Employing Process Maps to Identify Provider- and Site-Variation in Screening for Autism Spectrum Disorder

Background:  Challenges in moving scientific evidence into practice and policy are well-documented in the identification and treatment of autism spectrum disorder (ASD), especially for historically underserved communities. One factor thought to contribute to this translational lag is the time it requires to move a traditional research program from investigation of efficacy to effectiveness to implementation. To expedite the traditional research program, health services researchers are increasingly employing effectiveness-implementation hybrid designs that take a dual focus a priorion effectiveness and implementation. Blending these approaches into a single design is hypothesized to improve “clinical utility” of the study for practicing clinicians and decision makers. We demonstrate the value of a multi-method qualitative study that employed process maps- a systems-level visualization of the process logic and flow- to investigate fidelity and process efficiency of a three-stage screening process.

Objectives:  We present how the use of multiple qualitative methods informed the development, validation, and application of process maps, with implications for improvements in fidelity and process efficiency of the intervention protocol.

Methods:  We employ multiple qualitative methods to assess fidelity and process efficiency in the protocol for a three-stage ASD screening process. To improve the validity of process maps, we utilized respondent triangulation through inclusion of multiple samples, specifically: (1) research staff who developed and supported intervention approach (n=10), and (2) EI service providers who administered the two stage screening (n=21). All participants were asked to develop a process map of the screening process from point of initiation until time of completion. For trainers, we then conducted two concurrent focus groups to develop independent process maps and a subsequent member-checking focus to reconcile differences and validate findings. For EI providers, process maps were created during semi-structured interviews. Once collected, we individually analyzed trainer and EI provider process maps, coded, and summarized themes regarding protocol adaptation and provider variation.

Results:  Comparing process maps of research staff and EI providers revealed considerable variation in adaptations made to the multi-stage screening protocol. For example, while the process maps generated by research staff illustrated initiation of the process to be when screening tools were distributed to providers, the process maps from EI providers demonstrate multiple non-scripted criteria to initiate or deter the process, including (1) whether the EI service provider, other clinical team members, or parents expressed concerns for ASD, (2) assessment of parental readiness to discuss ASD, and (3) assessment of family’s service delivery needs and priorities. After initiation of the screening process, maps also revealed variation in how providers present ASD concerns indicated by the screening tools and the extent to which they expedited the process for further evaluation or relied on the family to move the process to subsequent screening stages.

Conclusions:  Our findings suggest considerable adaptation occurred to intervention protocol, but systematic investigation of adaptations provides opportunity for protocol enhancement and training. Results reported above, for example, calls for additional EI service provider training in a shared decision-making process that encourages meaningful family engagement while minimizing delays to diagnosis during this critical developmental period.