Table of Contents
College of American Pathologists (cap)
How to Implement a See, Test and Treat™ Screening and Prevention Program
Introduction
A.Exploring the Possibilities
Identifying an Underserved Population
Exploring Services to Be Provided
Inclusivity Is Key
Importance of Cultural Awareness
B.
Program Details
Location and Timing
Volunteer Licensing/Credentialing/Privileges
Patients
Personnel
Laboratory Supplies and Equipment
Other Equipment
Other Supplies
On-Site Program Details
Patient Follow-Up
Expenses
Grants
Samples
Indian Health Service Application for Initial Appointment to Medical Staff
Indian Health Service Pathology Privileges Request Form
Pap Test Result Form
Mammography Log
Event News Release
Certificate of Appreciation
Supplies and Equipment
Quick Stain Process for Pap Tests
Patient Flowchart
Patient Photo Release Form
Sample Budget – See, Test and Treat program – October 2001
Sample Budget – See, Test and Treat program – June 2002
C. How Can the College of American Pathologists Help?
D.Other Screening Options
E. CAP Staff Contact Information
See, Test and Treat - Screening and Prevention Program
Table of Contents
Introduction
INTRODUCTION
In October 2001, after more than two years of collaborative planning, the College of American
Pathologists (CAP) held its first See, Test and Treat Screening and Prevention Program (CAP See, Test and
Treat™ program) in McLaughlin, South Dakota, on the Standing Rock Reservation. By July 31, 2009,
a total of eight programs were held.
3 October 2001, in McLaughlin, South Dakota, on the Standing Rock Reservation
3 June 2002, in Rosebud, South Dakota, on the Rosebud Reservation
3 April 2003, in McLaughlin, South Dakota, on the Standing Rock Reservation
3 June 2003, in Rosebud, South Dakota, on the Rosebud Reservation
3 October 2005, in Minneapolis, Minnesota, at the NorthPoint Health & Wellness Center
3 May 2007, in Minneapolis, Minnesota, at the NorthPoint Health & Wellness Center
3 February 2008, in Juarez, Mexico
3 May 2008, in Minneapolis, Minnesota, at the NorthPoint Health & Wellness Center
A program is scheduled to be held in October 2009, at the NorthPoint Health & Wellness Center in
Minneapolis, Minnesota.
During each two-day CAP See, Test and Treat™ program, Native American women received free breast and
cervical cancer screening, test results, and necessary follow-up treatment. Current standards of care were
used throughout the process, but a new delivery model was used to provide immediate test results and
same-day follow-up care to patients. The program resolves transportation and communication issues,
child-care concerns, and other family issues surrounding women’s ability to obtain necessary health care.
The program also provides great emotional relief by offering not only immediate test results, but in most
cases, immediate follow-up treatment as required.
The goal of the College in developing the CAP See, Test and Treat™ program is to reduce barriers to
screening and to increase early interventions for breast and cervical cancers in women. With this goal in
mind, the College developed several objectives:
3 Increase awareness of and compliance for cervical and breast cancer screenings
3 Increase the number of women receiving needed follow-up care
3 Increase early detection and treatment of breast and cervical cancers
3 Improve survival rates for participating women diagnosed with breast and cervical cancers
3 Decrease anxiety related to test results and potential next steps
Introduction
Introduction
The program has been a great success, and it continues to grow. To date, more than 650 underserved and
uninsured women have been seen, tested, and treated for early detection of breast and cervical cancer.
This delivery model can be adapted to provide other types of screening, testing, and follow-up treatment to
any underserved and uninsured population of men, women, or children.
This manual has been developed to aid others in implementing programs similar to the CAP’s See, Test and
Treat™ program in their communities. In this manual you will find suggestions and general information about
developing your own program, as well as specific information on the College’s programs.
The CAP is available as a resource to you and your organization should you choose to present a See, Test
and Treat program.
Introduction
A. Exploring the Possibilities
Identifying an Underserved Population
Before you begin planning your first event, some groundwork needs to be done. It is important to clearly
define your target market:
3 Who can benefit the most from a See, Test and Treat program?
You may have some idea already, but it also helps to do a little research. Research your local
health statistics:
3 What population has the highest health risk and for which disease?
3 What population could benefit most from immediate care and from not having to come back for
follow-up care?
3 What can community leaders tell you?
3 What can local health providers tell you?
The CAP Experience
When the College first decided to develop a See, Test and Treat program, we began focusing on cervical
cancer prevention and researched national health statistics to find out where the highest incidence of cervical
cancer was located. Those statistics pointed toward Native American women.
According to 1996 National Cancer Registry statistics, Native American women in the Indian Health
Service’s Aberdeen Service unit had the highest cervical cancer death rate in the US. In fact, the female
age-adjusted cervical cancer death rate for that population was 1.6 times the rate for other races of US
females at the time of our research. The Aberdeen Service unit includes Iowa, North Dakota, South Dakota,
and Nebraska.
We used data from the National Institutes of Health and Indian Health Services to document our findings.
We learned that from 1999 to 2000, only 20.8 percent of Native American women from the McLaughlin,
South Dakota, area actually had a Pap test, compared with 64 percent of all adult women across the nation
as a whole.
We also talked with key health care leaders in several Native American communities across the country to
see whether and where this type of program might work best. Research and relationship-building efforts
are essential.
Identifying an Underserved Population (continued)
After talking to local community health leaders, we discovered that there were several factors contributing to
the high incidence of cervical cancer. These factors included lack of transportation to get to appointments,
lack of telephone service that inhibited communications efforts between patient and doctor, and social
barriers to care, among others.
According to research, 80 percent of women requiring follow-up care in the McLaughlin, South Dakota, area
did not receive it due to communication, transportation, and other issues.
As a result of our findings, we decided to focus on how we could work with local health care providers to
break through some of the barriers to health care faced by Native American women in South Dakota.
Exploring Services to Be Provided
Once the underserved population is determined, it’s important to define what services will be most needed.
3 Is your target audience male or female?
3 What age group(s) is to be served?
3 Which screening or prevention services, or both are most lacking currently?
3 What is impeding patients from receiving adequate care?
Be flexible. Whatever services you determine are needed at this stage may be modified as you get further
into the program.
The CAP Experience
While we knew we wanted to focus on cervical cancer prevention and education when planning our CAP
See, Test and Treat™ program, we did not know what else was needed, if anything. After many discussions
with key Native American health care leaders it became clear that both cervical and breast cancer programs
were needed to provide women with necessary screening and immediate care. That was because the same
barriers that prevented women from receiving follow-up care after Pap tests also prevented them from getting
follow-up care after mammograms.
Our service model became a single-visit program for cervical and breast cancer screening, education,
immediate diagnostic interpretation, and early intervention.
Inclusivity Is Key
For this program to work, there has to be local “ownership.” Key people in the community need to be
involved from the beginning. As you move through each stage of the planning process continually think
about whom else should be involved. Each community’s core group will be different. You may have to
include health care providers, tribal leaders, church officials, or other community leaders.
The CAP Experience
In our case, our events were spearheaded locally by the leading health care providers in each community. In
one case it was a nurse practitioner and in another it was the hospital administrator. The person’s title is not
necessarily important for this event leadership position, but their commitment to the project and stature in the
community are important. The local leader needs to know how to get things done in his or her community
and how to find and involve the most appropriate people.
In addition to the local leader, our core organization “committee” included the following people:
3 Two pathologists, one from the state and one from a neighboring state
3 One grant coordinator
3 One obstetrician/gynecologist
3 One nurse midwife from a neighboring Indian hospital
3 One leading women’s health medical professional from the Aberdeen regional office
3 The chief medical officer for the Aberdeen Area
3 A representative from each of the two United States Senator’s offices; one of these representatives
happened to be Native American and was well versed in how to approach the tribal councils
3 The local medical professionals who provided their community’s perspective, which was of
critical importance.
Other areas you might tap into include:
3 Churches
3 Hospitals
3 Racial/Ethnic leaders
Importance of Cultural Awareness
Especially if you are working within a minority population, it is very important to be aware of any cultural
sensitivities. The expertise of local leaders will be useful in this area.
Some questions to ask as you move forward:
3 If it is an event for women, will they be willing to see male physicians?
3 Where will your attendees be most comfortable? Where should the event be held?
3 Will you need translators?
3 Who has the local credibility to persuade people to attend the program?
3 What will make the program pleasant and rewarding for the participants?
3 What time of year is best?
3 Which days are best?
3 Are there any significant conflicting community events?
The CAP Experience
Within the Native American community our local leaders made us aware that on one reservation the women
preferred only female providers.
They also recommended that the women who would visit the program would be most comfortable coming to
a familiar location where they already had a built-in comfort level. After exploring several options,
including community centers and shopping areas, the local leaders recommended the clinic and or the
hospital, because they were facilities where the women were already used to receiving their health care.
The women in the Native American communities have a strong connection with “grandmothers,” female
elders in the tribe. We were told to best reach the women we should first reach the “grandmothers.”
In addition, the Native American communities have an established network of Community Health
Representatives (CHRs), who go door-to-door educating women about various health issues. The CHRs
volunteered to book appointments and answer any questions about the program.
It was recommended that we also should offer food and door prizes to attract women to the program. We
provided snacks during each event, and each participant also received a special t-shirt. We commissioned
a Native American woman in the community to create the design for the shirt, and that, too, was very
well received.
