Table 2 Participant suggestions for cervical cancer screening practice change

Barrier

Suggested solution

Details/examples

Patient concerns that the practice change is actually “less care” due to one test instead of two; perception of decreased quality of care

Clinician script and/or training on discussing evidence and high-value care

Accompany script with external resources (e.g., CDC, NIH) to explain the change—addresses concerns that KP or other health system is cutting corners or not providing the best care

Explain to patients that medical evidence is constantly changing

Ex script:

At KP, we want to provide you the highest quality, most evidence-based care. You can see from these national resources that primary HPV testing is the best possible choice for patients like you. While I can’t speak to what is going on in other systems, I can tell you that we want to do the best possible thing for you.

To make awareness of the patients to know that the test is being changed for the better and for more accurate and speedy results. Any kind of change you want it to be for the better and not just switching over because we think we should. We want a reason for it and the reason has to be better results. HPV_PT_001, Patient

If you go look at some of the research papers…They talk in more medical or science-based terminology that's not always something everybody is going to understand. I think the summaries are better than the full-on research paper…So, I would keep it simple but enough that the person who needs to be tested would trust…Because individually, I think it needs to be something that shows them why you're making that change and what the science is. HPV_PT_002, Patient

Yeah, I’m kind of concerned because what if I go in for my Pap, and I am told I will no longer be getting a Pap, and let’s say I’m not -- I don’t have HPV, and they said, okay, you’re free to go, I’d be concerned because I’d normally get a Pap, and I want to know what would have been said if I got a Pap. So what I want to know is will the HPV primary testing alone -- will that catch everything that would have been caught if I had a Pap? I would like to know. HPV_PT_005, Patient

Patient knowledge; additional resistance to loss of PAP test, the basis of which is fundamentally the fear of “missing cancer”

Develop a wide range of patient-facing resources for distribution both prior to and during rollout.

The theme of missing cancer is the primary concern related by patients (and some providers)—suggests the importance of addressing this fear first and foremost in ALL patient-facing materials—i.e.,

“99.7% of cervical cancer is caused by HPV.”

Brochures, flyers, other “one pagers” that address:

 Why the change?

 What are the benefits?

 What are the potential side effects and/or risks?

Other types of educational resources suggested:

 Posters in exam rooms and communal areas within medical centers

 Videos (waiting rooms, EMMI videos)

 Media/social media campaigns

 Patient portal (kp.org)

 Personalized letters before rollout

 Targeted reminder tied to the visit for the procedure

Have a one-page document with bullet points that they can give. Sometimes you’re listening to your doctor and then you go home and say, “What?” I love taking home little pamphlets. You guys are really great at doing your infographics. You feel like at least you got something that you can refer to. Especially if you were able to accept it from the doctor but you went home and couldn’t remember any of it, you’ve got this little piece of paper that reminds you. So, I like that. It doesn’t have to be a paper, although that’s probably best because not everybody has access to online. I thought they did but I just found out they’re not. I’m surprised. HPV_PT_002, Patient

Interviewer: Out of the ways you get contacted, either by email, phone or specific oPAP messaging, what’s your preferred method? What resonates with you the best?

Respondent: It’s hit and miss for me. They’re all three different honestly. Sometimes one is better than the other. I think my phone messaging is good. I like text messaging for certain things. For newsletter information stuff, I’d prefer that through email. HPV_PT_001, Patient

Kaiser is unique in the sense that every single one of your patients has to have a primary care physician. I specifically go to a gynecologist, but I know that any of the primary care physicians can perform a Pap smear. I think you’ve got the database there. You’ve got all the optics for all the women. You could start as simple as sending an email or note through the system from the doctor. You know who all of your women patients are. You know what their ages are. You could just announce there’s been a change. The next time you come in or if you have further questions, speak to your physician or gynecologist. Then have the doctors talk to you when you are in front of them. HPV_PT_003, Patient

Patient expectations for physician-patient communication about the switch to HPV primary testing

Clinically, this change may be perceived as simple by the provider and administrative stakeholders, but patient perceptions and concerns may be more than anticipated—they will likely expect/request proactive conversations with their doctors

Skipping this step in communication will likely lead to greater patient confusion and mistrust of the reasons for the change (i.e., KP is just trying to save money/increase convenience)

Physician and nurse teams need to be prepared with clear talking points and “scripts” to address this change with patients “early and often”:

Encourage clinicians to broach the topic of the practice change with patients at visits unrelated to a screening visit to better prepare patients for the change

A basic standard of care that I expect is to be given a guideline or a big picture of something. But I think they’re also responsible for working alongside you as well. A guideline isn’t the end-all-be-all. I think they’re also supposed to work alongside you and see what works best for you. HPV_PT_003, Patient

Tell me why what your change is better. “This is why we’re doing it.” Just by answering their question. Whether they like your answer or not, you’ve done your best. HPV_PT_001, Patient

