Using a Fishbone Diagram to
Assess and Remedy Barriers to
Cervical Cancer Screening in Your
Healthcare Setting
October 2007
This slide set was developed by members of the Cervical
Cancer Screening Subgroup of the AETC Women's Health
and Wellness Workgroup:
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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:
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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
3
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.
4
Common System Barriers
 Access to information
 Missed appointments
 Childcare
 Transportation
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Lack of trained & culturally competent providers
Documentation
Equipment and exam rooms
Fear factor (provider and patient)
Referral process
5
Common Cultural & Social Barriers
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Substance use
Intimate partner violence
Family history of reproductive cancers
Gender roles
Discrimination
6
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
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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.
2.
3.
4.
5.
6.
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
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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
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Environment
Procedures
People
Equipment
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Environment
Procedures
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
Emergencies / unexpected
complexity of appt.
Co-located srvs
not available
Not enough
clinic space
Long wait
time
Physical
space limited
Space
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
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Limited time for Pap
Environment
Lack of support services
No policy in place re:
referral f/u
Procedures
Referrals
Available services
EMR function to flag
provider not enabled
Referrals are made with no f/u
Time
Gyn services
unavailable on-site
Limited time w/ MD/NP
d/t large case load
Overall clinic time
limited
Emergencies / unexpected
complexity of appt.
Co-located srvs
not available
Not enough
clinic space
Long wait
time
Need for
Pap
Physical
space limited
Have to wait to use
exam room
No process to
flag need for Pap
Limited time to explain
procedures
Pt. understanding
Space
Space used by other
practitioners
Walk-in appts. Delay
scheduled appts.
Assume pt. is
already informed
No reminders
for pt. appts.
Appts. Made without
consultation with pts.
Appointments
No process to remind pts. of appts.
Lack of pt.
education re:
procedure
Staff responsibility to
provide education not
defined
Low rate of
Pap smears
Equipment
People
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Lack of support services
Environment
No policy in place re:
referral f/u
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
Limited time w/ MD/NP
d/t large case load
Overall clinic time
limited
Emergencies / unexpected
complexity of appt.
Co-located srvs
not available
Need for
Pap
No process to
flag need for Pap
Physical
space limited
Not enough
clinic space
Limited time to explain
procedures
Pt. understanding
Space
Long wait
time
No reminders
for pt. appts.
Space used by other
practitioners
Walk-in appts. Delay
scheduled appts.
Assume pt. is
already informed
Appts. Made without
consultation with pts.
Appointments
Have to wait to use
exam room
Lack of pt.
education re:
procedure
No process to remind pts. of appts.
Staff responsibility to
provide education not
defined
Low rate of
Pap smears
Expectations of staff
Expect pt.
won’t show
Competing priorities
and time
commitments
Assume pt. doesn’t
want to do Pap
Staff not aware of
problems with Paps
Don’t want exam
Staff
Billing may not result in
reimbursement
Svc. not covered
by malpractice
insurance
Pain
Don’t want to
perform Pap
Negative past experience
Pap not in area of
expertise
Expectations of
f/u on results
Don’t feel its
needed
Liability and billing
Cost of procedure
vs. other needs
People
Patients
Of pain
Competing
health
priorities
Too busy taking
care of others
Equipment
Of cancer
Of diagnosis
Of unknown
Unpleasant experience with colposcopy
Priorities
Fear
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No policy in place re:
referral f/u
Procedures
Lack of support services
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
Limited time w/ MD/NP
d/t large case load
Overall clinic time
limited
Emergencies / unexpected
complexity of appt.
Co-located srvs
not available
Need for
Pap
No process to
flag need for Pap
Physical
space limited
Not enough
clinic space
No reminders
for pt. appts.
Space used by other
practitioners
Appointments
Have to wait to use
exam room
Competing priorities
and time
commitments
Assume pt. doesn’t
want to do Pap
Lack of pt.
education re:
procedure
Trained staff
Limited funds for
equipment
Pain
Don’t want to
perform Pap
Don’t feel its
needed
Liability and billing
Cost of procedure
vs. other needs
People
Availability of equipment
Negative past experience
Pap not in area of
expertise
Expectations of
f/u on results
Low rate of
Pap smears
Staff not trained to use
equipment
Don’t want exam
Billing may not result in
reimbursement
Staff responsibility to
provide education not
defined
No process to remind pts. of appts.
Staff not aware of
problems with Paps
Staff
Svc. not covered
by malpractice
insurance
Pt. understanding
Appts. Made without
consultation with pts.
Expectations of staff
Expect pt.
won’t show
Limited time to explain
procedures
Space
Long wait
time
Walk-in appts. Delay
scheduled appts.
Assume pt. is
already informed
Patients
Of pain
Competing
health
priorities
Too busy taking
care of others
Equipment
Of cancer
Specialty equipment not
available. eg. tilting
exam table
Of diagnosis
Of unknown
Unpleasant experience with colposcopy
Priorities
Mobile Pap cart
not available
Fear
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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
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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
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Implement a Pap Festival
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 Example
Problem: Pap rate is still low after staff education and chart audits.
Objective: Entice / introduce women into GYN care via Pap Festivals.
Plan
Set date, identify
staff, include
consumers,
identify resources,
plan evaluation
Act
Need better,
more substantial
food, alonger,
more flexible
hours in that day
Do
Publicize free
activity, host Pap
Fest, document
services, survey
patients
Study
Reactions of the 21
participants, identify
barriers and
improvements thru
brief survey
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Jersey City Medical Center Example
Percents
JCMC Pap Rates
90
80
70
60
50
40
30
20
10
0
?
67
70
2005
2006
52
37
42
2002
2003
2004
2007
Year
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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 HIVInfected 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 Care
http://www.ihi.org/IHI/Topics/HIVAIDS/HIVDiseaseGeneral/Tools/
HIVQUALWorkbookGuideforQualityImprovementinHIVCare.htm
 National Quality Center
www.nationalqualitycenter.og
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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/PromotingGynecologicalGYNCareforHIVInfectedWo
men.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
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