We had to be aware of the schedule for community powwows, which are very significant social events
during the year, as we planned our events. In one area, there were powwows from June through September,
which limited the times we could host a program. If we had not been aware of this cultural event, and had
scheduled a See, Test and Treat program during that time, it would not have been successful.
B. Program Details
Location and Timing
Location and timing are two key elements that have to be strategically determined for a program to be
successful. The following are some questions to ask:
3 Where will the program be held to attract the most participants?
3 What time of year is best for the community?
3 Is weather a factor?
3 Which days of the week are best?
3 How many days should be scheduled for the program?
3 Who has the local, cultural credibility to promote the program?
The CAP Experience
Location
Local Native American leaders advised us that women would be most comfortable coming to a facility where
they were already familiar. After exploring several options, including community centers and shopping
areas, the local leaders recommended the clinic or hospital facilities where the women already had a level
of comfort for receiving health care.
Timing
In planning the event, we had to consider several factors, including the local event schedules and the
weather. Powwows in one of the communities prevented us from having an event in the June through
September time period. The potential for severe weather from November through late April prevented us
from scheduling it during that period as well. We were left with late April, May (which included Mother’s Day
weekend), and October. So although it might seem that the calendar schedule is wide open, be sure to take
into consideration potential obstacles such as weather and other important civic, cultural, or religious
schedules or events.
B. Program Details
B. Program Details
Volunteer Licensing/Credentialing/Privileges
Whether you are developing a See, Test and Treat program to be implemented in a federal, state, or private
facility, your volunteer health care providers will have to be licensed or credentialed and have privileges in
order to provide services at your location unless they already have credentials to practice in that location.
Other nonmedical volunteers may also have to complete a series of forms in order to participate in the
program. This process allows your volunteers to provide services to patients in that particular facility, and
should provide liability coverage or indemnify them from liability for the care they provide during
the program.
Here are some questions to ask:
3 What forms must be completed?
3 Who will need to complete credentialing, privileging, or licensing forms?
3 Does the state require out-of-state providers to complete any additional forms?
3 What is the deadline for submission of all forms?
3 Who can you contact with questions about the forms?
Early in your planning determine who your contact will be for credentialing, licensing, and volunteer
requirements, as well as what the process is for each and what the timeline is. Your local contact or someone
at your health care facility should be able to provide you with the requirements for credentialing volunteer
health care providers. Be sure to check with the state licensing board or department of professional
regulations to determine whether out-of-state volunteers have additional requirements. Again, your local
contact may be able to help you.
Even if your volunteers have provided services in the same or a similar facility on prior occasions, they may
still be required to go through an identical licensing or credentialing process. So make sure you ask what the
credentialing process again.
Physician providers and midlevel providers such as nurse-midwives or physician assistants may have to
complete more information than technicians.Radiologists and mammogram technicians must, by federal
regulation, provide even more extensive information than other providers.
Ask if there are any shortcuts. For instance, if your volunteers work for an institution accredited by the Joint
Commission (formerly known as JCAHO), their institution may have much of the required information on file.
Your volunteers may be able to sign a release form and have their institution forward all pertinent
information to you or the designated contact person.
It may take your volunteers several weeks or more to accumulate the documents and information required by
this process. Adequate time must also be allowed for processing of the credentials, licensing, and volunteer
information by the facility with which you are working.
B. Program Details
B. Program Details
Volunteer Licensing/Credentialing/Privileges (continued)
If you are able to obtain all the required forms from your local contact, you may have more control over the
process. You can be sure that each of your volunteers receives the appropriate forms on time, with a clear
explanation of what is expected. You may also want to ask your volunteers to send their completed packets
back to you. This way, you know who has completed their information and who has not, allowing you the
opportunity to send appropriate reminders, as necessary. Also, if you have volunteers who will participate
in more than one program, you can offer to make copies of their materials for them. However, always
offer your volunteers the option of sending their completed materials directly to the designated credentialing
contact. The credentialing forms require significant personal information and your volunteers may prefer that
you not have access to that information.
Of course if you initiate a See, Test and Treat program in your community supported by local, already
credentialed providers, concerns with credentialing should be minimal.
The CAP Experience
The CAP See, Test and Treat™ program was implemented on two Native American Indian reservations in
South Dakota. The federal government’s Indian Health Services provides health care services to American
Indian reservations. The credentialing processes for our two locations, McLaughlin and Rosebud, were
similar although not identical, and our volunteers who participated in both programs had to complete forms
for both locations. Indian Health Services requires that providers be credentialed to each specific service
unit. (Examples of required forms are included at the end of this section.)
Physicians and mid-level practitioners, such as nurse midwives, were required to complete a credentialing
packet including a request for appointment to the medical staff of the hospital and a request for hospital
privileges specific to his or her specialty. The credentialing packet required a copy of each volunteer’s license,
reference letters, and other materials. Our volunteer radiologists and radiology technicians were required by
federal regulations to submit additional information regarding recent continuing medical education credits
and number of mammograms read or performed.
Every volunteer, including physicians, nurse midwives, cytotechnologists, and nonmedical support staff was
required to complete a volunteer packet. Cytotechnologists and non-medical support staff were not required
to complete the more extensive credentialing packet.
B. Program Details
B. Program Details
Patients
In order to determine the number of volunteers you’ll need for the program, the supplies and equipment, and
the level of additional staff support for a successful program, you will have to estimate the number of patients
to be served during each program. You will need to rely heavily on the experience of staff at each See, Test
and Treat location in order to make this determination.
The first time you hold an event in any location, it will be difficult to correctly anticipate the number of
patients who may want to participate. If you determine that other health care programs have been offered
to the community in the same location, you may be able to use their numbers as an estimate.
You should also consider that the length of the event and the hours established for patient visits will limit the
number of patients who will receive services through the program.
Additional factors that will affect how many patients will participate are the location and the timing of the
program. Local providers may be able to provide an average no-show rate.
Be prepared that no matter what your anticipated number of patients is, it could be way off the mark.
Considerably more patients could appear, or fewer might show up. The key to the program is to be flexible
and learn from your experience.
The CAP Experience
In McLaughlin, the number of expected patients was overestimated locally, but the number of screenings and
education were enough to keep volunteers busy. For each of the two McLaughlin programs we saw about
60 patients, which was a significant number for that community. Appointments were scheduled for 100
patients and our average no-show rate was about 60 percent, which was about average for that
community. However, we also had approximately 20 walk-ins during each program. We also had a local
volunteer make reminder calls on the day of the event, which helped bring patients to the clinic.
In Rosebud, similar screening programs for different diseases had been offered previously. On each occasion
there was good patient turnout. We were able to anticipate that our schedule would be full for both days of
the program. In addition, we found that although we had an equal number of patients signed up for both
days, with some appointments left open to accommodate walk-ins, we had an influx of walk-in patients on
the second day. There was so much positive buzz about the program in the community that more patients
decided to participate. We saw 120 and 130 women during each of the two programs. Appointments
were scheduled for approximately 60 patients per day. We had a no show rate of 27 percent, which is much
lower than the hospital’s usual no show rate. For both days of each program we had a substantial number of
walk-ins. (An example of a Pap test result form is included at the end of this section.)
To provide some perspective, the number of women seen during these CAP events must be compared with the
number of women who usually receive Pap tests in both McLaughlin and Rosebud. In McLaughlin, the clinic
sees about 200 women a year for Pap tests and pelvic exams and 40 women per year for mammograms.
There are approximately 2,445 women in the McLaughlin area between 17 and 80 who should be seen, so
the clinic is currently seeing less than 10 percent of that population annually.
B. Program Details
B. Program Details
Patients (continued)
During each of our two-day programs we saw an average of 62 women. On average, 44 women had Pap
tests for each program. Over the course of two days, See, Test and Treat volunteers saw nearly 25 percent of
the total number of patients having Pap tests that the McLaughlin clinic sees in a year.
The first year of the program in McLaughlin, the mobile mammogram truck was available only for one day
and 15 women received mammograms. The second year the truck was available for two days, and we more
than doubled the number of women receiving mammograms. During the second year, 43 women had
mammograms over the two days. That is more than 100 percent of the total number of mammograms done
at the clinic in a typical 12-month period. In addition, the See, Test and Treat program allowed for delivery
of immediate results and follow-up care, which is not possible during a normal screening program.
In Rosebud, the hospital provides Pap test services each year for almost 10 percent of the 9,300 women over
the age of 17 in the Rosebud Service Unit area. Approximately 80 women receive Pap tests at the hospital
each month. During both of the two-day See, Test and Treat programs, we performed nearly 30 percent
more Pap tests than the hospital would expect to perform in any given month.
In addition, the hospital has reported that it performs 250 mammograms per year, or 20 per month.
During the first visit to Rosebud, we performed 38 mammograms although we had only one mammogram
unit available for use. On our second visit, we performed 71 mammograms with the use of two units, more
than tripling the number of mammograms the hospital would otherwise have performed in one month. And,
just as in McLaughlin, patients received their results and follow-up treatment immediately. This is something
that does not happen during regular mammogram screening at Rosebud Indian Health Services Hospital.
(An example of a mammography log form is included in this section.)
How will you recruit patients?
Assuming you have identified a location where your target population is familiar and comfortable, and you
have selected dates that will not conflict with major events involving your target population, the next most
important thing to determine is how patients will be recruited to participate in the program.
