Cervical screening QI module
About this module
Research shows that strong primary health care involvement is associated with greater cervical cancer screening participation rates. Specifically, the following primary health care activities have led to higher participation rates:
- Taking a patient centred approach; knowing your patient population, those at high risk and those under or never screened.
- Taking an all of practice approach involving the whole team in activities; practice admin, practice nurses and GPs.
- Having a GP encourage patients to undertake screening.
- Utilising recall and reminder systems.
- Participating in quality improvement programs, including audits and feedback cycles.
Watch the videos
Learn more about cervical screening in primary care and view the instructional video on how to use this module.
- Cervical Screening: a quick reference guide (PDF) to help you get started
- Cervical Screening: QI activity - level 1 (PDF)
- Cervical Screening: QI activity - level 2 (PDF)
- Cervical Screening: QI activity - level 3 (PDF)
- An overview of cervical screening
- Patient centred care
- Team approach
- Quality Improvement
- Data and systems
Contact us: email@example.com
An overview of cervical screening
- The National Cervical Screening Program (NCSP) identifies women and people with a cervix at increased risk of eventually developing cervical cancer, so they can be monitored and treated appropriately.
- The National Cancer Screening Register (NCSR) supports the operations of the NCSP by providing a secure, confidential register of screening records. See further information in data and systems.
- The Cervical Screening Test looks for the presence of human papillomavirus (HPV). In nearly all cases, an HPV infection that does not clear up is the first step in the development of cervical cancer1.
- By detecting HPV in women and people with a cervix who aren’t aware they have the infection, cervical screening prevents the development of cervical cancer and saves lives.
Eligibility for cervical screening
The Cervical Screening Test is recommended every 5 years for women and people with a cervix aged 25 to 74 who have ever been sexually active. This includes those who have had the HPV vaccine as the vaccine does not protect against all types of HPV that can cause cervical cancer.
Cervical screening is for women and people with a cervix:
- both HPV-vaccinated and unvaccinated
- who have and who have not been sexually active for a long time
- who have had sex with many partners or who have only had sex with one partner
- who have been sexually active with men and/or women
- who have an intact cervix and have ever been sexually active
It does not matter if they are straight, gay, lesbian, bisexual, trans, queer or intersex, or who they have had sex with. “Women and people with a cervix” is used throughout this module to include all of these people.
Women and people with a cervix are invited to take an exit screen from age 70 to 74. If the result is negative (no HPV found), then they can safely exit the program.
- More than 70% of cervical cancers occur in women who have never screened or are lapsed screeners.
- Almost all cervical cancers are caused by human papillomavirus (HPV).
- around 1 in 200 women will develop cervical cancer before the age of 85.
Patient centred care
Knowing your patient population is essential to delivering patient-centred care. Having supportive systems and accurate information in clinical software is key to effectively identifying at-risk patients, so that you can ensure information is tailored and care is responsive to people’s individual needs and preferences.
Populations with lower levels of participation in cervical screening can experience higher cancer incidence and mortality.2,3,4 There are various community groups who are less likely to participate in cervical screening including:
- Aboriginal Communities
- Culturally and linguistically diverse communities
- People with disability
- People of Diverse Genders and Sexualities
- People who live very remotely
- People in the lowest socioeconomic (SES) group
Other people who may also be less likely to screen include:
- People that have experienced sexual violence
- People who have had previous negative cervical screening experiences.
Tips to promote and encourage cervical screening among under-screened patients
- Understand your under-screened patient population by cleaning up your practice data and seeking support from your PHN. This will help you decide which population group/s your practice will prioritise.
- Seek patient feedback to understand what prevents them from participating in cervical screening and the actions your practice can take to promote cervical screening as being safe, as comfortable as possible and accessible for patients. The RACGP Patient feedback guide provides a comprehensive guide on methods for collecting and acting on patient feedback.
