Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

THE CANCER INFORMATION SERVICE 

Expanding Telephone Access 

JUNE GIBBS BROWN 

Inspector General 

MAY 1998 

OEI-09-97-0360 
OFFICE OF INSPECTOR GENERAL 

The mission of the Office of Inspector General(OIG), asmandatedby Public Law 95-452, is to 

protect the integrity of the Department of Health and Human Servicesprograms aswell asthe 

health and welfare of beneficiaries servedby them. This statutory mission is carried out through 

a nationwide program of audits, investigations, inspections,sanctions,and fraud alerts. The 

Inspector Generalinforms the Secretaryof program and managementproblems and recommends 

legislative, regulatory, and operational approachesto correct them. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) is one of severalcomponentsof the Office of 

Inspector General. It conductsshort-term managementand program evaluations (called 

inspections)that focus on issuesof concernto the Department, the Congress,and the public. The 

inspection reports provide findings and recommendationson the efficiency, vulnerability, and 

effectivenessof departmentalprograms. 

OEI’s SanFranciscoRegional Office preparedthis report under the direction of Kaye Kidwell, 

Regional Inspector General. Principal OEI staff included: 

REGION 

Paul Gottlober, Project Leader 

Carrie Lozano, Lead Analyst 

StevenZerebecki, Lead Analyst 

Jennifer Miller, Consultant 

Kathy Dezotte, Program Assistant 

HEADOUARTERS 

Alan Levine, Program Specialist 

BarbaraTedesco,Mathematical Statistician 

To obtaincopiesof this report,pleasecall the SanFranciscoRegionalOffice at 41S-437-7900. 

Reportsare also available on the World Wide Web at our home page address: 

http://www.dhhs.gov/progorg/oei 
EXECUTIVE SUMMARY 

PURPOSE 

To identify and evaluatethe causesfor the high busy signal rates, abandonmentrates and wait 

times on the Cancer Information Service (CIS) toll-free telephone service and to determine how 

to reduce or eliminate them. 

BACKGROUND 

The Cancer Information Service’s (CIS) mission is to be the “voice of the National Cancer 

Institute (NCI)” by providing the most current NC1 information to cancer patients, their 

families and friends, health professionals and the public at large. The CIS disseminatescancer 

information directly to consumersthrough its toll-free telephone service (l-800-4CANCER) 

and indirectly through its outreach program. 

Since 1976, CIS has provided cancer information to the public via its network of contractors, 

currently numbering 19. Callers are automatically routed to the contractor responsible for 

their geographic area. At eachcontractor, information specialistsanswer calls about the 

causes,prevention, diagnosis and treatment of cancer. They also refer callers to local 

community organizations. Contractors are also required to provide assistanceto community 

organizations through an outreach program. Estimated contractor funding in 1997 was 

approximately $15.8 million. ’ 

The CIS Branch, located in NCI’s Office of Cancer Information, Communication and 

Education, is responsible for contractor and program oversight. 

Accessto the service can be measuredin total calls taken, busy signal rates, abandonmentrates 

(the percentageof callers waiting in queuewho disconnectbefore reaching staff) and wait 

times (the averageamount of time a caller is on hold before speaking with staff). In 

1997, almost 1 out of every 3 of the attempted calls (or 240,860 calls out of 834,185) to CIS 

failed to reach an information specialist. Busy signal rates for the individual contractors 

ranged from 10 to 52 percent during the sameperiod. Network-wide averagebusy signal rates 

for 1995 and 1996 were similarly high. According to a National Performance Review Study, 

the top ranked private sector telephone servicesexpect busy signal rates of less than 2 percent. 

Our methodology consistedof mail surveys, telephone and in-person interviews, focus groups 

and a review of CIS-related statistics and information. 

1 Source: CIS Branch 

i 
FINDINGS 

The CIS is a valuable public service enhanced by its dedicated staff and strong training and 

quality assurance programs 

The CIS is a unique service that the public relies on for the most up-to-date, scientific 

information on cancer. Despite stressand frustration, staff remain dedicated to the mission 

and goals of CIS. A comprehensivetraining program and practical evaluation tool strengthen 

the service and serve as models for others to emulate. 

The CIS does not take full advantage of current telephone technology to improve access and 

customer service 

The CIS does not use its phone technology to route callers to the first available information 

specialist. Furthermore, it does not provide callers with important recorded messagesthat 

could preclude them from reaching a busy signal or waiting on hold. 

Data gathering requirements adversely affect call efficiency 

Although random sampling is a widely-accepted practice in both the private and public sectors, 

CIS requires contractors to document 100 percent of calls and collect demographic data on half 

of them. The software used to record the data is poorly designedand is accompaniedby 

unnecessarilyrestrictive policies, such as requiring information specialiststo document the 

sameinformation in both code and narrative form. The CIS staff regard the software and 

related policies as critical factors that inhibit their efficiency. 

Information specialists could be more efficient if their resources were more readily accessible 

and user-friendly 

Staff identified severalproblems with their main resource, the Physician Data Query. They 

also reported that non-computerized resources,such as “Fact Sheets,” are difficult to maintain 

and update and that their community service information is frequently inaccurate and 

incomplete. 

The regional structure does not contribute to a consistent and efficient phone service 

Demographic differences, the number of phone lines and the distribution of resourcesare some 

of the variables that have led to inconsistent contractor performance. Contractor performance 

is also affected by the level of support received from parent institutions as well as local 

managementpractices. While contractor staff continually and consistently volunteered that the 

current regional structure enhancesthe “personalized” service that callers receive, we found 

little supporting evidence. 

ii 
The US’s customer service standards do not address access to the toll-free service 

The CIS Branch has not set minimum accessstandardsfor CIS contractors. For example, CIS 

contractors are not expectedto keep their busy signal rates under a specific threshold. Similar 

health information organizations and other telephone service centersthroughout the country 

have implemented minimum standards. 

RECOMMENDATIONS 

The Cancer Information Service, through its telephone service, provides the public with an 

invaluable resource for information about cancerprevention, causesand treatment. To expand 

accessto the toll-free service, the Office of Cancer Information, Communication and Education 

should: 

. Complete and implement plans to upgrade CIS telephone technology to enhance 

contractors’ ability to respondto calls and provide information to all callers. 

. Establish technical requirements and performance standardsfor contractors. 

. Modernize and correct deficiencies in the Physician Data Query. 

. Improve efficiency by reducing data gathering requirements and computerizing 

more reference materials, such as “Fact Sheets.” 

. Discontinue collecting and disseminating community service information; 

instead, partner with national organizations to provide this information. 

. Re-evaluatethe regional structure. 

. Encourage contractors to further enhanceCIS staff training. 

AGENCY COMMENTS AND OIG RESPONSE 

We received written comments on the draft report from NC1 (seeappendix B). We are 

encouragedthat NC1 already has taken action on some of our recommendations. However, we 

remain concernedabout inefficiencies in vital areasof the program and would like to clarify 

and reassertthe following recommendations. 

We continue to believe that (1) to improve efficiency, NC1 should quickly adopt a statistically 

valid sampling methodology for all CIS data recording and collection efforts, (2) the CIS 

Branch and its contractors should ceaseduplicating private sector efforts by collecting, 

maintaining and disseminating information on community resourcesand (3) NC1 should 

. . . 111 
reconsider the regional structure of the phone service. The relationships between the phone 

service, the outreach program and researchactivities do not justify the current inefficient 

regional structure. 

iv 
PAGE 

EXECUTIVE SUMMARY 

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..f............................ 6 

Valuable public service,dedicatedstaff, strongtraining and quality assurance ........ 6 

Currenttelephonetechnology .............................................. . 