These are some other questions to ask:
3 Will your patient recruitment efforts rely on word of mouth, group meetings, personal visits, community
announcements, media exposure, or all of the above?
3 Is there a specific group or person within the community that has particular influence on your target
population?
3 Is there someplace in the community where your targeted population regularly gathers?
3 Will your program be family friendly? That is, can patients bring their children and spouses or partners?
3 If so, will there be something for the children, spouses, or partners to do?
3 Will you provide refreshments for patients and their family members while they wait for their screening,
test results, and follow-up care?
B. Program Details
B.Program Details
Each community is different. You may gain valuable knowledge from what works in your particular
community from on-site staff who have experience with prior health care programs. If you are targeting a
specific group, members of that group should already be involved in the planning of the program. You will
need them in your recruitment efforts. A community center, store, beauty parlor, church, school, sports event,
or health clinic are some of the places you may consider promoting your program. If you can identify a
common gathering place, brochures or leaflets about the program can be handed out, or local
representatives can make announcements or presentations.
The CAP Experience
For both the McLaughlin and Rosebud programs, community health representatives went out into the
community to personally register women for the program. At McLaughlin, local diabetes program leaders
and other volunteers also helped recruit. They made it clear to patients that they were welcome to bring
children, or their spouse or partner, or both with them to the clinic, and some did.
In McLaughlin, respected elderly women, or “grandmothers” of the tribe, also talked with potential
participants and emphasized the importance of women caring for their own health. They reminded them
that attending the program would help them in this regard. The personal outreach of the grandmothers, the
CHRs, and the other local volunteers was vital to the success of each program. In addition, media outreach
was also employed. The local radio and TV stations ran advance stories on the program. Two local
newspapers also ran advance stories on the event.
In Rosebud, radio ads and fliers were distributed throughout the community in addition to the personal
outreach efforts. (See the sample news release included at the end of this section.)
How will patients register for the program?
As you plan your program you will need to determine how you will handle the registration process.
Some questions to ask as you begin this part of the process are:
3 Can patients register via phone?
3 Must patients register in person?
3 Will patients receive a reminder phone call or postcard?
3 Will you accept walk-in patients?
If your program is being held at a clinic or hospital with established registration procedures that work, then
you might be able to use the process already in place. If your location generally accepts patients on a
walk-in basis, or is not an established health care location, you should determine a phone number where
patients can call to register. You can advertise the registration process throughout your recruitment efforts,
and emphasize that walk-ins will also be welcome.
B. Program Details
B. Program Details
If personal recruitment will be undertaken, whether in patient homes or at community events, have a
registration sheet available to make appointments. If it is at all possible, provide registrants with an
appointment card that lists the location of the program, the day and time of their appointment, and a
telephone number in case they need to change or cancel an appointment.
The CAP Experience
For the McLaughlin program, patients were registered during personal home visits from the CHRs, diabetes
program leaders, and other local volunteers. We were told by local contacts that this was the most effective
method. Patients received reminder phone calls the week prior and up to and including the day of the event,
as appropriate.
In Rosebud, patients used the established hospital clinic registration process. Walk-ins were also welcomed.
No matter how many patients register for the program, you can expect that some preregistrants will not keep
their appointments, and you are likely to have many walk-in patients.
How will patients get to the See, Test and Treat location?
Patients’ access to transportation will impact the success of your program. If access to transportation is an issue for your targeted population, you may consider working with your See, Test and Treat facility to organize
group transportation.
If public transportation is available, perhaps bus or train passes or tokens could be provided to patients who
register for the program in advance.
Our on-site contacts in Rosebud did not think lack of patient transportation would be a hindrance to the
program. Transportation in McLaughlin is somewhat more limited. Once the program was in full swing, CHRs
at McLaughlin did drive some patients to the event if they lacked transportation.
B. Program Details
B. Program Details
Personnel
Considering available space at your program location, an estimated number of patients, and the types of
services you are planning to provide, you will have to determine how many and what type of health care
providers you will need for the program.
Questions such as these should be considered:
3 Will there be local health care providers available to assist with the program?
3 Will there be other local support staff to help register patients, escort them from one area to the next and
pass out door prizes?
If you are providing breast and cervical cancer screening and follow-up care, you must have the
participation of the following categories of health care providers:
3 pathologists
3 cytotechnologists
3 gynecologists, nurse-midwives, or physician’s assistants
3 radiologists
3 mammographers
3 nurses
3 administrative Staff
You will need to identify avenues through which you can recruit volunteers.
3 Can you recruit through your own membership?
3 Can you recruit through state or national medical associations?
3 Will you advertise the program in order to obtain volunteers?
3 Will you obtain referrals from those involved in the development of the program?
3 How will you decide who is qualified to participate in the program?
3 Must volunteers be local, or can they be regional or out-of-state?
3 Will your patients see male physicians, or do they prefer female physicians?
3 Do other constraints exist?
The College of American Pathologists can help you recruit pathologists and cytotechnologists, if necessary.
B. Program Details
B. Program Details
Personnel (continued)
The CAP Experience
Having determined that our CAP See, Test and Treat™ program would provide breast and cervical cancer
screening and follow-up services for women, we tackled the question of what types of providers we would
need for the program.
Pathologists are essential to the program. Without pathologists on-site to read and interpret the Pap smears
and to perform fine-needle aspirations, patients cannot receive their test results on the same day as their
screening exams. Without test results, patients cannot receive immediate follow-up treatment.
Cytotechnologists are necessary for the program. Cytotechnologists stain the Pap smears almost immediately
after they are performed. They also screen and read the Pap tests.
To perform the pelvic examinations and Pap tests and provide necessary follow-up treatment, you must
involve gynecologists, nurse-midwives, or physician’s assistants in the program.
To perform mammograms, you need a qualified mammographer; and to interpret the films on site, you need
a qualified radiologist.
You will need nurses to help register patients, take their vital signs, assist with charting and procedures,
provide patient test results, possibly obtain informed consent, and assume all the other invaluable
professional responsibilities the nursing staff does on a daily basis.
Additional administrative help is always welcome in order to provide better service to waiting patients.
Someone needs to coordinate and oversee the distribution of door prizes, the provision of food to waiting
patients, and the availability of education materials, as well as be able to answer patients’ questions.
To recruit volunteers, we began with our own CAP membership. While we were not constrained to recruit
providers only from within South Dakota, we wanted to make sure to include some in-state providers, if
possible. Ultimately, the goal is to empower local area medical teams to hold future See, Test and Treat
programs. We consulted with the CAP Council on Public Affairs, under whose auspices this program was
developed, for recommendations of pathologists. We also looked to other College leaders for
recommendations. We talked with the groups involved in the development of the program and received
suggestions from them, as well.
Since pathologists work with cytotechnologists; we also asked our members to recommend cytotechnologists
and spread the word about the opportunity to participate in the program.
The response from our members and the interest of the cytotechnologists was overwhelming.
Next, we worked with the American College of Obstetricians and Gynecologists to identify gynecologists in
South Dakota. If a person was not available, he or she was usually able to provide a lead for us. We were
able to recruit several South Dakota obstetricians/gynecologists for each program.
We secured our nurse midwife for the events through our face-to-face meeting with the local Indian Health
Service and other groups involved in developing the program. The nurse-midwife practiced on another
reservation in South Dakota and was very familiar with the culture and with both McLaughlin and Rosebud.
B. Program Details
B. Program Details
Personnel (continued)
We found our radiologists through referrals from the pathologists and gynecologists whom we recruited for
the program. In addition, the American College of Radiology ran a story about the program in its monthly
newsletter, which created some interest.
Our volunteer radiologists helped to identify mammographers to participate in the programs. In one case,
the mammographer was provided by the hospital supplying the mobile mammography unit. She was not a
volunteer, and we had to pay her salary.
We depended primarily upon each site to provide nurses, because we knew we needed local professionals
familiar to the patients and the location. Some of their duties included registering patients, getting them to
exam rooms, taking their vitals, assisting with charting information, assisting with procedures when
necessary, and many other necessary tasks.
In both McLaughlin and Rosebud, local staff were very available and accommodating for the program. In
Rosebud, there were several on-site providers, including an obstetrician/gynecologist and a physician’s
assistant, who joined the program. On the second day of the first Rosebud program, several local nurses
volunteered on a Saturday to assist after hearing so many positive comments about the program from
patients who had participated that Friday. In addition, the second time we did the McLaughlin program, a
local medical technologist who had not participated in the first one, also volunteered on Saturday.
Each volunteer and hospital or clinic employee who participated in the See, Test and Treat programs
received a thank-you letter and a certificate of appreciation from the College. In addition, each received a
commemorative T-shirt designed especially for the event by a local Native American woman. (See a sample
certificate at the end of this section).
B. Program Details
B. Program Details
Laboratory Supplies and Equipment
Proper laboratory equipment and supplies are critical to the success of a See, Test and Treat program. (See
list of equipment and supplies at the end of this section.) Each location will differ in what they have on site,
and what you may need to bring with you to make the program a success.
In order to provide same-day test results and follow-up treatment for patients, pathologists and
cytotechnologists must be able to rapidly stain and read Pap test specimens. Either conventional or
liquid¬-based Pap test methods can be used to collect the specimen for screening. A special rapid stain is
mixed to provide a turnaround time of approximately twenty-five minutes. (See rapid stain procedure at the
end of this section.) If a liquid-based cytology collection method is used, a processing instrument must be
available on-site for use during the program.
