Using a Fishbone Diagram to Assess and Remedy Barriers to Cervical Cancer Screening in Your Healthcare Setting October 2007

Using a Fishbone Diagram to Assess and Remedy Barriers to

Cervical Cancer Screening in Your Healthcare Setting

October 2007

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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 Ideas Andrea Norberg, MS, RN; AETC National Resource Center Pamela Rothpletz-Puglia, EdD, RD; François-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 Center Rebecca Fry, MSN, APN; François-Xavier Bagnoud Center Kathy Hendricks, RN, MSN; François-Xavier Bagnoud Center Supriya Modey, MBBS, MPH; AETC National Resource Center Peter Oates, RN, MSN, ACRN, NP-C; François-Xavier Bagnoud Center Jacki Witt, JD, MSN, WHNP; Clinical Training Center for Family Planning

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Learning Objectives

1. Describe the rationale for cervical cancer screening and common barriers to completion

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

3. Identify the steps in constructing a fishbone diagram

4. 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

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Rationale for Cervical Cancer Screening Abnormal 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.

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Common System Barriers Access to information Missed appointments

Childcare Transportation

Lack of trained & culturally competent providers Documentation Equipment and exam rooms Fear factor (provider and patient) Referral process

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

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Introduction to Fishbone Diagrams

Continuous Quality Improvement (CQI) tool

Used to identify, explore, and display the causes of a particular problem

Also called a Cause and Effect Diagram

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Benefits of Constructing a Fishbone Diagram

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

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Steps in Constructing a Fishbone Diagram

1. Establish process facilitator and team members

2. Define problem

3. Generate main causes of the problem

4. Brainstorm ideas related to the main causes

5. Interpret results from diagram

6. Identify any causes or ideas where immediate action can be taken

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Case Study:

New Jersey HIV Family Centered

Care Network

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Overview Statewide Ryan White Treatment Modernization

Act Part D program Seven sites (e.g., university-based clinics, hospitals,

medical centers, and satellite sites) Serves entire State of New Jersey

Networkwide CQI process monitors clinical indicators Cervical Cancer Screening Completion Rates

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First Steps Facilitator and process members Problem

Low Pap smear completion rates Main Causes

Environment Procedures People Equipment

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Low rate of Pap smears

EnvironmentProcedures

People

Equipment

Limited time for Pap

Lack of support services

Available services

Gyn services unavailable on-site

Time

Limited time w/ MD/NP d/t large case load

Overall clinic time limited

Emergencies / unexpected complexity of appt.

Not enough clinic space

Walk-in appts. Delay scheduled appts.

Have to wait to use exam room

Co-located srvs not available

Physical space limited

Space

Space used by other practitioners

Long wait time

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People

Equipment



Available services


Time









Space


Long wait time

Need for Pap

EMR function to flag provider not enabled

No process to flag need for Pap

Appointments

No reminders for pt. appts.

Appts. Made without consultation with pts.

No process to remind pts. of appts.

Referrals

No policy in place re: referral f/u

Referrals are made with no f/u

Pt. understanding

Assume pt. is already informed

Limited time to explain procedures

Lack of pt. education re: procedure

Staff responsibility to provide education not defined

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Environment Procedures

People

Equipment



Available services


Time









Space


Long wait time

Need for Pap



Appointments




Referrals



Pt. understanding





Staff

Staff not aware of problems with Paps

Competing priorities and time commitments

Expectations of staff

Expect pt. won’t show

Assume pt. doesn’t want to do Pap

Don’t want to perform Pap

Billing may not result in reimbursement

Svc. not covered by malpractice insurance

Liability and billing

Pap not in area of expertise

Expectations of f/u on results

Patients

Don’t want exam

Pain

Negative past experience

Priorities Fear

Don’t feel its needed

Cost of procedure vs. other needs

Competing health priorities

Too busy taking care of others

Of pain

Of cancer

Of diagnosis

Of unknown

Unpleasant experience with colposcopy

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People

Equipment



Available services


Time









Space


Long wait time

Need for Pap



Appointments




Referrals



Pt. understanding





Trained staff

Staff not trained to use equipment

Availability of equipment

Limited funds for equipment

Specialty equipment not available. eg. tilting exam table

Mobile Pap cart not available

Staff

Staff not aware of problems with Paps

Competing priorities and time commitments

Expectations of staff

Expect pt. won’t show

Assume pt. doesn’t want to do Pap

Don’t want to perform Pap

Billing may not result in reimbursement

Svc. not covered by malpractice insurance

Liability and billing

Pap not in area of expertise

Expectations of f/u on results

Patients

Don’t want exam

Pain

Negative past experience

Priorities Fear

Don’t feel its needed

Cost of procedure vs. other needs

Competing health priorities

Too busy taking care of others

Of pain

Of cancer

Of diagnosis

Of unknown

Unpleasant experience with colposcopy

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Next Steps

Brainstorming 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

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Potential Strategies Document outcome of referrals Use incentives to encourage women to complete Pap smears Raise staff awareness about need for screening Provide 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

form Offer “personal” reminders to patients using phone calls or

birthday cards Establish formal policies and procedures for scheduling,

completion, and follow-up on Pap smears Implement a Pap Festival

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Networkwide Goal

Seventy percent (70%) of all women will receive

and have documentation of a Pap smear on an

annual basis.

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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 patients

Set date, identify staff, include consumers, identify resources, plan evaluation

Need better, more substantial food, alonger, more flexible hours in that day

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

Plan Do

Act Study

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Jersey City Medical Center Example

JCMC Pap Rates

37

67

4252

70

?

0102030405060708090

2002 2003 2004 2005 2006 2007

Year

Perc

en

ts

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Lessons Learned and Best Practices Skilled facilitator with knowledge of and experience

using fishbone diagrams is essential Manageable number of participants must be

selected Broad representation among participants leads to

more comprehensive discussion Participation in the process facilitates motivation to

tackle the problem Participation in the process facilitates communication

about possible remedies to the problem

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Concluding Remarks Cervical 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

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Helpful Resources

A Guidebook on Overcoming System Barriers to Cervical Cancer Screening for HIV-Infected Women In A Clinical Setting

Clinical Issues Training of Trainers Package Cervical Cancer Screening and HIV-Infected Women:

Pap Smears and Pelvic Exams slide set Human Papillomavirus (HPV) and HIV-Infected

Women slide set Common Sexually Transmitted Diseases and HIV-

Infected Women slide set

Resources available at www.aidsetc.org

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Helpful Resources (continued)

AETC National Evaluation Center (NEC)

www.ucsf.edu/aetcnec/ National HIV Quality Improvement (HIVQUAL)

Project HIVQUAL Workbook: Guide for Quality Improvement

in HIV Carehttp://www.ihi.org/IHI/Topics/HIVAIDS/HIVDiseaseGeneral/Tools/HIVQUALWorkbookGuideforQualityImprovementinHIVCare.htm

National Quality Center

www.nationalqualitycenter.og

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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 Cervical 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.htm

Rothpletz-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

Documents

Using a Fishbone Diagram to Assess and Remedy Barriers to Cervical Cancer Screening in Your Healthcare Setting October 2007