Burdensomedata gathering ............................................... .9 

Accessibility of resources ................................................ 11 

Questionableregional structure ............................................ 12 

Customer servicestandards ............................................... 15 

RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 

APPENDICES 

A: CIS Regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-l 

B: NCI’s comments on the draft report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-l 
PURPOSE 

To identify and evaluatethe causesfor the high busy signal rates, abandonmentrates and wait 

times on the Cancer Information Service (CIS) toll-free telephone service and to determine how 

to reduce or eliminate them. 

BACKGROUND 

The Cancer Information Service’s (CIS) mission is to be the “voice of the National Cancer 

Institute (NCI)” by providing the most up-to-date information from NC1 to cancer patients, 

their families and friends, health professionals and the public at large. The CIS disseminates 

cancer information directly to consumersthrough its toll-free telephone service 

(l-800-4CANCER) and indirectly through its outreachprogram. 

The NC1 is the federal government’s principal agency dedicatedto understanding the nature of 

cancer. The NC1 is a scientific institution with the majority of its resources(more than 

$2 billion in 1997) being spent on researchinto the causes,treatment and prevention of cancer. 

In 1971, President Nixon signed the National Cancer Act, authorizing additional funds for 

cancer research, prevention and education through the initialization of the National Cancer 

Program. In 1974, an amendmentto the Act made the CIS possible by mandating that the NC1 

Director: 

. ..provide a contract for a program to disseminateand interpret, on a current basis, for practioners 

and other health professionals, scientists, and the general public scientific and other information 

respecting the cause,prevention, diagnosis, and treatment of cancer. 

In the following 2 years, NCI’s Office of Cancer Communications and Division of Cancer 

Prevention and Control jointly conceived a national toll-free telephone information service. 

The NC1 offered contracts to its “ComprehensiveCancer Centers” (i.e., universities, hospitals 

and researchcenters) (1) to maintain regional information services, using information on both 

researchand treatment provided by NC1 and (2) to develop and maintain regional databaseson 

clinics and organizations serving cancerpatients. In 1988, the Office of Cancer 

Communications assumedfull oversight of the contractsthrough the CIS Branch. The CIS 

Branch and the International Cancer Information Center (the publisher of the Physician Data 

Query) are now under a new division called the Office of Cancer Information, Communication 

and Education. 

In late 1976, the CIS telephone service becameoperational. By that time, NC1 had contracted 

with 17 ComprehensiveCancer Centersthat respondedto calls within separate,specific 

geographic regions using individual toll-free telephone numbers. Available telephone 

technology in 1976 did not allow call routing to different regions via a single, national toll-free 

number. The new CIS contractors did not service the entire nation. Calls from areasnot 

1 
covered by CIS contractors were answeredby an alternate centrally-located contractor. In 

1983, CIS implemented a single, national toll-free number (l-800-4CANCER). Calls are 

routed automatically from the single number to the CIS contractors, basedon the callers’ 

locations. 

The current number of contracts is 19. Each contract respondsto calls within a specific 

geographic region. The sizesof the regions vary from covering a portion of a single stateto 

up to six full states. Together, the 19 contractsprovide service for the entire nation and Puerto 

Rico in English, Spanishand teletypewriter (TTY) for the hearing impaired. In addition to the 

19 contracts, CIS contracts for a Publications Ordering Service in Maryland. The publication 

service fulfills NC1 publication requestsfor the entire nation and also is reachedvia 1-800-

4CANCER. 

In addition to a small Federal staff in the CIS Branch, the CIS is staffed by a network of 

information specialists, telephone service managers,project directors, outreach managersand 

coordinators and support staff who are employeesof the 19 CIS contractors. Information 

specialistsare the voice of NCI; they answer incoming calls and provide information requested 

by callers. They use NC1 publications and NCI’s on-line databaseof cancer treatment, 

prevention and clinical trial information called the Physician Data Query (PDQ) as first-line 

resourcesto respond to callers. Information specialistsalso use community service databases, 

individually developed and maintained by the 19 contractors, to respond to callers’ requestsfor 

community information. Information specialistsdocument eachcall on-line using the 

Electronic Call Record Form. The form is used to record the reason for and responseto the 

call, the resourcesused during the call and the caller’s demographic information. 

The CIS Branch regularly evaluatesthe phone service by performing anonymous test calls to 

all contractors. The tool used for this evaluation is the CIS Telephone Evaluation and 

Reporting System (CISTERS). In short, CISTERS evaluates: 

t the correctnessof the information provided; 

b adherenceto policies and procedures; 

b the completenessof the call; 

b the appropriate use of resources; 

t customer service (making sure the caller understood and received the information he or 

she desired); 

b the information specialists’ demeanor, communication skills and credibility and 

t overall customer service. 

On the basis of CISTERS test call results, CIS identifies areasthat require improvement. The 

CIS Branch regularly provides contractors with reports of CISTERS test calls. 

Telephone call statistics are maintained on a daily basis by the contractors and a monthly basis 

by the CIS Branch. Daily statistics are aggregatedinto monthly reports. The Basic Call 

Management System, AT&T’s Federal Telecommunications Service (FTS2000) Management 

System and the Electronic Call Record Form are CIS’s instruments for measuring telephone 

statistics. Each contractor collects daily telephone statistics using the Basic Call Management 

2 
System, a computer system linked to the information specialists’ phone extensions. The 

AT&T provides separatedata from the FTS2000 Management System. Both the Basic Call 

Management System and FTS2000 record the number of calls taken, busy signal rates, 

abandonmentrates and the time connected. The Electronic Call Record Form records talk time 

for eachcall, a count of calls answeredduring a given period of time and information about the 

content of the calls. 

The number of calls reported by the Basic Call Management System, FTS2000 and the 

Electronic Call Record Form do not match. As a result, accuratefigures on the actual number 

of calls CIS is processing do not exist. The CIS Branch recently contracted with an 

engineering firm to explain the data discrepanciesand recommend changes. The firm also is 

analyzing telephone staffing and regional managementconfigurations. 

In addition to answering the toll-free line, CIS contractors are required to operate an outreach 

program and conduct limited research. Each contractor’s outreach coordinator servesas a 

liaison between CIS and other organizations interested in disseminating NC1 information and 

promoting NC1 messages. Outreach efforts also addressspecific cancer issues, such as breast 

and cervical cancer and clinical trials recruitment, with a particular focus on underserved 

populations and those individuals who have difficulty accessinghealth information. 

Total funding for the 19 CIS contractors in 1997 was $15,745,983,’ a decreaseof 9.4% from 

the 1996 funding level due to an NC1 mandate. In previous years, funding was: 

1993 1994 1995 1996 

$7,640,094 $17,272,420 $18,047,134 $16,786,158 

Phone Service Access 

Since its inception, CIS has answeredan increasing number of calls eachyear, from a low of 

approximately 47,000 in 1976 to a high of almost 600,000 in 1997.3 The phone service 

operatesfrom 9:00 AM to 4:30 PM, local time, Monday through Friday. Accessto the 

service can be measuredin total calls taken, busy signal rates, abandonmentrates (the 

percentageof callers waiting in queuewho disconnectbefore reaching staff) and wait times 

(the averageamount of time a caller is on hold before speaking with staff). 