- Discuss cervical screening self-collection with eligible people who decline to have a clinician-collected sample taken.
Case study: The Victorian Self-Collection Pilot Project
The Victorian Self-collection Pilot Project was a 12-month project conducted in three health services that support women experiencing disadvantage from a range of backgrounds.
The project evaluation report found that5:
- offering self-collection in a clinical setting was largely embraced by under-screened women
- a participation rate of 85.7% was achieved in the pilot
- self-collection was an acceptable and welcome alternative to a practitioner-collected cervical screening test
- under-screened women are likely to be experiencing multiple circumstantial and sociocultural barriers to cervical screening that are unlikely be overcome simply by the introduction of a new test
- health care providers need to have strong cultural competency and a good understanding of their local communities
Community-specific information and resources
Refer to the National Cervical Screening Program Toolkit for engaging under-screened and never-screened women which outlines the barriers to cervical screening for focus populations and strategies to engage with these communities.
Cervical screening resources for each of the focus populations are listed below.
- National Cervical Screening Program - Aboriginal and Torres Strait Islanders resources – posters, brochures and factsheets about cervical screening available in different Aboriginal languages.
- Cancer Institute NSW cervical screening information for Aboriginal women
- Cancer Institute NSW ‘What is cancer screening?’ (PDF) factsheet and brochure for Aboriginal communities explaining bowel, breast and cervical screening.
- South Eastern Sydney Local Health District ‘When’s Bub due?' poster (PDF) and video promoting the safety of cervical screening during pregnancy to Aboriginal communities.
- National Cervical Screening Program – translated resources – booklets, brochures and fact sheets about cervical screening in different languages.
- Cancer Institute NSW ‘Cervical Screening – taking care of your health’ flipchart and facilitator manual which are educational tools to support those providing information on cervical cancer and cervical screening to women from multicultural backgrounds.
- Cancer Institute NSW ‘What is cancer screening?’ factsheets and brochures explaining bowel, breast and cervical screening in different languages.
- South Eastern Sydney Local Health District resource promoting the safety of cervical screening during pregnancy (PDF) in multiple languages, including a specific poster (PDF) for the Mongolian community.
- Family Planning NSW cervical screening videos and brochures in different languages.
- Video resources funded by the Cancer Institute NSW and created by Metro Assist Inc, a non-government organisation, are available in Arabic, Bangla, Chinese, Hindi, Indonesian, Urdu and Vietnamese.
Do any of your patients need or prefer to speak languages other than English?
Access an interpreter through the Translating and Interpreting Service (TIS National) Doctors Priority Line on 131 450.
Family Planning NSW ‘Just Checking’ website provides a range of information and resources to encourage participation of people with intellectual disability in bowel, breast and cervical screening.
Offer cervical screening to all eligible patients, that is, all people with a cervix regardless of their gender identity, sexual practice, history or sexual orientation. This includes lesbian, bisexual, queer and same-sex attracted women, transgender men and non-binary people who have a cervix and have ever been sexually active.
- ACON’s ‘The Inner Circle’ initiative supports participation in cervical screening by sexuality and gender diverse people.
- Check OUT is a free and confidential sexual health and cervical screening clinic for LGBTIQ+ people, run by and for community. It is located in Sydney CBD.
- trans[TEST] is a peer-led, sexual health service for anyone who is trans or gender diverse (TGD) which provides cervical screening for TGD people. trans[TEST] is a partnership between ACON and the Kirketon Road Centre (KRC).
The toolkit recognises that each team is unique. It provides examples of members’ roles and responsibilities in Quality Improvement projects. Having a team member who champions quality improvement within your practice can be the key to successful quality improvement activities.
General practice performs around 85% of cervical screening in NSW.
Primary health care’s role is critical to the success of the National Cervical Screening Program and its objective to reduce the incidence of cervical cancer in NSW.
