Using a Fishbone Diagram to Assess and Remedy Barriers to Cervical Cancer Screening in Your Healthcare SettingTraining ExchangeSeptember 27, 2007

This slide set was developed by members of the CervicalCancer Screening Subgroup of the AETC Women's Health and Wellness Workgroup:

Laura Armas, MD; Texas/Oklahoma AETC Lori DeLorenzo, MSN, RN; Organizational IdeasAndrea Norberg, MS, RN; AETC National Resource Center Pamela Rothpletz-Puglia, EdD, RD; Franois-Xavier Bagnoud Center Jamie Steiger, MPH; AETC National Resource Center

Other subgroup members and contributors include:

Abigail Davis, MS, ANP, WHNP; Mountain Plains AETC Karen A. Forgash, BA; AETC National Resource CenterRebecca Fry, MSN, APN; Franois-Xavier Bagnoud Center Kathy Hendricks, RN, MSN; Franois-Xavier Bagnoud Center Supriya Modey, MBBS, MPH; AETC National Resource Center Peter Oates, RN, MSN, ACRN, NP-C; Franois-Xavier Bagnoud Center Jacki Witt, JD, MSN, WHNP; Clinical Training Center for Family Planning

Products OverviewClinical Issues Training of Trainers (TOT) PackageCervical Cancer Screening in HIV-Infected Women: Pap Smears and Pelvic Examinations slide setHuman Papillomavirus and HIV-Infected Women slide setCommon Sexually Transmitted Diseases (STDs) and HIV-Infected Women slide set

System Issues Technical Assistance (TA) PackageUsing a Fishbone Diagram to Assess and Remedy Barriers to Cervical Cancer Screening in Your Clinical Setting slide setGuidebook on Overcoming System Barriers to Cervical Cancer Screening for HIV-Infected Women in a Clinical Setting

Guidebook on Overcoming System Barriers to Cervical Cancer Screening for HIV-Infected Women in a Clinical SettingIntroductionDevelopment of the GuidebookAssessing Barriers to Cervical Cancer Screening In Your ClinicBenefits of Constructing a Fishbone DiagramSteps in Constructing a Fishbone DiagramCase Study: NJ HIV Family Centered Care NetworkCommon System Barriers and Strategies to Overcome ThemCase StudiesReferencesSample patient education materials, tracking forms, and patient information forms

Format of Training ExchangePart I: Presentation

Part II: Operator-assisted question & answer session

Participant phone lines will be muted until the Q & A session

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Presenter

Lori DeLorenzo, MSN, RNOrganizational Ideas

Learning ObjectivesDescribe the rationale for cervical cancer screening and common barriers to completion

Discuss the benefits of constructing a fishbone diagram to assess causes of a problem

Identify the steps in constructing a fishbone diagram

Discuss how the New Jersey HIV Family Centered Care Network successfully used a fishbone diagram to identify and address causes of low cervical cancer screening rates

Rationale for Cervical Cancer ScreeningAbnormal Pap smears are more than 4 times higher in HIV-infected women

HIV-infected women have a higher prevalence of HPV infection

HIV-infected women are 5 times more likely to develop squamous intraepithelial lesions (SIL)

Invasive cervical cancer is an AIDS defining illness

Sources:Cervical Dysplasia. In: Coffey S, ed. Clinical Manual for Management of the HIV-Infected Adult, 2006 Edition AIDS Education & Training Centers National Resource Center; 2006:(6) 13-15.

Maiman, M. et al. (1998). Prevalence, Risk Factors, and Accuracy of Cytologic Screening for Cervcial Intraepithelial Neoplasia in Women with the Human Immunodeficiency Virus. Gynecologic Oncology, 68, 233 39.

Common System BarriersAccess to information Missed appointments Childcare Transportation Lack of trained & culturally competent providers Documentation Equipment and exam rooms Fear factor (provider and patient) Referral process

Common Cultural & Social BarriersSubstance use Intimate partner violence Family history of reproductive cancers Gender roles Discrimination

Introduction to Fishbone DiagramsContinuous Quality Improvement (CQI) toolUsed to identify, explore, and display the causes of a particular problemAlso called a Cause and Effect Diagram

Benefits of Constructing a Fishbone DiagramDetermines root causes of a problem Encourages group participation Utilizes and increases group knowledge Uses an orderly, easy-to-read format

Steps in Constructing a Fishbone DiagramEstablish process facilitator and team members Define problem Generate main causes of the problem Brainstorm ideas related to the main causes Interpret results from diagram Identify any causes or ideas where immediate action can be taken

Sample of Blank Diagram

Case Study: New Jersey HIV Family Centered Care Network

OverviewStatewide Ryan White Treatment Modernization Act Part D program Seven sites (eg. university-based clinics, hospitals, medical centers, and satellite sites) Serves entire State of New Jersey