In 1997, almost one out of every three calls to l-800-4CANCER during operating hours failed 

to reach an information specialist. Almost 29 percent of the 834,185 attempted calls (i.e., 

240,860 calls) made to l-800-4CANCER resulted in a busy signal.4 Additionally, there are 

2 Source: CIS Branch 

3 Source: AT&T. 

4 Using CIS’s presentAT&T technology, it cannot be determinedhow representativethe busy 

signal rate is of the actual number of people who are attempting to reach the service and failing. 

3 
wide ranges in the accessstatistics for the 19 individual contractors. For example, in 1997 the 

averagebusy signal rate per contractor varied from 7 percent to 53 percent. If the Spanish 

telephone lines are included, the margin widens from 4 percent to 67 percent. The CIS Branch 

reports similarly high busy rates for 1995 and 1996. 

Contract funding for 19975indicates contractor spendingper completed call varied from 

$29 to $74 for 18 of the 19 contractors. The averagecost per call for the 19thcontractor was 

approximately $150. According to CIS, this unusually high cost per call can be attributed to 

the contractor’s reliance on outreach and the low volume of calls it receives. The averagecos 

per call (total contract spending divided by total number of completed calls) for the entire CIS 

network was $41. The variance among contractors may be explained, in part, by contractor 

spending on their outreach programs and the fact that contractors are required to employ 

managementstaff in equal numbers, regardlessof the number of lines they operate. 

CIS Contractor Variances (1997) 

Lines Contractors Average 

busy signal rates 

Average 

cost per call 

Average number of 

completed calls per line 

3 I 1 15% $1 506 480 

4 7 7-30% $29- 74 2921 - 4977 

5 I 5 22-32% $23-41 3933-6301 

6 6 9-50% $29-55 3799-4744 

Telephone Service Benchmarks 

On September 11, 1993, President Clinton signed Executive Order 12862 on “Setting 

Customer Service Standards”in government. The directive required all executive agenciesthat 

provide direct public servicesto set benchmarks for customer service performance. 

In February 1995, Vice President Al Gore’s National Performance Review included a Federal 

Consortium Benchmark Study Report. The report focused on best practices in telephone 

service and found that the top ranked private sector organizations used the following measures 

to predict customer satisfaction: 

t averagespeedof answer: less than 15 seconds 

b abandonedcall rate: less than 2 percent 

b busy signal rate: less than 1 percent 

t service level (total calls minus busy signals and abandonedcalls): 98 percent 

t first call resolution (one agent/no transfers): 85 percent resolution 

5 This is basedon the most recent budget figures received from the CIS Branch. During the course 

of the inspection, we received severaldifferent setsof contract funding figures. 

6 This region was closed for 3 months in 1997. Its budget was adjusted;therefore, the averagecost 

per call reflects 9 months of phone service. 

4 
Other attributes of the top ranked private sector call centers include: 

b a recognition that state-of-the-arttelephone and computer hardware and software 

technologies are top businessimperatives, 

t peak demand times are managedby offering callers the choice of live or automated 

service while scheduling staff to meet call demand and 

b substantial site consolidation. 

METHODOLOGY 

In addition to a mail survey to all information specialists, we conducted on-site focus groups 

with information specialistsat six contractor sites. Eighty-four percent (163 out of 195) of the 

information specialistsrespondedto our mail survey. We selectedthe six contractor sites 

basedon their call statistics, the populations they serve and their proximity to other national 

cancerorganizations. Using informal discussion guides, we also interviewed (in-person or by 

telephone) the project directors, telephone service managersand outreach staff at all 

19 contractors as well as telephone service supervisorsat most of the contractors. 

We chosea purposive sample of national cancer organizations to reflect the various types of 

organizations that could benefit from or make use of CIS information. The sourcesused for 

the sample included CancerCare’sA Helping Hand--The ResourceGuidefor People With 

Cancer, organizations identified by the CIS Branch and the Internet. Inclusion was basedon: 

1) the information or topic the organization addresses,2) their constituency and 3) the nature 

of servicesthe organization provides. Prior to conducting interviews, we verified that each 

organization serveda national constituency. We conductedinterviews with principal staff, 

which included directors and managers, from 56 organizations regarding their scopeof 

services, their information resourcesand their experienceswith CIS and the PDQ. 

We visited 10 privately- and publicly-funded health information and cancer organizations. 

Staffs were interviewed regarding their experienceswith CIS. We observedthe operations of 

health information servicessimilar to CIS and reviewed their information systems, call 

statistics and relevant policies and procedures. 

We reviewed and analyzed policy and training manuals, reports, call statistics, contracts and 

plans that CIS has developed over the last severalyears to improve the telephone service. We 

also interviewed staff from the outreach program, CIS Branch, CISTERS, the International 

Cancer Information Center and the contractor that is responsible for the Publications Ordering 

Service, portions of the PDQ and programming the Electronic Call Record Form. 

The findings in this report reflect the experiences,opinions and observations of contractor, 

Branch, cancer and health organizations and OIG staff. A companion report entitled “The 

Cancer Information Service--A Resourcefor National Cancer Organizations” 

(OEI-09-97-00361) contains additional information regarding how national cancer 

organizations use and value the Cancer Information Service and its resources. We conducted 

our review in accordancewith the Quality Standardsfor Inspections issuedby the President’s 

Council on Integrity and Efficiency. 

5 
THE CIS IS A VALUABLE PUBLIC SERVICE ENHANCED BY ITS DEDICATED 

STAFF AND STRONG TRAINING AND QUALITY ASSURANCE PROGRAMS 

The CISprovides a unique and valuable public service 

The CIS is a unique health information service. It is the only cancer information service that 

addressesall cancersand usesonly NC1 developed, reviewed and/or approved literature and 

data. Callers are the general public, cancerpatients, their friends and families and health 

professionals. Callers receive information from CIS that helps them to understand cancerand 

make better informed decisions about treatment or prevention. Through CIS, the public learns 

first-hand what advanceshave been made as a result of this nation’s investment in cancer 

research. The public relies on CIS for the most comprehensiveand reliable clinical trials 

listing available through a single toll-free phone service. Congressspecifically requires NC1 to 

inform the public of its findings, and CIS is one of NCI’s principal modes of communication. 

Other cancer organizations confirm that CIS is the most comprehensiveand credible sourcefor 

cancer information. One organization praised CIS saying, “You get more information from 

CIS than anyone else, and the information is scientific. Nationally, they are the most 

credible. ” The sentiment was echoedby many other organizations. For additional information 

on other cancer organizations’ perceptions of CIS, seethe companion report entitled 

“The Cancer Information Service--A Resourcefor National Cancer Organizations” 

(OEI-09-97-0036 1). 

Despite stress and frustration, staff remain dedicated to the mission and goals of CIS 

The staff of CIS, information specialistsin particular, confront the reality of cancer on a daily 

basis. Cancer patients and their friends and family, often desperatefor answers, turn to CIS. 

To respond, CIS staff must master volumes of complicated information. They must be 

sensitive to emotionally charged callers and to callers’ relationships with their physicians. 