Women and people with a cervix are more likely to undertake cervical screening if their health professional has discussed screening with them and has recommended that they screen.5
It is important for practices to have processes in place to systematically remind all eligible patients to attend for cervical screening.
Health professionals also play an important role in introducing and discussing cervical screening with patients, especially when engaging with those who are reluctant to screen and those who need reminding that they are overdue for their Cervical Screening Test.
By providing a friendly, safe and sensitive environment, primary care’s support is fundamental to a patient’s decision to have a potentially life-saving Cervical Screening Test. As part of the primary care provider discussions with patients about cervical screening, it is important to help patients understand important information, such as:
- what cervical screening involves – including an explanation about the choice of self-collection or clinician collection of a sample for testing
- why screening is important
- why the Cervical Screening Test is relevant to them
- what their test results mean.
- Education modules for Cervical Screening Test providers are available on the Cancer Council wiki guidelines website. These modules are based on the National Cervical Screening Program clinical guidelines.
- The National Prescribing Service (NPS) also have free online learning modules to train health care providers who conduct Cervical Screening Tests and follow-up management in accordance with the clinical pathway.
- Family Planning NSW provide reproductive and sexual health training including cervical screening, though a range of courses
- True Relationships & Reproductive Health have a free online course on Cancer Screening Education for General Practitioners which provides information, resources and tools to support promotion and management of patients through bowel, breast and cervical screening.
- VCS Foundation offer a HPV Self-Collection Clinical Audit (PDF) to support general practices develop an understanding of HPV self-collection and its role in improving cervical screening participation.
GPs play a key role in ensuring that all women and people with a cervix in the eligible age group participate in cervical screening. GPs can encourage patients to participate in cervical screening by:
- encouraging women and people with a cervix to participate in the program from age 25
- providing sound clinical advice about cervical screening
- performing Cervical Screening Tests as per the National Cervical Screening Program Guidelines
- setting recalls and reminders for cervical screening
- managing participants via the National Cancer Screening Register (check histories, edit patient details and submit information such as colposcopy information) managing patients (of any age) with symptoms of cervical cancer as per the guidelines.
Practice nurses have an important role to play in encouraging and supporting patients to participate in the NCSP. Primary Care Nurses can encourage patients to participate in cervical screening by:
- promoting the NCSP in your practice
- conducting screening audits of practice records to identify eligible patients
- talking to your patients aged 25-74 about screening
- performing Cervical Screening Tests (for nurses who are qualified to do cervical screening) as per the National Cervical Screening Program Guidelines
- establishing a Nurse-led Clinic for cervical screening
Nurse-led cervical screening can improve access and continuity of care for patients, particularly under-screened populations as they may feel more comfortable seeing a nurse for their CST.
See APNA for more information on establishing Nurse Led Clinics.
Practice management and administrative staff play an important role in the organisation and delivery of services within general practice. In relation to cervical screening management and administration staff can:
- Support systems in cervical screening.
- Oversee and support data and systems with up- to- date patient records.
- Direct patients to available cancer screening information in the practice.
- Engage in QI activities by supporting practice facilitation or technical expertise.
- Check eligibility for the PIP – Cervical Screening (PDF).
- Assist with connection to the NCSR.
Aboriginal Community Controlled Health Services (ACCHS) have an important role to play in supporting Aboriginal people in cervical screening.
- Support cervical screening to prevent cervical cancer.
- Provide strategies to encourage participation in the NCSP.
- Provide culturally appropriate cervical screening management of HPV positive results including follow up tests and if necessary, referral for colposcopy in accordance with the clinical guidelines.
- Encouraging Aboriginal patients to have their annual 715 assessments, which includes cervical screening and primary care approach.
Ngununggula - Walking and Working Together: A manual for health professionals supporting Aboriginal people with Cancer
Developed by The Illawarra Aboriginal Medical Service. This project has been a collaboration between AHMRC, University of Sydney (Michelle Dickson), UOW, and Menzies SHR and Coordinare PHN, and funded by Cancer Australia.
