October 2007

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

2. This slide set was developed by members of the Cervical • Cancer 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

3. Learning Objectives • Describe 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

4. 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.

5. 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

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

7. 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

8. 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

9. Steps in Constructing a Fishbone Diagram • Establish 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

10. Case Study: • New Jersey HIV Family Centered • Care Network

11. 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

12. First Steps • Facilitator and process members • Problem • Low Pap smear completion rates • Main Causes • Environment • Procedures • People • Equipment

13. Procedures Environment Lack of support services Limited time for Pap Available services Time Gyn services unavailable on-site Limited time w/ MD/NP d/t large case load Overall clinic time limited Co-located srvs not available Physical space limited Emergencies / unexpected complexity of appt. Not enough clinic space Space Long wait time Space used by other practitioners Walk-in appts. Delay scheduled appts. Have to wait to use exam room Low rate of Pap smears Equipment People

14. No policy in place re: referral f/u Lack of support services Procedures Environment Limited time for Pap Referrals EMR function to flag provider not enabled Available services Referrals are made with no f/u Time Gyn services unavailable on-site Need for Pap Assume pt. is already informed Limited time to explain procedures No process to flag need for Pap Limited time w/ MD/NP d/t large case load Overall clinic time limited Co-located srvs not available Physical space limited Pt. understanding Emergencies / unexpected complexity of appt. Not enough clinic space Space Lack of pt. education re: procedure Staff responsibility to provide education not defined No reminders for pt. appts. Appts. Made without consultation with pts. Long wait time Space used by other practitioners Appointments Walk-in appts. Delay scheduled appts. Have to wait to use exam room No process to remind pts. of appts. Low rate of Pap smears Equipment People

15. No policy in place re: referral f/u Environment Lack of support services Procedures Limited time for Pap Referrals EMR function to flag provider not enabled Available services Referrals are made with no f/u Time Gyn services unavailable on-site Need for Pap Assume pt. is already informed Limited time to explain procedures No process to flag need for Pap Limited time w/ MD/NP d/t large case load Overall clinic time limited Co-located srvs not available Physical space limited Pt. understanding Emergencies / unexpected complexity of appt. Not enough clinic space Space Lack of pt. education re: procedure Staff responsibility to provide education not defined No reminders for pt. appts. Appts. Made without consultation with pts. Long wait time Space used by other practitioners Appointments Walk-in appts. Delay scheduled appts. Have to wait to use exam room No process to remind pts. of appts. Low rate of Pap smears Expectations of staff Expect pt. won’t show Competing priorities and time commitments Staff not aware of problems with Paps Assume pt. doesn’t want to do Pap Staff Don’t want exam Billing may not result in reimbursement Pain Don’t want to perform Pap Negative past experience Svc. not covered by malpractice insurance Pap not in area of expertise Patients Of pain Expectations of f/u on results Equipment Competing health priorities Of cancer Don’t feel its needed Of diagnosis Liability and billing Too busy taking care of others Of unknown Cost of procedure vs. other needs Unpleasant experience with colposcopy People Priorities Fear

16. Procedures No policy in place re: referral f/u Environment Lack of support services Limited time for Pap Referrals EMR function to flag provider not enabled Available services Referrals are made with no f/u Time Gyn services unavailable on-site Need for Pap Assume pt. is already informed Limited time to explain procedures No process to flag need for Pap Limited time w/ MD/NP d/t large case load Overall clinic time limited Co-located srvs not available Physical space limited Pt. understanding Emergencies / unexpected complexity of appt. Not enough clinic space Space Lack of pt. education re: procedure Staff responsibility to provide education not defined No reminders for pt. appts. Appts. Made without consultation with pts. Long wait time Space used by other practitioners Appointments Walk-in appts. Delay scheduled appts. Have to wait to use exam room No process to remind pts. of appts. Low rate of Pap smears Expectations of staff Staff not trained to use equipment Expect pt. won’t show Competing priorities and time commitments Staff not aware of problems with Paps Trained staff Assume pt. doesn’t want to do Pap Limited funds for equipment Staff Don’t want exam Billing may not result in reimbursement Pain Don’t want to perform Pap Availability of equipment Negative past experience Svc. not covered by malpractice insurance Pap not in area of expertise Patients Specialty equipment not available. eg. tilting exam table Mobile Pap cart not available Of pain Expectations of f/u on results Equipment Competing health priorities Of cancer Don’t feel its needed Of diagnosis Liability and billing Too busy taking care of others Of unknown Cost of procedure vs. other needs Unpleasant experience with colposcopy People Priorities Fear

17. 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

18. 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

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

20. PDSA Cycle Example • Problem: Pap rate is still low after staff education and chart audits. • Objective: Entice / introduce women into GYN care via Pap Festivals. Plan Do Set date, identify staff, include consumers, identify resources, plan evaluation Publicize free activity, host Pap Fest, document services, survey patients Act Reactions of the 21 participants, identify barriers and improvements thru brief survey Study Need better, more substantial food, alonger, more flexible hours in that day

21. Jersey City Medical Center Example

22. 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

23. 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

24. 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

25. 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 Care http://www.ihi.org/IHI/Topics/HIVAIDS/HIVDiseaseGeneral/Tools/HIVQUALWorkbookGuideforQualityImprovementinHIVCare.htm • National Quality Center • www.nationalqualitycenter.og

26. References • Abercrombie, 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