Networkwide CQI process monitors clinical indicatorsCervical Cancer Screening Completion Rates

First StepsFacilitator and process members Problem Low Pap smear completion ratesMain Causes Environment Procedures People Equipment

Low rate of Pap smearsEnvironmentProceduresPeopleEquipmentLimited time for PapLack of support servicesAvailable servicesGyn services unavailable on-siteTimeLimited time w/ MD/NP d/t large case loadOverall clinic time limitedEmergencies / unexpected complexity of appt.Not enough clinic spaceWalk-in appts. Delay scheduled appts.Have to wait to use exam roomCo-located srvs not availablePhysical space limitedSpaceSpace used by other practitionersLong wait time

Low rate of Pap smearsEnvironmentProceduresPeopleEquipmentLimited time for PapLack of support servicesAvailable servicesGyn services unavailable on-siteTimeLimited time w/ MD/NP d/t large case loadOverall clinic time limitedEmergencies / unexpected complexity of appt.Not enough clinic spaceWalk-in appts. Delay scheduled appts.Have to wait to use exam roomCo-located srvs not availablePhysical space limitedSpaceSpace used by other practitionersLong wait timeNeed for PapEMR function to flag provider not enabledNo process to flag need for PapAppointmentsNo reminders for pt. appts.Appts. Made without consultation with pts.No process to remind pts. of appts.ReferralsNo policy in place re: referral f/uReferrals are made with no f/uPt. understandingAssume pt. is already informedLimited time to explain proceduresLack of pt. education re: procedureStaff responsibility to provide education not defined

Low rate of Pap smearsEnvironmentProceduresPeopleEquipmentLimited time for PapLack of support servicesAvailable servicesGyn services unavailable on-siteTimeLimited time w/ MD/NP d/t large case loadOverall clinic time limitedEmergencies / unexpected complexity of appt.Not enough clinic spaceWalk-in appts. Delay scheduled appts.Have to wait to use exam roomCo-located srvs not availablePhysical space limitedSpaceSpace used by other practitionersLong wait timeNeed for PapEMR function to flag provider not enabledNo process to flag need for PapAppointmentsNo reminders for pt. appts.Appts. Made without consultation with pts.No process to remind pts. of appts.ReferralsNo policy in place re: referral f/uReferrals are made with no f/uPt. understandingAssume pt. is already informedLimited time to explain proceduresLack of pt. education re: procedureStaff responsibility to provide education not definedStaffStaff not aware of problems with PapsCompeting priorities and time commitmentsExpectations of staffExpect pt. wont showAssume pt. doesnt want to do PapDont want to perform PapBilling may not result in reimbursementSvc. not covered by malpractice insuranceLiability and billingPap not in area of expertiseExpectations of f/u on resultsPatientsDont want examPainNegative past experiencePrioritiesFearDont feel its neededCost of procedure vs. other needsCompeting health prioritiesToo busy taking care of othersOf painOf cancerOf diagnosisOf unknownUnpleasant experience with culposcopy

Low rate of Pap smearsEnvironmentProceduresPeopleEquipmentLimited time for PapLack of support servicesAvailable servicesGyn services unavailable on-siteTimeLimited time w/ MD/NP d/t large case loadOverall clinic time limitedEmergencies / unexpected complexity of appt.Not enough clinic spaceWalk-in appts. Delay scheduled appts.Have to wait to use exam roomCo-located srvs not availablePhysical space limitedSpaceSpace used by other practitionersLong wait timeNeed for PapEMR function to flag provider not enabledNo process to flag need for PapAppointmentsNo reminders for pt. appts.Appts. Made without consultation with pts.No process to remind pts. of appts.ReferralsNo policy in place re: referral f/uReferrals are made with no f/uPt. understandingAssume pt. is already informedLimited time to explain proceduresLack of pt. education re: procedureStaff responsibility to provide education not definedTrained staffStaff not trained to use equipmentAvailability of equipmentLimited funds for equipmentSpecialty equipment not available. eg. tilting exam tableMobile Pap cart not availableStaffStaff not aware of problems with PapsCompeting priorities and time commitmentsExpectations of staffExpect pt. wont showAssume pt. doesnt want to do PapDont want to perform PapBilling may not result in reimbursementSvc. not covered by malpractice insuranceLiability and billingPap not in area of expertiseExpectations of f/u on resultsPatientsDont want examPainNegative past experiencePrioritiesFearDont feel its neededCost of procedure vs. other needsCompeting health prioritiesToo busy taking care of othersOf painOf cancerOf diagnosisOf unknownUnpleasant experience with culposcopy

Next StepsBrainstorming sessions on fishbone diagram results Discuss successful and unsuccessful strategies implemented in the past Identify new strategies Establish networkwide goal for addressing low cervical cancer completion rates

Potential StrategiesDocument outcome of referrals Use incentives to encourage women to complete Pap smears Raise staff awareness about need for screeningProvide cervical cancer screening onsite Create a mobile Pap cart Bring a GYN provider onsite Notify providers about a Pap smear that is due using a prompt Include Pap smears on the color-copied annual assessment formOffer personal reminders to patients using phone calls or birthday cardsEstablish formal policies and procedures for scheduling, completion, and follow-up on Pap smearsImplement a Pap Festival

Networkwide GoalSeventy percent (70%) of all women will receive and have documentation of a Pap smear on an annual basis.