They must also follow many confusing and arbitrary policies and procedures. For example, 

they: 

b must obtain their supervisor’s permission before sending certain types of publiclyavailable information (e.g., information for health professionals from Cancernet); 

b cannot send information to a third party even when the caller statesshe is inquiring on 

someoneelse’s behalf; 

t must follow an information hierarchy, even if the information is not relevant; 

b must ask if the caller has spoken with her physician about support groups before 

providing support group referrals and 

t can quote, but cannot send, certain NC1 and other publicly-available materials 

(e.g., Medline information). 

6 
The CIS’s goal is to provide callers with accurate, up-to-date information on very complex 

diseasesthat afflict 40 percent of the nation’s population. Staff are pressuredon two distinct 

fronts: (1) they must give callers all of the information relevant to their condition (and not 

rush the caller in the process)and (2) they must be able to answer and respond to all the callers 

who are trying to get through. Information specialistsare genuinely concernedabout the busy 

signal rate. In at least two contractor offices, information specialistshave resorted to covering 

up the queue indicators on their phonesbecausethey get ‘%tressedout” when they seethem 

while on a call. Accessproblems are a sourceof stressin their lives, and their self-evaluations 

of job performance are clearly affected by the service’s inability to deal with public demand. 

At most CIS contractors, information specialistsare afforded little opportunity for career 

advancement. Salary ranges, which are determined by eachcontractor’s parent institution, 

typically fall below $30,000 per year. Still, information specialistsremain dedicatedto CIS; 

more than 65 percent of them have been with the service longer than 3 years, and more than 

23 percent have been with the service longer than 5 years. 

Many information specialistsvolunteered that their ability to help people provides them with 

personal andjob satisfaction. At one CIS contractor, a retired physician decided to work for 

CIS becausehis son had been misinformed about cancertreatment options by his doctors. He 

felt that he could make a difference in the lives of cancerpatients while working at CIS. At 

another contractor, information specialistswere volunteering their own time for additional 

training that the contract was not funding. 

The CIS invests in an ambitious and comprehensive trainingprogram 

Information specialist training is comprehensiveand includes a continuing education 

component. All information specialistsare required to complete an initial 8-week training and 

certification process. Currently, applicants must have college degreesor must be registered 

nursesto qualify as information specialists. In the absenceof thesequalifications, they must 

have serveda minimum of 2 years as a CIS information specialist at another time. Initial 

training covers CIS policies and procedures, a general overview of cancer topics such as 

treatment, detection and staging and expandedtraining on breast, prostate and lung cancer. In 

order to maintain certification, information specialistsare required to complete a minimum of 

12 hours of continuing education per quarter, must answer the phones a minimum of 12 hours 

per week and must maintain quality per CISTERS standards. Contractors choosea variety of 

methods for information specialiststo complete continuing education, such as participation in 

hospital grand rounds, attendanceat lectures or assignedreadings. Finally, CIS contractors 

are required to conduct special training programs at the discretion of the CIS Branch. 

Eighty-six percent of information specialistsranked CIS training as either excellent or very 

good. While information specialistshighly regard their cancer training, they believe that 

managementtraining, software training, training on technical information and Internet training 

would be useful. 

7 
Cancer organizations are impressedwith CIS training. Two cancer organizations indicated that 

they would like to participate in CIS training when askedhow they would like to work more 

closely with CIS. A third commented that CIS training is a “real highlight” of a “generally 

wonderful” service. 

The CISTERSprogram is an excellent evaluation tool, although it is misunderstood by some 

con tractor staff 

The CIS Telephone Evaluation and Reporting System (CISTERS) program evaluatescontractor 

performance consistently and without bias, with an eye toward developing staffs’ ability to 

handle calls. With the participation of contractors, the staff at CISTERS developstest call 

“scenarios” that accurately representreal calls. They call all contractors and document the 

outcome of the calls on a custom computer software application. More than half of the 

contractors believe that CISTERS improves call efficiency. Several mentioned that it helps 

organize calls, although its suggestionsmay increasecall length. According to staff, “Test 

calls are valuable; they hit on important issues”and “CISTERS improved call efficiency 

tremendously. Call guidelines are helpful; they bring information specialistsback to key 

issues.” In a customer satisfaction survey that was conductedby the CIS Branch, most 

contractors said CISTERS was helpful and reported different and creative ways they use 

CISTERS reports to improve service. 

Staff from the CIS Branch suspectthat some contractors totally disregard CISTERS 

recommendations, while others employ varying degreesof action. Some contractor staff are 

concernedabout not following CISTERS criteria and view the reports as punitive rather than 

instructive. Comments from those staff members indicate that not everyone understandsthe 

purpose of CISTERS. We visited severalother health information telephone lines. None of 

them has an evaluation tool that comparesin usefulness. 

The program is not without its limitations, but the deficiencies we detectedwere minor relative 

to its merits. For example, CISTERS does not develop scenariosthat involve highly emotional 

callers, a scenariothat information specialistsappearto be struggling with. One information 

specialist asserted,“They (CIS Branch) don’t want us to think of ourselvesor call ourselves 

‘counselors.’ But we are, we really are.” We observedanother information specialist who 

appearedawkward on a highly emotional call, reading scripted customer service questionsat 

its conclusion. The program actually performs relatively few test calls, less than 10 per 

contractor per quarter. Some contractors have complained that such a small sample cannot be 

used to gaugetheir performance accurately. Sampleswill be increasedin 1998, however, 

according to CISTERS staff. 

8 
THE CIS DOES NOT TAKE FULL ADVANTAGE OF ITS CURRENT TELEPHONE 

TECHNOLOGY TO IMPROVE ACCESS AND CUSTOMER SERVICE 

Callers are not routed to the first available information specialist 

The CIS’s single toll-free phone number automatically routes calls basedon the caller’s 

geographic location. The contractor’s ability to promptly answer the call is not taken into 

consideration. Basedon CIS call statistics and our on-site visits, we discovered marked 

variancesin demand and accessamong the different contractors. We observedat least one 

contractor with phone lines open for most of the day, while other offices had persistent queues 

of waiting callers. The CIS’s policy of routing callers to geographic contractors is not the 

most efficient way to ensurethe highest level of accessand customer service. Although 

current CIS telephone technology allows callers to be transferred or routed among contractors, 

this technology is used only occasionally to offset temporary, unplanned closings. 

The CIS lacks important recorded messages 

The CIS does not provide callers with the option of obtaining recorded information that could 

preclude them from reaching a busy signal or waiting on hold. For example, recorded 

information is not offered about CANCERNET (a website for NC1 Fact Sheets,the PDQ and 

other cancer information), CANCERFAX (an automatedfax service to obtain NC1 printed 

materials), the PDQ SearchService for Health Professionals, frequently addressedcancer 

topics and other sourcesof cancer information, even though such information may help callers 

when the phone lines are full. 

Standardinformation, such as medical disclaimers (explaining that information specialistsare 

not physicians) and source citations (generally NC1 materials), is repeatedby information 

specialiststo every caller instead of through an introductory recorded message. Information 

specialistsmentioned that the requirement to repeat the disclaimers and citations is excessive, 

that the wording is stiff and scripted and that disclaimers often interrupt the flow of the call 

and damagetheir credibility. In addition, when CIS is inundated with calls about a particular 

topic arising from intense media coverage, CIS does not take full advantageof telephone 

technology by giving callers the option to listen to explanatory messages. 

DATA GATHERING REQUIREMENTS ADVERSELY AFFECT CALL EFFICIENCY 

The Electronic Call Record Form software is problematic 

The Electronic Call Record Form is marred by technical problems and restrictive policies on 

its use. At best, the form is only a slight improvement over paper forms. At worst, it 

significantly impedes information specialistsfrom quickly and efficiently taking calls. 