Ideally, the lab used should be dedicated to the See, Test and Treat program for the duration of the event.
If, however, the lab is located in a hospital or other health care facility in which other patients will receive
treatment, the laboratory for the program should be set up in a separate room. Any room with tables and
adequate lighting will suffice for setting up microscopes and interpreting Pap tests. However, microscopes
with the appropriate lenses must be provided and dedicated to the use of the program for its duration. One
microscope should be available for each cytotechnologist participating in the program, and an additional
microscope should be available for use by the pathologists. If your See, Test and Treat facility does not have
adequate microscopes, you may be able to solicit medical equipment companies to donate microscopes for
the program or arrange for cytotechnologists or pathologists to bring them.
A ventilated room with access to a sink and tap water is required for staining Pap smear specimens.
Adequate space is necessary to accommodate one or two staining stations, slide trays, Coplin-type jars,
and other supplies.
To perform fine-needle aspirations, appropriate syringes and needles are necessary, as well as a private
room for patients.
The CAP Experience
For the College’s program in McLaughlin, we secured donations for all of the equipment we needed.
Although we ordered and shipped most of the supplies, we brought some of them with us. The McLaughlin
Health Center is a small clinic and did not have any of the equipment, nor most of the supplies necessary
for the program.
The College received donations of microscopes for use during the program. Each microscope should
have 4x, 10x, 20x, and 40x lenses. Olympus donated several microscopes for the program, and one
pathologist also brought a microscope. We found it was easiest when they were all donated and a company
representative set them up, as happened with one of the McLaughlin events. We ordered an extensive list of
supplies, including the stains we needed for the Pap smears, swabs, microscope slides, and coverslips. Our
volunteer pathologists and cytotechnologists also brought extra supplies of their own, including Coplin-type
jars and slide trays.
B. Program Details
B. Program Details
Laboratory Supplies and Equipment (continued)
For the first Rosebud program, we were assured that all of the necessary supplies were on hand. However,
as we discovered, it is best to bring some of the critical equipment and supplies, such as microscopes and
stains. Although the microscopes that had been supplied were usable, they were not ideal for the program.
Although the appropriate stains had been ordered, they were delivered to the wrong Indian Health Services
location, approximately six hours away. Thankfully, one of our pathologists saved the day by bringing the
required stains from his own laboratory.
For the second Rosebud program, Olympus donated the use of four microscopes and Hologic (formerly
Cytyc Corporation) donated the use of a ThinPrepprocessor and all necessary specimen collection supplies.
We also ordered and brought with us the stains and reagents necessary to create the rapid stain.
B. Program Details
B. Program Details
Other Equipment
The largest piece of equipment required for the success of the See, Test and Treat program is a mammogram
machine. Some locations will have a unit on-site, but others will not. In some states, you may be able to
secure a mobile mammogram unit to use for your program. However, you must be sure to secure a mobile
mammogram unit that is appropriate for diagnostic mammograms, and that has on-board processing for the
films. This is vital in order to provide patients with same-day results and follow-up.
In addition, you may need to secure a colposcope, a LEEP instrument, a cryo machine, a mammogram view
box, and an ultrasound machine to provide follow-up treatment for women with abnormal Pap tests and
irregular mammograms. Again, medical equipment companies may donate the machines for use during the
program. Other possibilities include contacting neighboring health care facilities.
The CAP Experience
We worked with our medical volunteers to create an entire list of supplies and equipment. We then reviewed
that list with local contacts at each CAP See, Test and Treat™ facility to determine which supplies and
equipment they could provide and which we would need to procure for the program.
For the College’s McLaughlin program, in addition to other machines, we needed to secure the use of a
mobile mammogram unit. This was the most difficult piece of the program to obtain. We discovered that
there are only a few mobile mammogram units in the whole Great Plaines region. Some are not available
for use, and most are not equipped for on-board processing. However, we located a unit that met our
requirements at Avera McKennan Hospital in Sioux Falls, South Dakota, about six hours away. There was
a cost associated with using the unit, however. In addition, for one of the events, a mammographer from
Avera McKennan participated.
In addition to the mobile mammography unit, the following items were donated by medical supply
companies: an ultrasound machine, view box, cryo unit, and four microscopes. The LEEP machine and
colposcope were brought by the obstetrician/gynecologist and nurse-midwife, respectively.
Rosebud Indian Hospital is a bigger and more modern facility with many different departments, a lot of
equipment, staff and supplies. We were fortunate enough to have a mammogram unit and a mammogram
technician on site. What we discovered during the program, however, was that so many women came to the
program, we really needed a second mammogram unit, another mammographer and a mammogram view
box. All were secured for the second Rosebud program, and almost twice as many patients were able to
receive mammograms.
Other Supplies
An entire list of necessary supplies and equipment necessary for the program was provided by our
medical volunteers. (See list at the end of this section.) If you base your supply and equipment list on the
CAP list, double-check with your medical volunteers to determine if they have specific preferences for
some items.
As is the case with equipment, each See, Test and Treat facility will have different supplies. You may need
to purchase some basic supplies and bring them with you. The College suggests as bare minimum bringing
supplies necessary to create the rapid stain needed for the Pap tests.
B. Program Details
B. Program Details
On-Site Program Details
There are many additional details to be addressed to implement a successful See, Test and Treat program.
The College suggests developing an agenda for the day, indicating stations for patients and how much time
is expected to elapse during the patient visit. (See example of patient flow at the end of this section.) If
patients are expected to remain at your program location for several hours, you have to think about concerns
they might have and some enjoyable activities to keep them involved and interested in completing the
program while their results are being processed.
These are some questions you might want to consider:
3 Will you hand out door prizes?
3 Will there be health-related education?
3 Will you have food and beverages for patients?
3 Will child-care be provided?
3 Will you schedule something interesting and enjoyable for the women to do while they are waiting for
their results?
3 Will you provide food for the medical volunteers for breakfast, lunch, dinner, or for all meals?
3 Will you be talking photos during the event?
Don’t try to provide too many services during the program. Focus on one or two services, such as Pap tests
and mammograms. Added services slow the process, fewer women will get through the program, and the
length of each patient’s visit will be extended.
If you plan to take photos during the event, be sure to get permission from the patients. Respect their
decisions if patient choose not to have their photo taken. (A sample release form is included in this section.)
B. Program Details
B. Program Details
The CAP Experience
During the program, women received educational materials and, of course, private health information with
their test results. We learned from the first McLaughlin program, however, not to barrage patients with
educational videos.We found that the women wanted to feel special and not lectured at or forced into a
completely scheduled day.
During the second McLaughlin event the women played bingo and won small prizes, which they really
enjoyed, while they were waiting for their results.
In Rosebud, we were fortunate that many local businesses donated door prizes for our patients. We even
had a masseuse volunteer her time to give patients foot massages!
For many women, this was an opportunity to socialize with people they knew, and relax between
appointments. The College provided food and beverages, which were purchased from a local business.
In addition, each woman who participated in both the Rosebud and McLaughlin events received a T-shirt,
specially designed for the program by a Lakota Sioux woman from the Standing Rock reservation.
Patient Follow-Up
An important aspect of the See, Test and Treat program is patient follow-up.
Each patient receives her test results and information on recommended next steps in a private setting. This
information is provided to each patient by a local nurse or other health care provider. The majority of
patients requiring follow-up will be able to receive follow-up treatment immediately. However, it is incumbent
upon the local health care providers to follow up with those who require more advanced procedures.
In many cases, program participants are patients at a local health care facility and already have a chart on
file. In those cases providers will often have a history and will be able to follow-up with the patient. For new
patients, however, a chart must be created, and the patient must be followed by local providers for purposes
of continuity of care.
The CAP Experience
Patients participating in both the McLaughlin and Rosebud programs were generally patients who had
previously received care at the respective facilities. Most were known to the local providers, so those few
who needed further follow-up after the program were carefully tracked and received necessary care.
In addition to staining and interpreting a patient’s Pap test on site, health care providers sent all slides to the
pathology group in Bismarck, North Dakota, for correlation of results. The slides were reviewed and reports
were filed as usual. The Bismarck group is the group that usually provides pathology services to both the
Standing Rock and Rosebud reservations.
Staff in Rosebud reported lasting effects of the CAP See, Test and Treat™ program. For example, several
patients who were unable to attend the program were prompted by news of the program to come in for
cervical and breast cancer screenings. Several more were prompted to come in for follow-up treatment they
knew they needed.
B. Program Details
B. Program Details
Expenses
The biggest cost for the program is travel expenses for the out-of-town medical volunteers. The more local
professionals you can recruit the better. This will not only create greater community ownership in the
program, but will also reduce your overall program expenses.
The CAP Experience
The budgets for two of the events are included at the end of this section. Note that the other big expense, in
addition to travel, was the mobile mammogram unit. If you have a mammography unit on-site, your
expenses will be reduced. To provide immediate feedback on mammograms, we needed a mobile machine
with on-board processing, which can be difficult to obtain. In the entire state of South Dakota there was only
one unit and it was six hours away. The program budget had to pay for gas and expenses for the driver and
mammographer. Using digital mammography could perhaps reduce costs, but that has not been fully
explored yet.