PDSA Cycle ExampleProblem: Pap rate is still low after staff education and chart audits.Objective: Entice / introduce women into GYN care via Pap Festivals.

Publicize free activity, host Pap Fest, document services, survey patientsSet date, identify staff, include consumers, identify resources, plan evaluationNeed better, more substantial food, alonger, more flexible hours in that day

Reactions of the 21 participants, identify barriers and improvements thru brief surveyPlanDoActStudy

Jersey City Medical Center Example

Chart1

37

42

52

67

70

85

Pap Rate

Year

Percents

JCMC Pap Rates

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Sheet1

YearPap Rate

200237

200342

200452

200567

200670

200785

Sheet1

0

0

0

0

0

0

Pap Rate

Year

Percents

JCMC Pap Rates

?

Sheet2

Sheet3

Lessons Learned and Best PracticesSkilled facilitator with knowledge of and experience using fishbone diagrams is essentialManageable number of participants must be selectedBroad representation among participants leads to more comprehensive discussionParticipation in the process facilitates motivation to tackle the problemParticipation in the process facilitates communication about possible remedies to the problem

Concluding RemarksCervical cancer screening is critical for women living with HIV Many barriers lead to low screening rates Fishbone diagrams are useful when identifying causes of a problem After completing a fishbone diagram, follow up discussion can lead to the implementation of useful strategies

Helpful ResourcesA Guidebook on Overcoming System Barriers to Cervical Cancer Screening for HIV-Infected Women In A Clinical SettingClinical Issues Training of Trainers PackageCervical Cancer Screening and HIV-Infected Women: Pap Smears and Pelvic Exams slide setHuman Papillomavirus (HPV) and HIV-Infected Women slide setCommon Sexually Transmitted Diseases and HIV-Infected Women slide set

Resources available at www.aidsetc.org

ReferencesAbercrombie, P.D. (2003). Factors Affecting Abnormal Pap Smear Follow-Up Among HIV-Infected Women. Journal of the Association of Nurses in AIDS Care, 14(3), 41-54.Anderson, J.R, ed. (2005). A Guide to the Clinical Care of Women with HIV. Health Resources and Services Administration HIV/AIDS Bureau.Brassard, M., ed. (1998). The MEMORY JOGGER: A Pocket Guide of Tools for Continuous Improvement. Methuen, MA:GOAL/QPC.Cervical Dysplasia. In: Coffey S, ed. Clinical Manual for Management of the HIV-Infected Adult, 2006 Edition. AIDS Education & Training Centers National Resource Center; 2006:(6) 13-15.Cetjin, H.E. et al. (1999). Adherence to Colposcopy Among Women With HIV Infection. Journal of Acquired Immune Deficiency Syndrome, 22(3), 247-56.Hirschhorn, L.R. et al. (2006). Gender Differences in Quality of HIV Care in Ryan White CARE Act-Funded Clinics. Women's Health Issues, 16, 104-112.Maiman, M. et al. (1998). Prevalence, Risk Factors, and Accuracy of Cytologic Screening for Cervcial Intraepithelial Neoplasia in Women with the Human Immunodeficiency Virus. Gynecologic Oncology, 68, 233-39.New York State Department of Health AIDS Institute. (2000). Promoting GYN CARE for HIV-Infected Women: Best Practices from New York State. Retrieved on July 12, 2007 from http://www.ihi.org/IHI/Topics/HIVAIDS/HIVDiseaseGeneral/Tools/PromotingGynecologicalGYNCareforHIVInfectedWomen.htmRothpletz-Puglia, P. & Lewis, S. (February 2006) Gynecologic Care and Pap Screening in Ryan White CARE Act Title IV Programs: Summary of Results. Reported submitted to Health Resources and Services Administration HIV/Bureau by HIV/AIDS National Resource Center for Title IV, Francois Xavier Bagnoud Center, University of Medicine and Dentistry of New Jersey.Shuter, J., Kalkut, G.E., Pinon, M.W., Bellin, E.Y., & Zingman, B.S. (2003). A computerized reminder system improves compliance with Papanicolaou smear recommendations in an HIV care clinic. International Journal of STD & AIDS, 14(10), 67-80.The Balanced Scorecard Institute. Basic Tools for Process Improvement Module 5: The Cause and Effect Diagram. Retrieved on July 12, 2007 from www.balancedscorecard.org/files/c-ediag.pdf

Q & A session