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appointments and schedules, blueprint, health service, organization, and administration, mammography screening, mammography, utilization, outcome and process assessment, patient satisfaction



  1. Dodendorf, Diane M.
  2. Deogun, Gurvinder K.
  3. Rodie, Amy Risch
  4. Pol, Louis G.


Abstract: This study overviews an operational blueprint that diagrams the activities and interactions of all participants in a typical screening mammography appointment in a large medical center. The blueprint is constructed from multiple sources of data collected from mammography patients, service providers in the radiology department, and medical records. The benefits from using patient perspectives, the insights gained from the blueprint development process, and the value of the resulting screening mammography appointment blueprint are included.


It is estimated that there were 182,800 new invasive cases of breast cancer and 40,800 deaths due to this disease in the United States in 2001.1 While rates of breast cancer incidence increased from 1940s to 1980s, peaking at a 4 percent average annual increase between 1982 and 1988, since 1990, there has been a leveling in the rates. In addition, breast cancer-specific death rates have fallen by about 1.8 percent per year since 1989.1 Most of the mortality rate decreases are attributed to early detection of abnormalities. Nevertheless, despite a rise in referrals and early detection and a decline in deaths attributable to breast cancer,1-3 several issues and concerns about mammography have yet to be resolved.* Fletcher et al.4 reported that regular mammography screening can reduce breast cancer mortality by at least 30 percent in women age 50 and over, yet many women in this age group do not seek regular tests. Lane and Messini5 found that nearly 39 percent of the women ages 40-49 were underusers of mammography services. Clearly, more progress with respect to increased testing and early detection is needed.


One area of concern is how to encourage women to have regular mammograms and at the same time remove barriers to testing. Mammography is different from many other preventive services in that most often it is the result of a referral from a woman's primary care physician and necessitates a subsequent appointment. Thus, a woman may have to make additional and substantive efforts to have an examination. Moreover, until recently, there was no standardized way in which a woman learned of the test results.+ In many cases, the "no call means good news" approach was taken by both radiologists and primary care physicians, and a great deal of anxiety was generated as women waited to not receive a telephone call. Other problems with mammography services have been documented, such as difficulties in communication between radiologists and primary care physicians, and it is reasonable to assume that shortcomings, including barriers, in the mammography process are partly responsible for underutilization of these services.


Rimer et al.7,8 have categorized mammography intervention studies and summarized barriers to mammography use. There is an absence of study on the appointment process, and none of the studies bring together information from both patient and service provider perspectives. It is also recognized that events and issues outside of the radiology department can influence the appointment process.


A better understanding of the mammography appointment process is needed because of the way patients are likely to evaluate their experience with appointments.9 Patients have high expectations for providers' knowledge and skills, making it difficult to satisfy patients via medical expertise that surpasses their expectations. Most patients recognize that they lack the expertise to evaluate the quality or diagnoses of the x-rays; in fact, patients rarely see their x-rays. On the other hand, patients are very capable of evaluating the quality of their experience during a mammography appointment. Research findings show that patient perceptions can be improved by enhancing the process by which care is delivered-the aspect patients are most likely to evaluate.10


Insights into the process can be gained by viewing mammography from an operational perspective. One method for developing an operational perspective is the "appointment blueprint." The blueprint captures the entire mammography appointment in pictorial form and includes information from both patients' and health professionals' perspectives. The blueprint portrays clearly the structure of the entire appointment, each component, and the points of interaction between patients and staff and among staff members. This paper describes appointment blueprints, the data sources needed to construct them, and their value to improving the appointment process for patients and providers.