I think just for this, it’s just a big educational piece with patients, just letting them know it is okay, we are doing the right thing here for you…As long as they explain why they think it’s a better test and that we don’t need that Pap…So, I think that will maybe be a little education as to why that’s safe and okay. HPV_001, Family Medicine Physician

…just bringing it up and asking patients if they have questions…so making sure they say, “You know, I want to take a minute to talk about this screening or whatever. What questions do you have? What concerns do you have?” Just that transparency and bringing it up and keeping us aware that there has a been a change or there might be a change or whatever. HPV_PT_007, Patient

Barrier

Suggested solution

Details

Provider resistance to change

Improve chance of buy-in by presenting a brief summary (e.g., fact sheets) of the evidence prior to the rollout:

Providers expect evidence to include:

 Rationale for the practice change

 Underscore evidence comes from a reputable external source (i.e., ACOG, USPSTF, etc.)

 Assuage concerns about “missed cancers”

Provide information in multiple formats:

 Departmental announcements via email and at meetings (from both Chiefs and DAs)

 In-service trainings from internal/external subject experts or “champions”

 Include stories of positive patient impact

 Independent learning modules on KP Learn

 Scripts or talking points to improve patient-provider communication on the subject

Like, there’s people that are more visual, there’s people that need to read it or need to see a demonstration…hit every learning angle, I guess, if that’s what you want to call it. HPV_006, Ob-Gyn LVN

…if the provider is not sold on it…it would be hard for them to convince a very anxious, nervous patient that this would be the right thing to do. HPV_022, Family Medicine Physician

Definitely a FAQs sheet. Doctors don’t like to read a whole lot of things like that...They just want the points…show me why and how… HPV_012, Family Medicine Department Administrator

Sometimes, at the family department meetings or the OB/GYN meeting, they would probably give out some information on that, or at the offsite [meeting], you’ll hit pretty much all the physicians there, specialists and primary docs. Emails, of course…and they just give us a little handout saying, “These are the new guidelines.”…So, it’s always good to get it from multiple sources, because I think one is not enough. HPV_001, Family Medicine Physician

It’s typically sort of multifactorial…usually, we’ve got visual, whether it’s flyers, the handouts, documentation, examples…demonstrate that…we’re not just throwing this out and saying, “Oh, now we’re doing this, now we’re doing that” But we’re saying, “Okay, here’s the change, here’s the benefits of the change, here’s the reasons why we’re doing the change. Here’s what you need, your part for participating, implementing this change.” HPV_003, Ob-Gyn Assistant Department Administrator

Provider learning curve

Address and satisfy questions about changes:

 Concerns about the follow-up algorithm in particular for primary care physicians

 Ease concerns that the workflow change may result in increased appointments and/or access issues

Specify the new FU algorithm clearly (a simple one-page flowsheet)

Bring in someone from gynecology to do a presentation

Utilize champions and DAs to train physician-nurse teams before rollout/reinforce during transition

For the workflow change, provide the nurse team with:

 Practical manual (e.g., visual aid for tray change)

…the first [barrier], which I already mentioned to you. But – inability to perform proper follow-up in three months for women of positive results. HPV_004, Ob-Gyn LVN

A staff meeting and literature….If I still had questions, I would definitely call our case manager – dysplasia case manager….they would be up to date. HPV_004, Ob-Gyn LVN

People are very visual. You put pictures of one tube versus two tubes. So, have one tube with a circle and then two tubes you would X out…everybody has a different way of doing it so whenever I work with different MA-LVNs I sometimes have to teach them how to do it and that is a burden for physicians because it should be a natural automatic standardized information. HPV_015, Family Medicine Physician

Potentially most challenging provider to garner “buy-in” from for the change

Do not overlook nurses and/or female providers who may view this change through a dual lens—as both a clinician and a female patient:

 As stakeholders, they may have heightened resistance to this practice change

They need clear/concise evidence; may be the most challenging to persuade, so provide evidence that speaks to the “why” as well and address their concerns head on about potential for “missed cancers” under new testing protocol

Do not forget about float pool of nurses—they often miss valuable trainings

…sometimes, they just said, “Oh, well. This is what we're implementing.”…We want to know why – why is this change happening? Are we losing anything? Are we gaining something from it?...[also]…is it ACOG-approved…Or is this just Kaiser changing it just because. HPV_004, Ob-Gyn LVN

For the nurses, they just want to understand why this happening and what the potential impact for them and the patients are. HPV_011, Ob-Gyn Department Administrator

They sometimes have floating nurses [and] there are part-time nurses, and then there are nurses who normally are on the phone, but then they end up stepping in, and they didn't get trained, and they don’t know what they're doing. So, you want to [capture] everybody. HPV_022, Family Medicine Physician