Managers, supervisors and information specialistsagreethat the Electronic Call Record Form 

software is a source of inefficiency and a weaknessin the telephone service. Information 

specialists, in particular, believe that the software is in dire need of improvement. Examples 

of software problems identified by information specialistsinclude: 

9 
b the inability to move to a new Electronic Call Record Form without completing the 

current form on the screen. This meansthat information specialistsmust complete the 

form even if there is a queue; 

t the need to manually insert codes. For example, if a caller refusesto answer the 

demographic questions, the software does not automatically input refusal codesto all 

questions. Instead, information specialistsmust input a refusal code for eachquestion; 

t the need to type a narrative for the call as well as enter codes for the sameinformation 

provided in the narrative and 

b computer crashesand freezescausedby the software under certain circumstances. 

One telephone service supervisor, who also answerscalls, capsulized the frustrations of many 

respondents, 

The form isjust storage. It doesn’treally takeadvantageof computerabilities. If 

there’sa problemwith it, everyoneneedsto log-outandstart-up. This totally disrupts 

calls. NC1doesn’tunderstand.If you leavea field blank, an error comesup, andit is 

difficult to correct. Centralsupportrespondedto this by saying,“fill in all blanks.” 

The Electronic Call Record Form software causesthe computers to go down two to three times 

per week, according to a manager at another contractor. 

100 percent data gathering is excessive 

To capture detailed information about the nature of the calls, the demographics of callers and 

trends in eachregion, CIS requires that information specialistscomplete an Electronic Call 

Record Form for each call. Becauseof this, information specialists cannot move quickly from 

call to call. According to information specialists, completing demographic questionsadds 

severalminutes to every call. Documenting everything else, from the reason for the call to the 

responseto the inquiry, adds even more time. Nevertheless,CIS has mandatedthat 

information specialistsdocument 100 percent of calls and gather demographic data on half of 

them, despite the negative impact on phone service and current accessproblems. 

Randomly sampling populations for multi-variate analysis (including the type CIS does with its 

call data) is a widely acceptedpractice in government and the private sector. Service 

providers, including those providing health information, regularly use random samplesto 

monitor their customer service, quality improvement and quality control. A government health 

information service similar to CIS is sampling 1 in 30 callers for all data gathering. This 

includes the reasonsfor the call, responsesby staff and customer satisfaction. 

10 
INFORMATION SPECIALISTS COULD BE MORE EFFICIENT IF THEIR 

RESOURCES WERE MORE READILY ACCESSIBLE AND USER-FRIENDLY 

The Physician Data Query inhibits call efficiency 

The Physician Data Query (PDQ) is technologically archaic and time consuming. While 

contractors believe that PDQ information is typically “excellent,” nearly all of them identified 

problems with the program. Although most of the problems relate to the PDQ’s 

user-friendliness, staff reported myriad other problems such as incomplete, incorrect and 

out-dated information. One staff member described the amount of problems as “ungodly,” and 

another statedthat “the PDQ needsto be completely overhauled, becauseit isn’t easyto use 

when on a call. ” 

BecauseCIS usesa DOS-basedcomputer version of the PDQ, information specialistscannot 

conduct keyword searchesor easily move within or between documents. As a result, they 

cannot quickly scroll through information, and they may not be able to locate information on 

specific topics such as “hot flashes” or “nausea.” While there is a clinical trial searchtool, staff 

mentioned that the tool is not consistentand doesnot always return appropriate trials. To 

avoid navigational and searchproblems throughout the PDQ, several regions take time to 

download it into WordPerfect files or Folio View, and at least one region usesa hard-copy 

PDQ rather than the computerized version. 

While CIS contractors report most PDQ problems to NCI, staff from several contractors 

believe that NC1 is not responsive. According to NCI, the programming requirements of the 

PDQ do not allow problems to be addressedeasily. 

Community service databases are inaccessible, incomplete and inaccurate 

More than half of all information specialistsreported that their community service databases 

are inaccessible,mostly becausethey are not computerized. Information specialists in several 

regions must thumb through a Rolodex or binder to identify community service referrals 

during calls. They claim that calls would be shorter if the community serviceswere indexed 

on their computers. While some regions have computerized their community service 

databases,not all regions have the technology, time or expertise to do this. Further, 

computerization does not mean that the databasesare accurateor up-to-date. 

The lack of a clear policy and direction for gathering and maintaining community service 

information has resulted in inaccurate and incomplete databasesat some contractors. While a 

majority of contractors reported that community service referrals are important, there was 

inconsistency in the staffs’ understanding of (1) NC1 policy and direction with regard to 

community referrals, (2) what standardsshould be imposed for inclusion of community 

organizations and (3) when and how to update their databases. For example, some contractors 

have opted to use databasesprovided by other organizations. One contractor is mainly using 

“Fact Sheets”on how to find and choosea community organization, while other contractors are 

providing referrals to national organizations only. Information specialists complained that 

their community service databasesare the least complete and accurateresourcethey use. 

11 
Managers corroborated with comments like, “Referral servicesare very problematic, especially 

for the staff. We only have a few resources,” and “Having current resourcesis a sourceof 

great trouble. We need to be up-to-date.” For additional information on community service 

referrals, seethe companion report entitled, “The Cancer Information Service--A Resourcefor 

National Cancer Organizations” (OEI-09-97-00361). 

Contractors cannot easily maintain and update NCI ‘%act Sheets ” 

Staff at CIS contractors complain that the processof updating “Fact Sheets”is wasteful. “Fact 

Sheets”are one of the primary resourcesinformation specialistsuse during calls, becausethey 

cover a range of frequently addressedtopics in a concise and easy-to-understandmanner. 

Becausemost regions maintain “Fact Sheets”in binders at eachdesk, the current system for 

updating them (which includes downloading, photocopying, distributing and making sure the 

old ones are discarded) is inefficient. Updating is complicated by the fact that one “Fact Sheet” 

may be revised severaltimes within a short time period. According to staff, computerization 

would easethe updating processand allow easier organization and access. One contractor is 

using a scannerto computerize the sheets;however, most contractors do not have this 

capability. 

THE REGIONAL STRUCTURE DOES NOT CONTRIBUTE TO A CONSISTENT AND 

EFFICIENT PHONE SERVICE 

Demographic differences among the regions may affect demand on CIS 

There are measurabledifferences in the contractors’ regional populations, and it doesnot 

appear that CIS resourcesare equitably allocated to addressthe most basic of thesedifferences. 

For example, total resident population and percentageof population over age 

65 (most cancersoccur in those over age 65) probably influence contractor demand. Regions 

consist of populations that range from approximately: 

t 1.2 million to 22.4 million7 in total residents, 

b 10.5 percent to 16.7 percent in residentsover age 65, 

b 395,000 to 3.7 million in population per available CIS phone line in the region and 

b 51,000 to 508,000 in residentsover age 65 per available CIS phone line in the region. 