Although some of the supplies were provided by the local medical facility, the vast majority had to be
purchased and shipped. The more supplies that can be provided locally, the less your overall expenses
will be.
Grants
Securing grants is certainly an option. If you need a sample of a grant proposal, please contact the Public
Affairs area at the College of American Pathologists at [email protected]. It may help with the format as
you draft your own proposal. If you are working within a specific minority community, there may be grants
targeted to help serve that population.
Grant targeted specially to health concerns may also be available in your state or local community. The
Internet is a great place to start when researching grant opportunities through foundations.
Grant proposals are often due six months to one year before the grant funds are distributed, so you want to
plan ahead for this portion of the project. Preparing a grant proposal is time-consuming but truly worth it in
the end.
The CAP Experience
The CAP See, Test, and Treat™ programs were funded in part by grants from two organizations. In addition,
in-kind donations for equipment and incidentals were provided by various organizations.
B. Program Details
B. Program Details
SAMPLE – INDIAN HEALTH SERVICE Application for Initial Appointment TO MEDICAL STAFF
MEMORANDUM
Date:
To:
From:
Subject: PROFESSIONAL CREDENTIALS
The __________________________ maintains credentials files on all health care providers. This file is
updated on a regular basis to comply with the Indian Health Service and JCAHO standards. Please help
us maintain the standards of high-quality patient care by providing the Rosebud Medical Staff Credentials
Committee with the following information:
____ Copy of your current license (wallet card), which has/will expire on ________,
in the state of ______________
____ Copy of your current CPR, ATLS, ACLS. PALS, which has/will expire on _________________
____ Current health statement (attached)
____ Copies of your continuing education for 20________
____ Copy of Curriculum Vitae
____ Professional Letter(s) of Reference (3)
____ Copy of Medical Degrees
____ Copy or Residency Training
____ Copy National Board Certification
____ Copy of DEA
____ Signature on attached Statement of Understanding and Release
____ Documentation of procedures (Copy of privileges granted at other hospitals of which you were on the
medical staff; if resident, a letter from the director of the residency program indicating procedures you
were qualified to do and the number of procedures done of privileges requested
____ Completion of the attached REQUEST FOR REAPPOINMENT
Return all information in the envelope provided.
Thank you for your cooperation.
B. Program Details
B. Program Details
PLEASE TYPE OR PRINT LEGIBLY
INDIAN HEALTH SERVICE
APPLICATION FOR APPOINTMENT TO
THE MEDICAL STAFF OF
___________________________________________________________________________________________
Appointment requested: (Circle One)
as a: Physician Dentist Optometrist Audiologist Psychologist Podiatrist PA NP CNM
Other _______
1.DEMOGRAPHIC INFORMATION:
A.
Name in Full:______________________________________________________
B.
Office Address:___________________________________________________
Telephone: (_____) ____________________________
Home Address:___________________________________________________
C.
Telephone: (_____) ____________________________
D. Date of Birth:_____________ Birthplace:__________________________
E.
Citizenship:_____________________
SS#_______________________
B. Program Details
B. Program Details
2.HEALTH STATUS: Applicant is required to provide evidence of a health status statement signed by a physician stating that the applicant is mentally and physically capable of exercising the clinical privileges
requested.
A.
Note any significant physical or mental conditions; present or past drug abuse or
dependency, or chronic contagious disease that would render the applicant mentally or
physically incapable of carrying out the required functions of their medical staff role and
clinical privileges requested.
B.
Last Medical Exam:
Date:____________ Location:______________________________
C.
Examiner:
Name:________________________________________________
Address:______________________________________________
D.
Immunity Status:
Disease
Rubella
Rubeola
E.
Tuberculosis Status:
Date of Last PPD: ___________________ Result: Pos:______
If positive, explain:___________________________________________
Date of Vaccination/Titer
_________________
_________________
Titer Result
Neg:__________
B. Program Details
B. Program Details
3. PRE-PROFESSIONAL EDUCATION: If more than two schools, give information on an attached sheet.
College/University:___________________________________________
Address:____________________________________________________
Dates Attended:______________________________________________
Date of Graduation:_____________ Degree:______________________
Honors:_____________________________________________________
Address:____________________________________________________
Dates Attended:______________________________________________
Date of Graduation: _____________Degree:______________________
Honors:_____________________________________________________
4. PROFESSIONAL EDUCATION: If more than one school, identify and explain on a separate sheet.
Address:____________________________________________________
Date of Graduation:______________Degree:______________________
Honors:_____________________________________________________
5.INTERNSHIP: (or other single postgraduate year)
Hospital/Location:____________________________________________
Address:____________________________________________________
Type/Specialty:__________________Dates:_______________________
B. Program Details
B. Program Details
6.RESIDENCIES: Fellowships, Preceptorships, Postgraduate Education, Teaching Appointments
(most recent first)
Hospital/Location:___________________________________________
Address:___________________________________________________
Type/Specialty:________________
Dates:______________
Address:___________________________________________________
Type/Specialty:________________
Dates:______________
Address: ___________________________________________________
Type/Specialty:_______________ Dates:______________
7.SPECIALTY BOARDS:
CERTIFIED
DATE
A.________
A.________
B.________
B.________
RECERTIFIED
C.________
C.________
DATE
D.________
D.________
8. PROFESSIONAL LICENSURE (Certification, registration): List all jurisdictions in which you currently hold
or have ever held a professional license; continue on a separate sheet if more than three:
STATE
NUMBER
A.________
A.________
A.________
B.________
B.________
B.________
EXPIRATION DATE
C.________
C.________
C.________
9.DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBER:________
B. Program Details
B. Program Details
10. AFFILIATIONS: List all present and previous clinical practice affiliations. Include all work experiences
at IHS, Tribal, or Urban Indian health care facilities.
A.
Individual/Group:
Name:________________________________________________________
Address:______________________________________________________
Nature/Position:_________________________Dates:________________
Name:________________________________________________________
Address:______________________________________________________
Nature/Position:_________________________Dates:________________
Hospital/Medical Staff: Include military or other Federal or State Government services:
B.
Name:_____________________________________________________
Address: ___________________________________________________
Position/Title: __________________________ Dates:_______________
Name:_______________________________________________________
Address: _____________________________________________________
Position/Title: __________________________ Dates:__________________
Name:__________________________________________________________
Address: ________________________________________________________
Position/Title: __________________________ Dates:____________________
11. MEMBERSHIP IN PROFESSIONAL SOCIETIES:
A._______________________________________________________
B._______________________________________________________
C._______________________________________________________
B. Program Details
B. Program Details
12. PROFESSIONAL REFERENCES:
The names, mailing addresses, and telephone numbers of at least three (3) individuals are required.
Name:_______________________________________________________
Address:_____________________________________________________
Telephone: (________) _______________________________________
Name:_______________________________________________________
Address:_____________________________________________________
Telephone: (________) _______________________________________
Name:_______________________________________________________
Address:_____________________________________________________
Telephone: (________) _______________________________________
Note: Written information from three references is required before action can be taken on this application.
For those in training, one reference must be from the director (Chief of Service) of the training program. For
other applicants, who are currently members of one or more medical staffs, one letter must be from where
the applicant is on the active medical staff. Information will be requested regarding professional judgment,
competence, and personal character. References will be evaluated based on the extent of direct work with the
clinical observation of the applicant.
13. CONTINUING PROFESSIONAL EDUCATION:
Describe topics, sources, and dates of all continuing education you have completed in the last three years
and a professional recognition certificate received, if applicable (a summary sheet may be attached).
14. CARDIOPULMONARY RESUSCITATION TRAINING:
Current training and certification in Cardiopulmonary Resuscitation (CPR), basic life support, is highly
desirable for all professionals involved in direct patient care. The CPR training will be required of some in
accordance with medical staff bylaws, particularly of physicians, dentists, and optometrists.
A.
I have had no CPR Training within the past year. ___________________
B.
I am certified in basic life support?
C.
I am certified in advanced cardiac life support?
______ expires:__________
______ expires:_______
D.
I am certified in advanced trauma life support? _______expires: _______
E.
I am certified in pediatric advanced life support? ______expires: _______
B. Program Details
B. Program Details
15. LIABILITY INSURANCE: (List current carrier first and any other carriers for the past 10 years –
continue on a separate sheet if necessary)
Carrier:_____________________ Amount of Coverage:__________
Agent:______________________ Policy No.:__________________
Expiration Date:____________________________________________
16. LIABILITY CLAIMS AND ADVERSE ACTION:
If your answer to any of the following is “yes,” please provide full details on an attached separate sheet or in the blank section that follows:
A.
Have liability claims been filed against you, or against a hospital, other health care entity,
corporation, or government, based on a case under your care?
YES:_________________
NO:___________________
B.
Have judgments or settlements been made involving you or against a hospital, corporation,
or government based don a case under your care?
YES:_________________
NO:___________________
C.
Have you ever had, or are you about to have, your professional liability insurance declined,
cancelled, issued on special terms, or refused for renewal?
YES:_________________
NO:___________________
D.
Has your professional license (certification or registration) to practice in any jurisdiction ever
been limited, placed in probationary status, restricted, suspended, denied, revoked,
voluntarily surrendered, or not renewed:
YES:_________________
NO:__________________
E.