Quality Improvement (QI) encompasses a combination of factors that can improve processes and systems within your practice, which ultimately improve patient outcomes.
The work your practice undertakes as part of this toolkit can contribute to your eligibility for the Practice Incentive Program Quality Improvement Incentive which includes an Improvement Measure for the proportion of patients who are up-to-date with their cervical screening. Speak to your Primary Health Network (PHN) representative for more information.
Refer to the Cervical Screening: a quick reference guide (PDF) which will help your practice to assess current processes in place to encourage participation in cervical screening and where improvements can be made. The Quick Reference Guide includes a cervical screening readiness checklist and example Model for Improvement based on a Plan Do Study Act cycle (PDSA).
Quality Improvement (QI) activities in relation to cervical screening can be broken down into three categories, depending on how engaged your practice is with QI. Ideally level one activities would be foundational and support progression to level 2 and further to level 3 as these are more involved activities.
Level 1 QI Activities
Introductory level, starts with improving data quality, particularly useful if claiming the PIP QI and as cervical screening is one of the 10 QI measures. Level 1 QI ideas include:
Identify under screened or never screened patients who are at higher risk of developing cervical cancer, utilising a clinical audit tool
- Perform a data clean-up within clinical software, for example: marking relevant patients as ‘inactive’, delete or update all reminders/recalls once complete, create a defined list of cervical screening reminder codes
Download the Cervical Screening: QI activity - level 1 (PDF)
Level 2 QI Activities
Clinical level, based on addressing cervical screening at a clinical level with activities focussed on care delivered by GPs & Nurses. Level 2 QI ideas include:
- Run a cervical screening clinic (run by nurses that are trained to provide cervical screening or GPs) that is easily accessible and supportive for people to get screened
- Use health assessments as opportunistic times to provide advice and encourage cervical screening to eligible patients
Download the Cervical Screening: QI activity - level 2 (PDF)
Level 3 QI Activities
Practice level, the team may choose to focus on cervical screening as a major focus area for the practice. Level 3 QI ideas include:
- Support focus populations where cervical screening participation rates are low (eg. Aboriginal, culturally and linguistically diverse, or rural and remote populations, and LGBTQ people) to undertake cervical screening. Read the toolkit for engaging under screened and never screened women and consider engagement aims and strategies with vulnerable populations in your care. Visit APNA for more information in establishing Nurse led Clinics
- Create a supportive practice environment that encourages people to have Cervical Screening Tests through promotional information within the practice (eg. posters/letters/SMS reminders) and conversations with clinicians.
Download the Cervical Screening: QI activity - level 3 (PDF)
Data and systems
Good data and systems provide insight and understanding about your practice population who are eligible for cervical screening. Understanding your practice population allows you to target preventative activities and supports staff to provide reliable care to help drive increased participation in cervical screening.
Refer to the information below for tips on improving the quality of your cervical screening data and systems.
Use the lists of test results in the links below to check that the Cervical Screening Test results used by your pathology providers are recognised by the software that you use to create patient reminder lists (i.e. data audit tools or your practice software). This will ensure that your practice generates accurate cervical screening participation statistics and identifies patients who are due or overdue for screening.
|Software provider||Recognised cervical screening test results|
(Scroll down to ‘Pathology codes’)
|Medical Director||Cervical screening result searches|
|BP||Access BP resources|
A high-quality recall and reminder system for cervical screening will allow your practice to:
- systematically remind all eligible patients about cervical screening (often reminders are only set for when a result comes in, overlooking patients who are not screening)
- identify and appropriately engage under-screened patients
- support clinicians to deliver better care to patients who are under-screened
- track your cervical screening participation rates (which is key to knowing whether what you are doing is working or not).
It is important that the way your practice handles cancer screening recall and reminders is consistent. If you have multiple labels/codes for the same recall reason, it is difficult to accurately undertake recall searches.