In addition to the variances in demographics among the regions, there are variancesin 

demographics among contractors who have the samenumber of phone lines. For example, a 

contractor with only 4 phone lines is serving a region with 3.9 million residents, while another 

contractor with 6 phone lines is serving only 1.4 million residents: 

7 Source: 1997projections--US CensusBureau and the CIA World Factbook (for Puerto Rico only) 

12 
Number of Telephone Lines Compared to Regional Demographics 

Lines Contractors Regionat population 

per line 

Resident population over 

age 65 per line 

3 1 395,000 51,000 

4 7 2.6 - 3.9 million 312,000 -482,000 

5 5 1.4 - 3.7 million 152,000 - 505,000 

6 6 1.4 - 3.7 million 185,000 - 508,000 

It is not clear that the regional structure positively contributes to customer service 

Despite CIS’s assertion that the regional structure enhancescustomer service, we were unable 

to identify any factual basis to support the claim. Furthermore, we interviewed staff from 

health information servicesproviding telephone servicessimilar to CIS and found that 

disseminating technical health information and dealing with callers in crisis from a central 

location can be done efficiently and achievea high level of customer satisfaction. One cancer 

organization statedthat they have not had any objections to their centralized service (that was 

recently consolidated from many regional locations), because“if you give [callers] what they 

want, they don’t care where you are.” 

We found no evidencethat callers are better servedby information specialists located within a 

geographic region that the caller is likely to identify with. In fact, the opposite is true. It is 

unlikely, given CIS’s current regional structure, that 1) a large majority of callers identify with 

the location of their CIS contractor office and 2) CIS contractor staff are necessarily more 

aware of all of the areasthey serve simply becauseof their location (seethe appendix for the 

current CIS regional structure). 

The CIS also claims that the regional configuration is important for the outreach program. 

While it is true that outreach targets communities within the region, the relationship between 

outreach and the phone service is superficial at best. Although the telephone service and the 

outreach coordinators are housedin the samecontractor offices, most contractors did not 

identify a strong relationship or interdependencebetweenthe two programs. In most regions, 

the information specialistsdo not participate in outreach and the only relationship between the 

two programs is that outreach promotes the telephone service, the telephone service fields calls 

for outreach and information specialistssometimesprovide the outreach coordinator with 

technical information. In fact, severalproject directors indicated that they are struggling to 

find a relationship between the two programs becausethey have different “missions,” “reach 

different groups” and “are two separatepiecesthat do not always function together.” 

Con tractors receive different levels of support from their parent institutions 

Most project directors believe that they have good relationships with their parent institutions, 

but somebenefit more from theserelationships than others. For example, some contractors 

receive money towards salaries, free spaceor renovated space. They also receive equipment 

13 
(including computers), furniture, technical support, administrative support, promotion and a 

general sensethat the parent institution believes in the CIS mission and goals. Some 

contractors have enough office spaceto provide information specialists with their own work 

area away from the phone room. Among contractors that receive considerable support from 

their parent institutions, project directors told us that “the center fills gaps that the contract 

doesn’t cover” and “[Our parent institution] understandsthat we are part of NCI, but they still 

provide us with whatever we need.” 

Unlike thesemore fortunate contractors, other contractors receive only benefits that are 

available to all employees of the institution such as discounts on tuition and accessto training 

and speakers. They are often housed in less desirable spacewhich is not on, or even adjacent 

to, the main campus. Their computer equipment is outdated and technical support is “catch as 

catch can.” Information specialistsmust sharedesksand have no private study space. They do 

not even have dividers between their workstations. Similarly, the more fortunate contractors 

have the capacity to computerize information to make it more accessible,while thesedo not. 

Personnelclassifications vary by contractor, as well. Some classifications do not seem 

appropriate for information specialists.’ For example, information specialistsat one contractor 

had been classified as “phone operators” while at another they had been classified as 

“coordinators.” In contrast, the parent institution of another contractor worked closely with the 

project director to create a ‘(medical information specialist” classification to acknowledge the 

special skills that the job entails. 

Contractor policies, procedures and management practices affect telephone access and 

employee morale 

Although the CISTERS program and other quality assurancemeasuresinsure that CIS 

contractors provide consistent information, there is little consistencyin the way contractors 

managetheir workload. These include the ways they conduct clinical trial searches,assemble 

mailings and retrieve information. Though most contractors have assignedstaff who are 

scheduledto conduct clinical trial searches,other contractors allow information specialiststo 

complete clinical trial searchesat any time. Similarly, at some contractors, mailings are 

handled by administrative or assignedstaff or during scheduledoff-phone time, while at others 

information specialistsassembletheir mailings between eachcall, even if there is a queueof 

waiting callers. Further, some contractors have insured that assembling mailings is as efficient 

as possible by having commonly used items pre-copied and commonly sent packagesprepared, 

but others photocopy information and assemblepackagesfor eachmailing. Some contractors 

have said that information specialists, being highly trained professionals, should not spend 

their time filling and stamping envelopes. The CIS Branch has plans to institute an electronic 

publication ordering service, but this can only be done after contractor computer hardware is 

upgraded. Furthermore, only some contractors have the capacity, support and interest to 

computerize as much information as possible, thus making the information easier to accessand 

organize. 

s Note: the OIG did not collect personnelclassifications from all 19 contractors. 

14 
Variations in how managersinteract and allocate work frustrate some staff and may affect 

accessto the phone service. During focus groups, information specialists expressedfrustration 

that managersare not involved enough in the daily operations of the telephone room. They felt 

that this made it difficult when managersinstituted change, becausemanagerswere not always 

aware of how changeswould affect telephone room operations. While a majority of telephone 

service managersanswer the phone lines, information specialists at a few contractors expressed 

frustration that their managersdo not take calls. At one contractor, staff complained that they 

are not receiving the breaks they are entitled to becauseof the demandsof the telephone line; 

however, their manager does not take calls to help alleviate this problem. Staff also 

complained that their manager interrupts them during calls to give them written “reminders” 

and make sure they give callers complete information. Information specialists find this 

practice frustrating and demoralizing. Additionally, severalproject directors expressed 

concern about the inadequatemanagementand supervisory skills in their offices. 

There also are variances in the opportunities for professional growth that contractors offer 

information specialists. Severaltelephone service managersexpressedfrustration about their 

ability to provide information specialistswith opportunities for professional growth. However, 

some contractors have tried to addressthis by expanding the role of the information specialist 

to include rotating supervisory responsibilities or other assignments,such as database 

development and maintenance. 

THE CIS CUSTOMER SERVICE STANDARDS DO NOT ADDRESS ACCESS TO THE 

TOLL-FREE SERVICE 

Benchmarks or standards aimed at reducing access barriers have not been developed 

Contractors are not required to keep their busy signal rates, wait times and abandonmentrates 

under any specific threshold. Standardshave not been developed, such as minimum expected 

number of calls, maximum allowable cost per call or maximum allowable busy signal rate. 

Contractors do not know what the CIS Branch expectsin relation to accessindicators, if 

anything. Some contractors are uncertain about how to balanceproviding quality, personalized 

and detailed attention to callers with their need to reduce busy signals and wait times. One 

telephone service manager commented that “the number of standardsin the contract should be 

investigated” and suggestedthat standardsbe developed separatelyfor each contractor. In the 

absenceof standardsprovided by the CIS Branch, this manager has instituted a standardfor the 

number of calls that her staff should complete per day. 

Similar national health information telephone services have benchmarks and standards 

One nonprofit telephone health information service is applying private sector standardsand 

techniquesthat are similar to those mentioned in the National Performance Review. Located in 

a single national call center, the service recruited and hired a manager who had manageda 

corporate call center. The service has goals for wait times, abandonmentrates and “service 

levels.” Technology permits them to virtually eliminate their busy signal rate. The service 

currently experiencesa 15-secondaveragewait time with a goal of 12 secondsand has a 

15 
3.5 percent abandonmentrate with a goal of less than 3 percent. The percentageof calls 

answeredin 30 secondsor less is 88 percent, with a goal of 90 percent. 