Have you ever been censured or reprimanded by a licensing (certifying, etc.) board, hospital
medical staff, professional society, or other professional society, or other professional
organization?
YES:_________________
NO:__________________
F.
Have you ever been refused membership on a medical, dental, or other professional staff?
YES:_________________
NO:__________________
G.
Have any or all of your privileges at any health care facility ever been or are about to be
limited, reduced, suspended, revoked, voluntarily surrendered in the course of an
investigation, or not renewed? Have you resigned from a medical staff because of concern
that your privileges might have been limited, suspended, or revoked? Have any other
professional disciplinary actions been taken against you?
YES:__________________
NO:__________________
H.
Has your narcotics registration, Federal or State, ever been denied, limited, suspended,
voluntarily surrendered, not renewed, or revoked?
YES:__________________
NO:__________________
B. Program Details
B. Program Details
I.
Have you ever been denied membership, or renewal thereof, or been subject to disciplinary
action in any professional society or organization?
YES:__________________
NO:__________________
J.
Have any civil or criminal charges ever been filed against you, or are you under an
investigation that might lead to such charges?
YES:__________________
NO:__________________
K.
Have you ever been sanctioned by Medicare or a Medicaid program, or by any other
Federal agency?
YES:__________________
NO:__________________
L.
Are you currently involved in or have knowledge of a pending investigation, review, or
surveillance of your professional practice or conduct that could result in an adverse action concerning your ability to bill and collect from Medicare or Medicaid programs; your
narcotics registration; your professional license registration or certification; or your medical
staff membership or privileges?
YES:___________________
NO:__________________
B. Program Details
B. Program Details
I agree to abide by all lawful standards, policies, and rules of the facility, the Area, the Indian Health
Service, the US Public Health Service, and the Department of Health and Human Services as they
apply to my responsibilities and practice as a member of this medical staff. I pledge to maintain
an ethical practice and to provide for the continuous care of all my patients. I further agree to
immediately disclose to the medical staff and/or governing body more detailed information related
to all “yes” responses in Section 16 of this application, if asked to do so. In addition, I agree to
immediately report to the Clinical Director any new information concerning a “yes” response or
concerning a response that becomes “yes” after filling out this medical staff application, either while
medical staff membership and/or privileges are pending or after they have been granted.
Applicant’s signature:________________________ Date:______________
B. Program Details
B. Program Details
STATEMENT OF UNDERSTANDING AND RELEASE (To be signed by all applicants)
By applying for appointment to the medical staff, I signify my willingness to appear for interviews in regard to my application and authorize Indian Health Service (IHS) representatives to consult with
administrators and members of medical staffs of other institutions with which I have been associated
and with others (including past and present insurance carriers, state licensure boards, etc.) who may
have information bearing on my professional competence, character, and ethical qualifications. I
further consent to the release/disclosure to this facility’s professional staff and IHS representatives of
all personnel, professional, and personal medical records and documents (including alcohol and
drug abuse records at other institutions) that may be material to an evaluation of my professional
qualifications and competence to carry out the clinical privileges requested, as well as my moral and
ethical qualifications for staff membership.
I further consent to the disclosure, by authorized IHS representatives, or records of my professional service with IHS relating to my personal character and professional qualifications and competence to
carry out the clinical privileges granted to me by this IHS facility. This information may be disclosed
to any subsequent practitioner(s), facility, State or county medical society, or licensing board to
whom or to which I may apply for clinical privileges, membership, or licensure. This may include
information regarding drug or alcohol abuse or dependency. At such time, completion of the form:
“Authorization for Release of Information,” Form No. HRSA-810, will be requested. I fully under
stand that a false answer to any question in this application, or the misrepresentation of information
otherwise provided, may constitute cause for denial/revocation of medical staff appointment and/or
imprisonment (U.S.C., Title 18, Section 1001).
I certify that the statements/documents that I have made/provided in this application are true,
complete, and correct to the best of my knowledge and belief and are made in good faith.
I hereby release from liability all representatives of the Federal Government for their acts performed
in good faith and without malice in connection with evaluating my credentials and qualifications, and
I hereby release from any liability any and all individuals and organizations who provide
information to these representatives in good faith and without malice concerning qualifications for the
medical staff and any applicable clinical privileges.
I agree to abide by the bylaws, rules, and regulations of the medical staff.
Signature:_________________________________Date:_____________
B. Program Details
B. Program Details
REQUEST FOR APPOINTMENT
I hereby apply for appointment to the ________________category of the medical staff, and will
request privileges from that category. (The privilege request form will accompany or follow this
application.)
Applicant’s Signature:________________________ Date:_____________
RECOMMENDATIONS AND APPROVALS FOR MEDICAL
STAFF ADMISSION
1.DISCIPLINE-SPECIFIC SUPERVISOR OR CONSULTANT
____________________ has completed the application process for admission to the Medical Staff.
I do______; do not______recommend appointment to the Medical Staff.
Comments:__________________________________________________
___________________________________________________________
Signature______________________ Date__________________
2. CLINICAL DIRECTOR
I do______; do not______recommend appointment to the Medical Staff in the following category (select only one):
______provisional
______active ______temporary
______courtesy
Comments:__________________________________________________
___________________________________________________________
Signature______________________ Date__________________
3.SERVICE UNIT DIRECTOR
I do_________; do not______recommend appointment as noted above.
Comments:__________________________________________________
___________________________________________________________
Signature______________________ Date__________________
4. CHAIR, SERVICE UNIT GOVERNING BODY
Appointment is _______________is not_______________approved.
Comments:_____________________________________________
Signature:______________________Date:____________________
B. Program Details
B. Program Details
MEDICARE AGREEMENT
It is required that all physicians treating Medicare patients sign the following statement annually. This applies to all physicians at this facility.
NOTICE TO PHYSICIANS: Medicare payment to hospitals is based in part on each patient principal and secondary diagnoses and the major procedures performed on the patient, as attested to by the
patient’s attending physician by virtue of his or her signature in the medical record. Anyone who
misrepresents, falsifies, or conceals essential information required for payment of Federal funds may
be subject to fine, imprisonment, or civil penalty under applicable Federal laws.
Applicant’s Signature:___________________________ Date:_____________
B. Program Details
B. Program Details
HEALTH STATEMENT
ROSEBUD SERVICE UNIT
MEDICAL STAFF
Print Name
___________________________________________________________________________________________
Please note any significant physical problems. (If none, write none)
Indicate any hospitalizations in the past five years and reason for being hospitalized.
Last Physical Exam
Date_______________________Location______________________________
Examiner_________________________________________________________
Address__________________________________________________________
Current medications:________________________________________________
Current therapy: ___________________________________________________
I hereby certify that I have no health conditions which could affect my practice.
Applicant Signature__________________________________Date__________
Confirming Signature
Signature___________________________________________Date__________
(For Appointment/Initial Privileges: Training Program Director, Chief of Service, Chief of Staff,
designated licensed physician; Re-appointment: CD) (MS 5.4.3)
B. Program Details
B. Program Details
SAMPLE – INDIAN HEALTH SERVICE pathology privileges request form
PATHOLOGY PRIVILEGES REQUEST FORM
INTRODUCTION:
The Pathology Privileges Request Form must be accompanied or preceded by a complete application
for medical staff appointment, including the necessary supporting documents. Many clinical
privileges pertinent to the practice of pathology are listed below. The request for privileges must
reflect both the applicant’s and the facility’s/staff’s ability to carry out or support the various
functions. Documentation of training and/or experience in performing various procedures/
modalities must accompany this request. Any additional privileges may be requested on the form or
may be presented in an attached list.
INSTRUCTIONS FOR COMPLETING THE FORM
APPLICANT:
With a check in the appropriate location, indicate for each item whether you are requesting LIMITED
or FULL privileges. LIMITED means that any applicant may function in the area of the stated clinical
privileges only under the direct supervision of a provider holding FULL privileges. FULL means that
the applicant is entitled to function independently, following standards consistent with the medical
community at large. Be sure to sign the request as indicated on page __.
DISCIPLINE SPECIFIC SUPERVISOR OR CONSULTANT
Indicate your recommendation for each requested clinical privilege by placing a check mark in the
appropriate location for either FULL, LIMITED, or NOT recommended (NR). Please explain any
recommended limitations or denial of privileges on an attached sheet. This recommendation is
considered by the governing body when granting or not granting privileges.