Below is an example of what multiple cervical screening labels/codes might look like:
|Cervical Screening Test|
REMINDER: Screening recall labels and processes are ONLY for asymptomatic patients.
View cervical screening recall and reminder label/codes (PDF).
It is important to understand what diagnoses are excluded from cervical screening by your practice software to minimise the chance of sending a screening reminder to a patient inappropriately.
In addition to patients for whom “Not required” or “Excluded” has been manually selected in practice software, patients with the diagnoses listed in the links below will also be automatically excluded from cervical screening eligibility lists:
|Software provider||Cervical screening exclusions||Viewing patients excluded from cervical screening|
|CAT4||Diagnosis codes that PEN uses to assign patients to ‘ineligible’||When you complete cervical screening searches using the provided recipes a pie chart will be produced, a section of which is ‘ineligible’, click on this section and export a list to excel using the standard process.|
|Genie||Custom report||Custom report|
|Medical Director||Cervical screening result searches||Excluding patients from cervical screening searches|
|Best Practice||See software provider||See software provider|
Have an appropriate staff member (practice nurse or GP) review the list to identify any patients who may be eligible to return to cervical screening. It is important to periodically review patients who have been excluded from cervical screening to assess the appropriateness of them returning to screening based on clinical guidelines. The reason for the decision must be explained to them prior to inclusion back into screening reminder processes.
Your practice has the option of extracting a list of patients that your records show are overdue for cervical screening. This provides you with a list that you can then utilise patient records via access to the NCSR.
|Software provider||How to extract a list of patients overdue for cervical screening|
|CAT4||Cancer screening - reminder workflow|
|POLAR||See your PHN for support|
The NCSR will send back the pathology results for any of the patients who have recorded results. This will allow you to identify the patients who are up to date with their screening and focus on the patients who are overdue.
The Healthcare Provider Portal is a self-service alternative for health professionals to access and submit cervical screening data electronically in the NCSR.
The Healthcare Provider Portal allows those with a provider number and a Provider Digital Access (PRODA) account to communicate with the National Register in order to:
- Search for a participant and view their test results and screening histories
- Submit information and forms to the National Register – cervical (and bowel-related) program forms
- View and update your patient’s details
- Opt out, defer or cease your patient’s correspondence for either for bowel or cervical programs
- Nominate other people to assist your patient (such as a personal representative or another healthcare provider)
The Healthcare Provider Portal is integrated with most clinical information systems to enable healthcare providers to access and report clinical data for the National Cervical Screening Program from existing clinical information systems, including Best Practice Saffron (Jan 2021), Medical Director 4.0 (Aug 2021) and Communicare (Dec 2021)
For more information on accessing the portal, visit the website and/or contact your PHN for support in access.
TIP - To integrate GP practice software, practices are required to complete one linkage for authentication via PRODA account. Once integration is complete, the practice will have access to all the functionalities of the healthcare provider portal whilst working within their practice management system.
TIP - To access the Healthcare Provider Portal, you will need to create a Provider Digital Access (PRODA) account. Check with your PHN that this is set up for your practice to access the portal.
GP practices can access support from an NCSR specialist. Book your walk-through with an NCSR specialist using this link – Please don’t delay the NCSR are there to help.
- Self-collection allows women and people with a cervix to have the option to take their own vaginal sample for HPV testing, removing a significant barrier to participation in screening.
- It has the potential to remove the cultural and personal barriers that currently discourage some women and people with a cervix to screen, especially Aboriginal and Torres Strait Islanders, culturally and linguistically diverse women, and gender and sexually diverse people.
- Health professionals will need to explain to their patients how to collect a self-collected sample from the vagina.
Note: The Australian Government announced that from 1 July 2022, the National Cervical Screening Program will expand, offering self-collection as a choice to all people participating in cervical screening.
Establishing your baseline participation rates for cervical screening will allow you to:
- Benchmark your performance against state averages.