Another health information service, operating under a federal government contract, has call 

volume standardsset by the contracting agency. The service is under contractual obligation to 

complete a minimum number of calls per year. 

16 
The Cancer Information Service, through its telephone service, provides the public with an 

invaluable resource for information about cancerprevention, causesand treatment. To expand 

accessto the toll-free service, the Office of Cancer Information, Communication and Education 

should: 

1. Complete and implement its plans to upgrade CIS telephone technology to enhance 

contractors’ ability to provide information to all callers. 

Among the improvements that should be consideredare: 

b the ability to route callers nationally to the first available information specialist; 

t the use of recorded messagesthat (1) notify callers of their estimated hold time 

or place in queue, (2) prompt callers to call back if all lines are full, (3) prompt 

callers to chooseeither the first available information specialist nationally or an 

information specialist in their region, (4) provide basic cancer information and 

(5) include the medical disclaimer and a citation that only NC1 resourcesare 

used unless otherwise noted by an information specialist and 

t the option to listen to recorded messagesthat provide telephone numbers for 

CANCERFAX and the PDQ SearchService for Health Professionals, 

information about CANCERNET and up-to-date NC1 responsesto current 

media eventson cancer (e.g., green tea and cancer, the nuclear fallout study). 

2. Establish minimal technical requirements and performance standards for 

contractors. 

This could be accomplishedby: 

t implementing minimum requirements regarding CIS contractors’ computer 

hardware and software, staff computer aptitude and technical support, 

b creating a single LAN for CIS contractors to (1) eliminate many of the problems 

with maintaining and updating databasesand software and (2) facilitate the 

computerization of more information and 

b using benchmarks similar to those in the National Performance Review. 

3. Modernize and correct deficiencies in the Physician Data Query. 

t Continue efforts to redesign the PDQ to enhancesearchand navigational 

capabilities, completenessand accuracy. 

17 
b Insure that CIS staff, including information specialists, continue to be involved 

in PDQ improvement efforts. 

4. Improve the efficiency of information specialists by reducing data gathering 

requirements and computerizing more reference materials, such as “Fact Sheets.” 

t Improve the Electronic Call Record Form by eliminating technical problems and 

restrictive policies, such as the needto manually insert codesand enter codesas 

well as narrative. 

b Require documentation of calls and collection of demographic data by utilizing 

statistically valid random sampling. 

b Allow contractors to use disclaimers and citations at their discretion, given that 

callers will hear a recorded message. 

w Move forward with plans to institute a system whereby contractors would not be 

responsible for the actual mailing of publications to callers. 

5. Discontinue collecting and disseminating information on community services; 

instead, partner with national cancer organizations who would provide this 

information. 

The CIS has been unable to routinely collect, update and disseminate information on 

community resources. Two national cancer organizations have committed considerable 

resourcesto this effort and would like to partner with CIS to provide referrals. Seethe 

companion report entitled “The Cancer Information Service--A Resourcefor National 

Cancer Organizations” (OEI-09-97-00361) for more information on this subject. 

6. Re-evaluate the regional structure of contractors. 

b Basethe structure on objective criteria, analysis and performance indicators. 

t Consider reducing the number of contractors and increasing the number of lines 

to eliminate inconsistenciesand allow contractors to answer more calls. 

b Reallocate resourcesbasedon historic and expecteddemographic predictors of 

call volume (e.g., resident population, cancer incidence). 

7. Encourage contractors to further enhance training. 

b Regularly evaluatethe training needsof CIS staff with the goal of not only 

increasing cancer knowledge but also career advancementskills. 

b Clarify and publicize the instructive purpose of CISTERS and contractors’ 

obligations to addressCISTERS recommendations. 

18 
AGENCY COMMENTS AND OIG RESPONSE 

We received written comments on the draft report from NC1 (seeappendix B). We are 

encouragedthat NC1 already has taken action on some of our recommendations. However, we 

remain concernedabout inefficiencies in vital areasof the program and would like to clarify 

and reassertthe following recommendations. 

1. DATA GATHERING PLAN 

Sampling is a scientifkally valid methodfor collecting caller information 

To improve the efficiency of CIS, NC1 should quickly adopt a statistically valid sampling 

methodology that would capture caller data and information. For example, our statisticians 

have suggestedthat an annual sample of no more than 6 to 10 thousand callers could provide 

adequateand reliable data to project to the universe of callers. In order to addressCIS’s 

concernsabout collecting adequatedata specifically from small groups of under-servedcallers, 

our statisticians suggestthat sample sizescould be modified using a screening question. 

2. COMMUNITY SERVICE INFORMATION 

Private sector organizations are in better positions to provide the public with information about 

community resources,and CIS should no longer attempt to duplicate their efsorts 

Since considerableprivate sector resourcesare being spentto develop, maintain and 

disseminateinformation for the public on community resources,we must emphasizeour 

recommendation that CIS discontinue duplicating private sector efforts. Given their finite 

resourcesand inability to implement efficient systemsfor developing and maintaining a 

community referral system, we recommend that CIS contractors no longer operate such 

systems. Instead, CIS should rely on national organizations who also have toll-free 

information servicesto provide this service. 

Using one national database,CIS contractors could refer callers to organizations that maintain 

up-to-date information on local resourcesfor cancerpatients, their families and friends. By 

doing so, contractor resourcescould be committed to where they are neededmost--providing 

NC1 information about the prevention, causesand treatment of cancer to the public in a timely 

and easy-to-understandmanner. 

3. CIS REGIONAL STRUCTURE 

Thephone service’s current regional structure is ineficient. Furthermore, it cannot be 

justified by the phone service’s relationships with the outreach program and research activities. 

Regardlessof CIS’s outreach program and researchactivities, the current regional structure 

does not strengthenthe telephone service. Specifically, there is no correlation between the 

19 
regions’ sizes, budgets, number of attempted and completed calls, number of phone lines and 

number of staff. 

While the CIS telephone service and outreachprograms are collocated, they are not 

interdependent. The programs have different missions, different audiencesand, with few 

exceptions, different staff members. 

During the course of the inspection, there was little mention of the researchactivities or their 

effect on the phone service. Contractors who did mention researchparticipation explained that 

such activities may consist of asking callers additional questionsor providing them with 

additional information. Contractors’ participation in the researchprojects varies. Some 

contractors did not believe that such projects interfered with the day-to-day work of the phone 

service, while others did not believe that it is appropriate for CIS staff to conduct research. 