B. Program Details
B. Program Details
PATHOLOGY PRIVILEGES REQUEST FORM
1. I hereby request the clinical privileges as indicated on the forms attached.
_________________(Applicant)
2. I hereby recommend the clinical privileges as indicated.
_________________(Supervisor/Consultant) ________________(Date)
3. As chairperson of the Medical Staff Executive Committee, I hereby recommend the clinical
privileges: (Check one)
_____ As noted
_____ With the following exceptions, deletions, additions, or conditions:
_________________(Clinical Director)
4. I hereby recommend the applicant for clinical privileges.
_________________(Service Unit Director)
5. Privileges are hereby granted: (Check one)
_____ As noted
_____ With the following exceptions, deletions, additions, or conditions:
_________________(Chairperson of Governing Body) _________(Date)
________________(Date)
________________(Date)
________________(Date)
B. Program Details
B. Program Details
1. Autopsies: Non-Forensic
Ltd
Full
NR
Ltd
Full
2. Intraoperative surgical pathology
3. Surgical pathology: microscopic examination,
gross examination, and diagnosis with report
4. Cytology: microscopic examination and diagnosis
with report
5. Fine-needle aspiration and biopsy: microscopic
examination & diagnosis w/report
6. Bone marrow aspirate and biopsy: microscopic
examination and diagnosis with report
7. Muscle biopsy: light microscopic examination and
diagnosis with report
8. Muscle biopsy: light microscopic immunocytochemistry
and for electron microscopic examination
and diagnosis
9. Renal biopsy: light microscopic examination and
10.Renal biopsy: light microscopic, electron microscopic,
immunocytochemistry examination
11.Neuropathology: light microscopic examination and
12.Cytogenetic studies on tissues
13.Forensic pathology
14.Open lung biopsy: light microscopic examination
and diagnosis with report
15.Open lung biopsy: light microscopic, electron
microscopic, and/or immunohistochemistry
examination and diagnosis with report
16.Hematology and coagulation
17.Immunohematology consultation
18.Clinical chemistry consultation
19.Medical microbiology and parasitology consultation
20.Medical microscopy consultation
21.Serology and general immunology consultation
B. Program Details
B. Program Details
SAMPLE – Pap Test Result Form
Example
Pap Test Result Form
Patient Name
Date of Birth
Pap Result
B. Program Details
B. Program Details
SAMPLE – Mammography Log
Name
HX#
Exam
Radiologist
Diagnosis
Follow-Up
B. Program Details
B. Program Details
SAMPLE – Event News Release
FOR IMMEDIATE RELEASE
Contact: [Insert Contact Name and Phone Number]
[Insert Date]
Free Upcoming Program Scheduled to Help Remove Barriers
to Early Cervical and Breast Cancer Diagnosis for Local Women
MINNEAPOLIS, MN – A free “See, Test and Treat” breast and cervical cancer screening program will be
held at the Community Center of Excellence in Women’s Health at NorthPoint Health and Wellness Center in
Minneapolis, Minn. on May 13, 14 and 15. Appointments are being scheduled from 8:30 am to 4:00 pm
on May 13 and 14 and from10:30 am to 4:00 pm on May 15 by area community health representatives
and other staff members.
Language interpreters will be onsite to help patients on Wednesday, May 14 (Spanish) and on Thursday,
May 15 (Hmong). To register, call 612-302-4738 (English), 612-348-4711 (Spanish), and 612-287-2121
(Hmong). Walk-ins are also welcome.
“Cancer survival rates are directly related to the stage of the disease at the time of diagnosis, so it’s impor
tant to remove all barriers to early diagnosis and treatment for all women,” said Brad Linzie, MD, FCAP,
a pathologist at Hennepin County Medical Center in Minneapolis. “This ‘See, Test and Treat’ program will
provide immediate breast and cervical cancer diagnosis and follow-up for local women who are uninsured
or underinsured.”
This is the third See, Test and Treat event at the NorthPoint Health and Wellness Center and the seventh
such program held throughout the country. The first was held in McLaughlin, South Dakota, in
October 2001.
The College of American Pathologists (CAP) supports efforts to expand cervical cancer screening
programs to include currently underserved populations of women in the United States.
B. Program Details
B. Program Details
SAMPLE – Event News Release (continued)
The College also recognizes that lack of access to health care for low-income adults and children is a
significant societal problem, especially as it relates to important diagnostic and screening tests and tests
related to disease treatment. As an organization of physicians acutely interested in the well-being of patients,
the CAP supports efforts, such as the See, Test and Treat events, to find balanced, realistic and achievable
means to expand health care coverage to uninsured Americans.
During the See, Test and Treat visit in May, women will be given a pelvic exam, along with a Pap test to
detect any potential early signs of cervical cancer, and a mammogram for early detection of breast cancer.
They will then receive their Pap test results immediately in a private setting, and if any follow-up is needed,
will receive appropriate information or treatment during the same visit. Mammogram results will be provided
following the event.
Traditional screening procedures would have women visit health care professionals twice for a Pap test—
once to get examined and once for follow-up care. Factors such as poor access to transportation, lack of
childcare, inability to take time off from a job, and other issues present barriers to women in getting the care
they need.
“By removing these barriers and using a one-stop, See, Test and Treat model of cancer screening, we
hope to reduce the rate of cancer in women in this area,” Dr. Linzie said.
Pathologists recommend that any woman who is older than 21 or who is sexually active should have
regular Pap tests. The Pap test is a quick and simple procedure that could change a woman’s life. If a woman
is 30 years of age or older, it is also appropriate for her to have a human papillomavirus (HPV) test.
In addition, the CAP agrees with the recommendations of the American Cancer Society that all women
40 years and older should have annual mammograms, based on their physician’s recommendation.
B. Program Details
B. Program Details
SAMPLE – Event News Release (continued)
While all women 20 and older should conduct a breast self-exam every month, women between the ages
of 20 and 39 should have a clinical breast exam every three years and should begin having clinical breast
exams every year when they turn 40.
See, Test and Treat is sponsored by the College of American Pathologists, the National Community Center
of Excellence (CCOE) on Women’s Health at NorthPoint Health and Wellness Center, Department of Health
and Human Services Office on Women’s Health, and a coalition of pathologists, cytotechnologists, and other
medical professionals in the Minneapolis area. The goals of the program are to encourage healthy behavior,
and to have both testing and follow-up done in a single visit.
The “See, Test and Treat Single Visit Cervical and Breast Cancer Prevention Program” is funded by the
College of American Pathologists and the National Community Center of Excellence (CCOE) on Women’s
Health at NorthPoint Health and Wellness Center.
Cytyc, a Hologic Company, is donating the Thin Prep machine and supplies. Local businesses will provide
small gifts for all women who participate in the program.
The College of American Pathologists is a medical society that serves more than 17,000 physician
members and the laboratory community throughout the world. It is the world’s largest association composed
exclusively of pathologists and is widely considered the leader in laboratory quality assurance. The CAP is
an advocate for high-quality and cost-effective medical care.
###
B. Program Details
Date
With grateful appreciation for your participation
in the College of American Pathologists/
NorthPoint Community Center of Excellence
See Test & Treat™ program
Name, MD, FCAP
B. Program Details
SAMPLE – See, Test and Treat certificate
B. Program Details
B. Program Details
SAMPLE – Supplies and Equipment
CAP See, Test and Treat™ Program
Supplies & Equipment
Equipment
Microscopes (4x,10x, and 40x, objectives)
LEEP equipment
Cryosurgery equipment
Liquid-based cytology processor (if applicable)
Mammogram unit w/ on-site processing capabilities
Mammography view box
Portable ultrasound equipment
Pathologists
For FNAs
10cc syringe pistol
1 box of 10cc syringe
25 gauge needle
Gloves (2 boxes) – latex free, powder free, hypoallergenic, size medium
4 x 4 gauge
Band-aids
Diff Quick solution
80% alcohol or other fixative as requested by cytotech for preparation of slides
Pap stain
For Pap Tests
Lens cleaner (liquid, in bottle), Lens paper
Slide labels
Scotts tape
Filters for stains
Quick stain – 12 bottle stain rack
Gauze (useful for coverslipping)
Slide trays
Extra microscope light bulbs (in case they blow out),
Microscope for screening slides
B. Program Details
B. Program Details
SAMPLE – Supplies and Equipment (continued)
Cytotechnologists
Supplies needed for processing Paps and breast FNAs
Gloves – one box small, one box medium
Glass slides – 4 boxes (2 gross)
Coverslips 24 x 50 – 4 boxes (4 oz)
Mounting media – any xylene/toluene based (not aqueous)
Access to sink and tap water
Stains:
Gill II Hematoxylin – 1 pint
EA-65 (or EA-50) – 1 pint
OG-G – 1 pint
Diff-Quik 3 stain set
95% alcohol – 3 gal.
Absolute alcohol – 1 pt.
Xylene – smallest container available
30 Coplin jars (50-ml) or other small glass jar (use for staining AND wet fix specimen collection)
Slide folders
Dotting pens
Obstetrician/Gynecologists
Required supplies and equipment for pap smears, colposcopy and Leep
Medium powder free gloves
Medium Graves speculum
Frosted VCE slide
Cytology brush
Wooden cervical spatula,
Cytology fixative spray
KY jelly for the vaginal exam
Size medium powder free gloves.