- Compare your actual performance against your perceived performance (practices often find that screening participation in their practice is lower than anticipated).
- Track your improvement over time as a result of your cervical screening quality improvement activities.
Before you begin, it is important to decide:
- Record your baseline participation in your QI workplan CAT recipe - Cervical Screening Participation Rate.
- How often you will monitor your participation rates (quarterly is recommended, as this allows some time to see change).
- How you will share and celebrate progress with the practice team (team newsletters, lunchroom display, team meetings, etc.).
Connecting with patients through provision of cervical screening reminders is an important preventative activity.
- Patients who are reminded by their GP are more likely to screen.6
- The RACGP’s Putting prevention into practice lists organisational change and targeted reminders systems as the two most effective implementation strategies for improving preventative care in general practice (p.42).7
- Integration of cervical screening with activities that support improved patient care and business outcomes (e.g. General Practitioner Management Plans 715 Aboriginal and Torres Strait Islander health assessments, 40 to 49 and 45 to 49-year-old health assessments, and health assessments for people with intellectual disability.)
Consider surveying your patients to better understand their preferences for receiving cervical screening reminders (eg. SMS, emails, letters, phone calls, voice messages). Below are some templates to support implementation of the cervical screening recall and reminder workflow.
|Cervical screening letters (docx)|
|Cervical screening SMS (docx)|
The recall and reminder workflow incorporates cervical screening into existing preventative practices for Aboriginal people, and those with (or at risk of) chronic disease. This is an excellent way to provide integrated person-centered care and lift screening participation rates among people who may have an increased risk of cancer due to age and/or lifestyle risk factors.
The cervical screening information below can be attached or embedded into your templates for Aboriginal health assessments (MBS item 715), 45 to 49-year-old health assessments and GP Management Plans (GPMPs) and GPMP reviews:
|Patient problems/needs/relevant conditions||Goals (changes to be achieved)||Required treatments and services, including patient actions||Arrangements for treatments/services (when, who, and contact details)|
Patient understands the benefits of cervical screening.
Patient completes cervical screening as per recommended intervals.
Date of last Cervical Screening Test: _________________
Date of next screening ______________________
GP or practice nurse to provide cervical screening.
GP to set a screening reminder (if appropriate).
1. Ronco G, Dillner J, Elfstrom KM, et al. Efficacy of HPV-based screening for prevention of invasive cervical cancer: Follow-up of four European randomised controlled trials. Lancet 2014;383:524–32.
2. Australian Institute of Health and Welfare. Access to health services by Australians with disability. Canberra: AIHW, 2017.
3. Carroll, B. Women’s Cancer Screening Program Consumer Research: Project Completion Report. Ballina, NSW: North Coast Primary Health Network, 2018.
4. Eastgate G, Scheermeyer E, van Driel M, Lennox M. Intellectual disability, sexuality and sexual abuse prevention – a study of family members and support workers. Aust Fam Physician 2012;Vols.41:135–9
5. Self-collection Pilot Project – improving access to cervical screening for under-screened women Evaluation Report Developed by the University of Melbourne and Victorian Cytology Service Ltd for the Victorian Department of Health and Human Services February 2017 https://www.vcs.org.au/wp-content/uploads/2018/09/Self-collection-pilot-project-final-report-3.pdf
6. Duffy S, Myles J, Maroni R, Mohammad A. Rapid review of evaluation of interventions to improve participation in cancer screening services. J Med Screen 2017 Sep;24(3):127–145. doi:10.1177/0969141316664757
7. Duffy S, Myles J, Maroni R, Mohammad A. Rapid review of evaluation of interventions to improve participation in cancer screening services. J Med Screen 2017 Sep;24(3):127–to145. doi:10.1177/0969141316664757.
8. Royal Australian College of General Practitioners. Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting (The Green Book), 3rd Edn. East Melbourne: RACGP, 2018.