<p> 2011 Mammography Facility Survey</p><p>The Metropolitan Chicago Breast Cancer Task Force is collecting this information on behalf of the Illinois Department of Healthcare and Family Services. Please have someone knowledgeable within your institution complete and return this form based on practices in calendar year 2011 to Jennifer Orsi at [email protected] or fax it to Jennifer at 312-563-2448 within 30 days of signing the provider agreement. Instructions: Please fill out ONE form for EACH mammography facility at your institution.</p><p>MQSA Number: ______</p><p>Facility name: ______Address: ______City: ZIP ______Institution affiliation (if any): ______Name of person(s) completing questionnaire: Phone: ______</p><p>Position or title(s):______</p><p>Lead Contact for your Facility: ______Phone: ______</p><p>Position or title(s): ______Email: ______</p><p>Current Capacity: 1. How many hours is you facility performing breast imaging from Monday-Friday? ______2. How many hours is your facility performing breast imaging on the weekend? ______3. How many analog (film screen) mammography machines are in operation? ______4. How many digital mammography machines are in operation? ______a. How many of these are Fuji CRM units? ______b. How many of these are flat panel (stand-alone) units? ______5. How many imaging techs dedicated to mammography (>75% of time)? ______6. How many imaging techs who spend <75% of their time on mammography? ______7. How many radiologists who are dedicated to breast imaging (>75% of time)? ______8. How many general radiologists who read mammograms? ______9. How many screening mammograms does this facility perform? ______per month 10. How many diagnostic mammograms does this facility perform? ______per month 11. During operating hours, for what percentage of the time is there at least one attending radiologist on site</p><p><10% 10-25% 26-40% 41-59% 60-75% 76-90% >90%</p><p>What percentage of your patients: <10% 10-25% 26-40% 41-59% 60-75% 76-90% >90% 12 Are African-American 13 Are Hispanic 14 Have no private or public insurance 15 Have Medicaid 16 Are IBCCP patients 17 Are funded through other grant </p><p> sources (i.e. SAC, Silver Lining) 18 Are self-pay (i.e. not covered by a grant/state program; out of their own pocket)</p><p>1 Computer-Aided Detection 19. Does your facility use Computer-Aided Detection (CAD) when interpreting mammograms? 1 Yes 2 No</p><p>20. If yes, please select which mammograms are routinely read with CAD (CHECK ALL THAT APPLY): All screening mammograms All diagnostic mammograms</p><p>Double-reading of mammograms 21. Does your facility routinely (as usual practice) employ double-reading of mammograms (i.e. a second radiologist reads the film)? 1 Yes 2 No</p><p>22. If yes, please select which mammograms are routinely double read by a second radiologist (CHECK ALL THAT APPLY): All screening mammograms Screening mammograms with an abnormal interpretation All diagnostic mammograms Diagnostic mammograms with an abnormal interpretation</p><p>Performance feedback 23. What types of feedback are provided to radiologists on interpretive performance for screening mammography? Monthly Quarterly Annually Less than Annually Never Recall rate Biopsy rate Cancer detection rate % minimal/early stage </p><p>24. What types of feedback are provided to radiology technologists for screening mammography? More than Weekly Weekly Monthly Quarterly Annually Less than Annually Never Positioning Compression Other (specify): ______</p><p>What percentage of: <10% 10-25% 26-40% 41-59% 60-75% 76-90% >90% 25. Mammograms are read on site at your facility? 26. Screening mammograms are read same day as exam? 27. Normal screening results provided before she leaves? 28. Abnormal screening results provided before she leaves? 29. Diagnostic mammograms are read same day as exam? 30. Diagnostic results provided before she leaves?</p><p>Does your facility offer: 31. Diagnostic mammography? 1 Yes 2 No 32. Breast ultrasound? 1 Yes 2 No 33. Breast MRI? 1 Yes 2 No 34. Radiology guided breast biopsies? 1 Yes 2 No</p><p>35. For how many months were you unable to fill a position for a: mammography technician? breast imaging specialist? general radiologists mammographer? </p><p>36. As of today, how many days is the wait for: a screening appointment? a diagnostic appointment? a biopsy appointment? ______</p><p>2 37. Typically, what percentage of mammogram appointments are no-shows? </p><p>38. How many minutes are set aside for: screening appointments? diagnostic appointments? </p><p>39. In order to assess capacity, please provide us with a Microsoft excel spreadsheet that lists a count of screening mammograms by patient zip code that your facility provided in calendar year 2011. </p><p>NOTE: Do not include diagnostic mammograms.</p><p>Example: Screening Mammograms Provided at Facility X in Calendar Year 2011 by Patient Zip Code Patient Count of Screening Zip Code Mammograms 60601 5 60602 10 60603 11</p><p>3</p>