Rectal swabs
Thin prep preservative fluid
5% acetic acid
B. Program Details
B. Program Details
Obstetrician/Gynecologists
Required supplies and equipment for Pap tests, colposcopy, and LEEP
Lugol’s solution -pour into plastic med cup
Hurricaine liquid topical anesthetic
Tischler’s-Morgan 7mmx3mm biopsy forceps
Endocervical curette
Bozeman’s tissue or Ring forceps
2-3 formulin bottles for the separate biopsy specimens with labels
Monsel’s paste
Chux
Punch biopsy
.25% marcaine for papacervicals
95% ethanol bottles to dip them
gc/chlamydia tests
Surgilube packets
Hemocult boards
Normal saline drops
KOH drops
Endometrial pipettes
Surgical mask
Ground pad for the LEEP machine
Special plastic coated speculum
Big Q tips, (Scoppets) for colposcopy
1% Lidocaine with Epinephrine in 10 ml syringe
alcohol pad
Needle to draw up lidocaine
18-22 gauge spinal needle to inject into cervix
Extender for the LEEP hand control pencil
4 sizes of loops- we use the UTAH company and the colors are green, yellow, beige, and white
Ball-tip cautery
Sanitary napkin for patient post procedure
B. Program Details
B. Program Details
SAMPLE – Quick Stain Process for Pap Tests
Quick Stain Process for Pap Tests
70%
Water
Hematoxylin
Water
70%
95%
OG
95%
95%
EA
95%
95%
100%
Xylene
10 dips
10 dips
30 seconds
10 dips
10 dips
10 dips
30 seconds
10 dips
10 dips
2 minutes
10 dips
10 dips
10 dips
1 minute
B. Program Details
B. Program Details
SAMPLE – Patient Flowchart
Patient Flowchart
REGISTRATION
LOBBY
PHYSICAL EXAM
SCREENING ROOM AND EXAM
ROOM (when called)
Pap Test needed
____ yes
____ no
Mammogram needed
____ yes
____ no
MAMMOGRAM
BINGO/REFRESHMENTS
EDUCATION/RESULTS
X-RAY ROOM
CONFERENCE ROOM
DOCTOR’S OFFICE/SOCIAL
SERVICES
B. Program Details
B. Program Details
SAMPLE – Patient Photo Release Form
Release
I hereby release, discharge, and agree to hold harmless the College of American Pathologists, the
photographer, his representatives, and any persons acting under his permission or authority. I
acknowledge that these photographs may be used for media purposes.
Date_____________________________________________
Signature__________________________________________
B. Program Details
B. Program Details
SAMPLE BUDGET – October 2001
Cost/Unit
# of Units
Project Budget
Actual
I. Personnel:
Salaries
Project Coordinator
Benefits and Taxes
Professional Fees:
Cytotechnologist
2 needed*
3
Gynecologist
2 needed*
1 OB/GYN; 1
Nurse Midwife
Pathologist
2 needed*
2; plus project
leader
Radiologist
2 needed*
1
Nurses
3 needed (will be
locally provided)
3
Mammogram Nurses
2 needed*
—
Nurse Practitioner
3 needed*
1
Educator
2 needed
1
Receptionist
2 needed
(1) Staff
coordinator
II. Operating
Expenses:
Insurance
Telephone
Postage/Shipping
Copying/Printing
Supplies:
Pap Disposables
(slides, fixative,
speculums, biohazard
bags, gowns, table
rolls, cytobrushes)
$2,095.56
LEEP Disposables
N/A
Printed Materials
(Intake Forms,
Consent Forms, Patient
Satisfaction Surveys,
Educational
Materials)
N/A
B. Program Details
B. Program Details
SAMPLE BUDGET – October 2001 (continued)
Cost/Unit
# of Units
Project Budget
Actual
III. Equipment
Colposcope
1 needed
Donated
LEEP machine
Donated
View boxes
Donated(3)
Microscope
Donated(3)
Mammogram
machine
$1,662.52
Education Materials:
Video
Donated
Brochures
Donated
Meeting Expenses
Air Travel
Approx. $400 RT 13 people
(average sample
price) based on
LA to Rapid City
with Saturday stay
$5,200
$3,706.02
Local Transportation
$100 economy
rental car for 3
days
13 cars needed for
3 days
$1,300
*added into
participant’s
expenses which are
captured in “meal
allowance” section
Housing Costs
$50-$60/night
*13 people/
2 nights
Meal Allowance
Breakfast: $10
Lunch: $20
Dinner: $30
Total: $60 per
person
3 days/
13 people
Breakfast: $30
Lunch: $60
Dinner: $90
Total per person:
$180
Total: $2,340
* $1,390.25
includes food and
rental car
expenses for
participants
Accounting and Legal
Fundraising
B. Program Details
B. Program Details
SAMPLE BUDGET – October 2001 (continued)
Cost/Unit
# of Units
Project Budget
Actual
Food – per session
$100
2
$200
$200
Food – per outreach
session
$50
4
$200
––
Promotional t-shirts
$8
100
$800
$1,000 *
Total invoice for
t-shirts/sweatshirts
was $2,988.30,
divided between
three events
Door prize
$10
14
$140
$140
Newspaper article(s)
No cost
1-2 articles
No cost
Promotion/Publicity/
Outreach:
Other
Photography
Total Expenses
$240.28
$11,990
$11,875.49
* = assumes these people would not be local and would have to be brought into the area.
B. Program Details
B. Program Details
SAMPLE Budget – June 2002
Cost/Unit
# of Units
Grant Supported
Costs
Total Costs**
Cytotechnologist
N/A
3 needed*
N/A
3 CAP-recruited volunteers
Gynecologist
N/A
3 needed*
N/A
2 CAP-recruited volunteers,
1 Rosebud volunteer
Pathologist
N/A
4 needed*
N/A
4 CAP-recruited volunteers
Radiologist
N/A
1 needed*
N/A
1 CAP-recruited volunteer
Nurses
N/A
6 needed
N/A
6 Rosebud
employees/volunteers
Mammo Technician
N/A
1 needed
N/A
1 Rosebud
employee/volunteer
Nurse-Midwife
N/A
1 needed*
N/A
1 CAP-recruited volunteer
Physician Assistant
N/A
1 needed
N/A
1 Rosebud
employee/volunteer
Educator
N/A
3 needed
N/A
1 CAP-recruited volunteers;
2 Rosebud employee/
volunteers
I. Personnel:
Receptionist
2 needed
2 Rosebud employee/
volunteers
Rosebud Staff
Coordinator
1 needed
1 Rosebud employee/
volunteer
Pap Disposables
On Site
N/A
LEEP Disposables
On Site
N/A
Printed Forms
On Site
N/A
Colposcope
On Site
N/A
LEEP machine
On Site
N/A
Microscope
On Site
N/A
Mammo Machine
On Site
N/A
Prior Purchase
N/A
II. Operating
Expenses:
Supplies
Equipment
Education
Materials
Video
$100
B. Program Details
B. Program Details
SAMPLE Budget – June 2002 (continued)
Cost/Unit
# of Units
$200
Prior Purchase
Air Travel
Varied
8 persons
$2,419
$3,219
Ground Transport
Varied
4 persons
$800
$1060
Local Transport
Varied
14 persons
$1,089
$2,239
Housing Costs:
Hotel
$100/person
14 persons
$1,404
$1,923
Meal Allowance
$60 per diem
13 persons X 5
days
$300
$1,335
Food for
participants
$150/day
2
$300
Promotional t-shirts
$80
100
$800
Door Prizes
Unknown
14
Donated by local
businesses
Public Service
Announcements
No cost
multiple
No cost
Newspaper
article(s)
No cost
1-2 articles
No cost
Brochures
Grant Supported
Costs
Total Costs**
N/A
III. Meeting
Expenses
IV. Promotion,
Publicity, and
Outreach:
Total Expenses
$6,012
$10,876
B. Program Details
C. How Can the CAP Help?
HOW CAN THE COLLEGE OF AMERICAN PATHOLOGISTS HELP?
The CAP See, Test and Treat™ program, developed by the College of American Pathologists, serves as an
important template for the development of a health care delivery model to reach underserved populations
that emphasizes comprehensive, single-visit services.
The success of this program depends on many elements, but especially upon the quick turnaround time of the
tests provided by the laboratory team of pathologists and medical technologists.
Working in Partnership
If you decide to work in partnership with the College to develop and implement a CAP See, Test and Treat™
program, the College will provide support in a variety of ways.
3 The College will provide you with names of local pathologists and cytotechnologists who may be
interested in volunteering for your program.
3 The College will assist you in securing donations of necessary medical equipment.
3 The College will also provide guidance to generate media attention for your event, including developing
a press release, radio announcements, and arranging radio interviews for participating pathologists.
3 The College will provide CAP See, Test & Treat™ T-shirts to be given to all program patients and
volunteers.
3 College staff will serve as a resource as you take the lead in the development and implementation of
the program.
Working Independently
If you choose to develop your own independent See, Test and Treat program, the College will be happy to
provide a See, Test and Treat manual to guide your efforts and will be available to answer questions you
may have. However, the College’s name will not be associated with the program and we will not provide
additional staffing support.
C. How Can the CAP Help?
D. Other Screening Options
Can the See, Test and Treat Model Be Employed
to Address Other Screening, Testing, and Follow-up
Care for Other Underserved Populations?
The See, Test and Treat program model is adaptable to provide needed services to any underserved
population of men, women, or children in a variety of different locations. The program is adaptable to
providing other types of screening and follow-up services or other types of patient care.
If your organization is interested in providing other health care services to an underserved population,
the College will work with you to determine the necessary laboratory requirements in order to expedite
processing and diagnostic interpretation to provide same-day results and follow-up treatment.
Please contact the CAP Public Affairs area at [email protected] with any questions.
D. Other Screening Options
Staff Contact Information
Sandra B. Grear
Vice President, Membership and Professional Development
College of American Pathologists
325 Waukegan Road
Northfield, IL 60093
847-832-7536
[email protected]
Julie Monzo
Senior Manager, Public Affairs
325 Waukegan Road
847-832-7538
[email protected]
Carolyn Barth
Manager of Spokespersons and Member Communications
325 Waukegan Road
847-832-7185
[email protected]

Table of Contents

Transcription

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