using a fishbone diagram to assess and remedy barriers to cervical cancer screening in your...
TRANSCRIPT
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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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
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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Low rate of Pap smears
Environment Procedures
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
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
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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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
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
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