20 
APPENDIX A 

THE CIS REGIONAL CONFIGURATION 

A-l 
THE CIS REGIONAL CONFIGURATION 

Region I Area Served I 

1 Connecticut, Maine, Massachusetts,New Hampshire, Rhode Island, and Vermont 

2 New York City, Long Island, and WestchesterCounty, NY 

3 I New York State(excluding NYC and WestchesterCounty), and WesternPennsylvania I 

4 IDelaware,New Jersey,and EasternPennsylvania I 

IDistrict of Columbia, Maryland, andNorthern Virginia I 

6 IGeorgia, North Carolina, and South Carolina I 

7 Florida and Puerto Rico I 

8 Alabama, Louisiana, and Mississippi I 

9 Arkansas,Kentucky, and Tennessee I 

10 Ohio, WestVirginia, and SouthernVirginia I 

11 Iowa, North Dakota, Minnesota, SouthDakota, and Wisconsin I 

12 IIndiana and Michigan I 

13 IIllinois, Kansas,Missouri andNebraska I 

Oklahoma and Texas 

15 IAlaska, Montana, Oregon, Washington StateandNorthern Idaho 

16 IArizona, Colorado, New Mexico, Utah, Wyoming, and SouthernIdaho 

INevada andNorthern California 

ISouthernCalifornia I 

I 

A-2 
APPENDIX B 

NCI’S COMMENTS ON THE DRAFT REPORT 

B-l 
DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service 

National Institutes of Health 

APR 24 1998 Bethesda, Maryland 20892 

TO: June Gibbs Brown 

Inspector General, OS 

FROM: Deputy Director for Management 

SUBJECT: Office of Inspector General (OIG) Draft Reports, 77~ Cancer Information 

Service: Expanding TelephoneAccess,OEI-09-97-00360, and The Cancer 

Information Service: A Resourcefor National Cancer Organizations, 

OEI-09-97-00361 

Attached are the National Institutes of Health comments,preparedby the National Cancer 

Institute (NCI), on the subject draft reports. These reports provide confirmation of previous NC1 

findings aswell as further insight into the issuesaffecting accessto this valuable resource for the 

American public. 

We agreegenerally with the OIG recommendationsor with the objectives of the 

recommendations. However, in somecaseswe believe that theseobjectives can be met through 

actions or initiatives other than those recommendedin the reports. Our commentsdescribe the 

stepsthat NC1 has taken or plans to take to addresseachrecommendation. 

Should your staff have any questions, pleasecall William Gillen, Office of Management 

Assessment,at 301-496-2462. 

Attachments 

MAY.7i 

B-2 
DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service 

National Institutes of Health 

National Cancer Institute 

Bethesda, Maryland 20892 

TO: June Gibbs Brown 

Inspector General 

Through: Director, NIH APR2 3 1998 

FROM: Director, National CancerInstitute, NIH 

SUBJECT: Offke of Inspector General Draft Report: Cancer Information Service: 

Expanding Telephone Access(OEI-09-97-00360) 

Office of Inspector General Draft Report: The Cancer Information Service: 

A Resource for National Cancer Organizations (OEI-09-97-00361) 

We have reviewed the above-referenceddraft inspection reports that assessaccessto the National 

Cancer Institute’s Cancer Information Service. The inspections were conducted in cooperation 

with NC1 program staff and the contractor staff at the regional CIS offices. The reports provide 

confirmation of previous NC1 findings aswell as further insight into the issues affecting accessto 

this valuable resourcefor the American public. 

Our detailed comments on both reports are attached. Thank you for the opportunity to review 

and comment. 

-% Richard D. Klausner, M.D. 

Attachments 

B-3 
National CancerInstitute Commentson 

Oftlice of Inspector General Draft Report: 

Cancer Information Service: Expanding Telephone Access 

OEI-09-97-00360 

NC1 GENERAL COMMENTS 

The Office of Inspector General study provides confirmation of NC1 findings and tbrther insight 

into the issuesaffecting telephone accessto the Cancer Information Service. It is useful to have 

this additional, independent assessmentasthe National Cancer Institute proceedswith its plans to 

upgrade the CIS and improve accessto this important source of accurate, up-to-date cancer 

information for the public, patients, and health professionals. 

OIG RECOMMENDATION 

Completeand implement plans to upgrade US telephone technolog), to enhance contractors’ 

ability to respond to calls andprovide information to all callers. 

NC1 RESPONSE 

The Institute agrees. Plans to upgrade the CIS telephone technology have been in 

progress since 1996, and the NCI-commissioned report of an independent engineering 

assessmentof the system,routing, and equipment hasbeen completed. On the basisof 

this information, implementation of upgradesto telephone equipment is under way and 

will be completed in FY 1998. 

OIG RECOMMENDATION 

Ektablish minimum technical requirements and performance stanakr& for contractors. 

NC1 RESPONSE 

The Institute agreesthat standardsare necessary. With the completion of the NCIcommissionedengineering assessmentof the CIS telephone service, the program has 

baselinemeasurementsthat allow for implementing technical, operational, and 

performance standards. This implementation is under way. 

OIG RECOh4lvfENDATION 

Modernize and correct deficiencies in the PDQ database. 

NC1 RESPONSE 

B-4 

I 
The Institute is undertaking a major redesignof its entire clinical trial information system, 

including PDQ. The new clinical trial information systemwill increasefUnctionaMy, 

integrate all NCI-produced information products, tailor information to meet the needsof 

diverse users,and makeinformation available in a variety of mechanismsand formats, 

including the World Wide Web. 

OIG RECOMMENDATION 

Improve the efjkiency of information specialists by reducing data-gathering requirements and 

computerizing more reference material. 

NC1 RESPONSE 

The Institute agreesthat efficiency can be improved. The Institute is working with the 

CIS Evaluation Task Force, statisticians, and Institute staff to analyzethe data gathering 

requirements, sampling plan, and the requirement for a narrative that documentsthe call in 

addition to coding. However, the Institute believes that data collection is critical if the 

program is to 1) continue to respondto information requestedby the public, Congress,the 

press,or individuals and organizations interested in what the public wants to know about 

cancer; 2) allow the CIS to participate in cancercontrol researchprojects; and 3) conduct 

quality assurance. 

The CIS is preparing to install a new document managementsystemto facilitate the 

development, updating, and accessof CIS referencematerials. When implemented,the 

systemwill allow the assemblyof all resourcesinto a searchable,computerized collection 

accessibleby subject and keyword. 

OIG RECOMMENDATION 

Discontinue collecting anddisseminating information on community services; instead, partner 

with national cancer organizations who would provide this information. 

NC1 RESPONSE 

The Institute agreesthat a more efficient and effective community servicesreferral 

program is needed,but we continue to think that this type of information is helpfil to 

many people. Redesign of a centralized listing of national organizations providing 

community resourcesand referrals is under way. The Institute is actively seeking 

partnerships with other national organizations to shareand reciprocate in this task. 

OIG RECOMMENDATION 

Re-evaluate the regional structure. 

NC1 RESPONSE 

The CIS program includes not only the telephone service but also an outreach program 

and a researchcomponent that are strengthenedby a regional structure. 

The CIS outreach program develops partnershipswith nonprofit, private, and government 

B-5 
agenciesat the national, regional, and state levels. The regional CIS offtces reach partners 

that have an establishedpresencein the region, are trusted within their communities, and 

are dedicatedto serving minority and underservedpopulations. Through collaborations 

with cancercenters and universities, regional CIS ofices participate in investigatorinitiated cancercontrol and health communications research. All three program 

componentsmust be consideredwhen evaluating the regional structure of the program. 

AI1 options for structuring the program will be consideredwhen preparing for the renewal 

of the CIS contracts. 

OIG RECOMMENDATION 

Encourage contractors tojirther enhance CIA’staff training. 

NC1 RESPONSE 

The Institute agreesthat staff development is important. The CIS program begana 

managementinitiative in March 1998 to emphasizethe importance of professional 

development and skills building in regional CIS offices. Additional training programsto 

enhancecareerdevelopment for CIS staff are appropriate for contractors and indicate 

institutional commitment to the CIS program. 

B-6