serving the underserved residents in Southwestern PA. The goal of the CCSP is to review the current pap workflow in comparison to the ASCCP guidelines, HPV vaccine, and correct documentation. Methods: This project utilized the Model of Improvement and the PDSA approach in the implementation of the CCSP in a selected primary care clinic. A program charter was developed with the FQHC stakeholders that guided the CCSP implementation and evaluation. After training sessions with the staff and providers the CCSP workflow processes was implemented, Audits of the EHR documentation reviewing compliance with ASCCP guidelines and HPV vaccine guidelines. Results: After completion of CCSP, EHR documentation audits compliance with the CCSP improved by 75% as compared to pre-implementation EHR documentation. The CCSP workflow was adopted with the recommendation that the NextGen Clinical Care Guidelines module to be implemented to support compliance and monitoring of the CCSP process. This will result in improved UDS cervical cancer screening performance measures.

Keywords: cervical cancer screening, cervical cancer guidelines, HPV, cervical cancer tracking, EHR, HIT, HIT/cancer



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Nursing Commons