Purpose
The purpose of this document is to outline the steps for data collection, aggregation, charting, and submitting aggregate data to ACR for the Mammography Positioning's collaborative measure using the exam review tool and control chart template.
Preparation
- Download the LN Mammography Control Chart Template (12.27.2023)
- Save the template to your shared drive or upload to your organization's Microsoft 365 cloud. This could be either a One drive, Teams space, or SharePoint location for your project.
NOTE: You need a version of Excel later than Excel 2019 to support the template. If you use Excel 2016 or 2019, you will encounter a XLOOKUP error.
Overview
For the Mammography Positioning Improvement Collaborative we will use the following Excel worksheets within the template.
Setup Exam Entry Form 1 Data Summary P Chart
Criteria Performance Technologist Performance Evaluator Performance
Setup
On the Setup worksheet you will select the collaborative you are participating in using the drop down in cell B2, and enter your organization's name in cell B3.
Exam Entry
Data may be collected using a customizable Image Audit Form. For more information, please see our article on How to Customize the Exam Image Audit Form.
How to Customize the Exam Review Tool
To customize the exam review tool on the Exam Entry worksheet, enter your Locations, Technologists, and Image Evaluators starting in row 29 of columns B, C, and D accordingly. These options will then appear in the dropdown menus.
To increase the number of entries for Locations, Technologist, or Image Evaluators, unprotect the worksheet and insert rows between row 29 and 47 for the number of additional rows needed. Please email [email protected] to request the password, should you need to unprotect the worksheet.
How to Enter Exam Review Results
Exam-level and auditor information for the exam image being reviewed is captured in cells C2 through C8.
If needed, clear out previous results by highlighting cells C2 through C8 and pressing Delete on your key board.
Use the dropdown box for Image Evaluator, Location, and Technologist to select the unique options for your organization. To edit the dropdown options, please reference How to Customize the Audit Tool. The Procedure Date field will be converted into a date format based on your entry. The remaining fields are free text.
If your organization has an AI system, you can enter the AI result using the dropdown box. If you do not have an AI system, you can leave cell C8 blank.
Exam review criterion-level data is captured in rows 12 through 24. Column C is for Left breast images and Column D is for Right breast images.
If needed, reset all fields to Meets before entering audit results. To do this, select Meets from the dropdown and copy and paste to all cells in columns C and D between rows 12 and 24.
Use the dropdown menu to select the appropriate value for each breast and positioning exam review element. For criteria guidance, reference the Positioning Review Guidelines Table.
When the exam image review is complete, click on the Form 1 tab to navigate to the Form 1 worksheet. Insert a row at the bottom of the Form 1 table. To insert a row, highlight the the last row of the table, right click, then click on Insert Row.
Go back to the Exam Entry worksheet by clicking on the Exam Entry tab.
Select the Copy Me range by clicking on the dropdown in the upper left corner of the Exam Entry worksheet. The first option that should appear is Copy Me. Click on Copy Me to select this range. These cells contain your exam review results in a format that can be transferred to the Form 1 worksheet.
To copy the cells within the Copy Me range, right click and select Copy or use the keyboard shortcut CTRL-C.
Navigate to the Form 1 worksheet by clicking on the Form 1 tab.
Form 1
If you are exporting the values from the Microsoft audit form, check that the column headings and order in the Microsoft audit form match the column headings and order on the Form1 tab in your control chart. If they do not match, update the headings and order in the control chart so that they match the Microsoft audit form, prior to transferring your data.
In an open row in the table, paste the values from the Copy Me range or from the Microsoft audit form results. To paste values, highlight an open row in the table, right click, and select Values. If you do not paste values, it will copy the formulas from the Copy Me range. If you do this by accident, don't worry. Just repeat the pasting process in the current row and make sure to select Values when pasting.
Data Summary
The Data Summary worksheet aggregates weekly audit results entered on the Form1 tab. No data entry is needed on this page if you are using the audit tool built into the template.
NOTE: The data is aggregated weekly, Sunday to Saturday. For example, if you reviewed an exam with procedure date of Friday June 3, 2022 it will be aggregated under Date 5/29/22.
How to send weekly aggregate data to ACR, click on the weekly hyperlink in column G. A prepopulated Smartsheet form will appear. Select the Submit button. No additional data entry is required to submit the form.
If edits are made to your weekly aggregate data, you can use the same hyperlink to re-submit the updated data.
P Chart
For the Mammography Positioning Improvement Collaborative measure, we will use the P chart to visualize the weekly exam review data results. On the P Chart worksheet you will label, designate mean groupings and target values, and annotate your control chart. No exam data is entered on the P Chart worksheet.
How to add a chart title and label chart axes: Input your chart title, left axis title, horizontal axis title, and right axis title in the fields within the Chart Title and Axes section appropriately. The titles will automatically appear on the P chart.
How to group data means: Enter the start and end date for your baseline data in row 8 columns B and C appropriately in the Mean Groupings section. When a shift in your data is confirmed, you can group a second or third mean by entering the appropriate start and end date for these ranges in rows 9 and 10 appropriately. Based on the start and end dates, the mean and control limits will be graphed on the P chart.
NOTE: Control limits will only appear for the ranges identified in the Mean Groupings section.
How to add target dates and value: Enter the end date and target value specified in your SMART goal on row 14 in the Smart Goal Date and Value section. The target line will be graphed on the P chart between the stated start date in cell B14 and end date stated in cell C15.
How to add annotations: To add annotations to your P chart, enter the date for a data point that need annotation using the dropdown menu in column A in the Annotations section. Enter the annotation in column B. The annotation will appear on your P chart for the defined date.
NOTE: If you used your own audit tool and copied and pasted your weekly aggregate data into the Data Summary worksheet, no data or graphs will appear on the Criteria, Technologist or Evaluator Performance worksheets.
Criteria Performance
The Criteria Performance worksheet contains a dashboard displaying the aggregate results of each exam review criteria. No exam data is entered on the Criteria Performance worksheet.
Technologist Performance
The Technologist Performance worksheet contains a dashboard displaying the exam review results of each technologist. No exam data is entered on the Technologist Performance worksheet.
Evaluator Performance
The Evaluator Performance worksheet contains a dashboard displaying the exam review results of each evaluator. No exam data is entered on the Evaluator Performance worksheet.