The document describes how a fishbone diagram was used by the New Jersey HIV Family Centered Care Network to identify barriers to cervical cancer screening. A fishbone diagram identified numerous barriers related to environment, procedures, staff, equipment, and patients. Potential strategies were then discussed, such as onsite screening and reminders. The network set a goal of 70% of women receiving annual Pap smears. Use of the fishbone diagram engaged participants and facilitated identifying both causes of low rates and potential remedies.

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

2. 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. 3
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

4. 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. 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. 6
Common Cultural & Social Barriers
 Substance use
 Intimate partner violence
 Family history of reproductive cancers
 Gender roles
 Discrimination

7. 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. 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. 9
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

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

11. 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. 12
First Steps
 Facilitator and process members
 Problem
 Low Pap smear completion rates
 Main Causes
 Environment
 Procedures
 People
 Equipment

13. 13
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

14. 14
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

15. 15
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

16. 16
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
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

17. 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. 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. 19
Networkwide Goal
Seventy percent (70%) of all women will receive
and have documentation of a Pap smear on an
annual basis.

20. 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.
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

21. 21
Jersey City Medical Center Example
JCMC Pap Rates
37
67
42
52
70
?
0
10
20
30
40
50
60
70
80
90
2002 2003 2004 2005 2006 2007
Year
Percents

22. 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. 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. 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. 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. 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/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