APPLYING QI TO COMMUNICABLE DISEASES: INITIAL STORIES FROM THE NNPHI QI AWARD PROGRAM Janelle Elza, Red Cliff Community Health Center Pamela Davis, South.

APPLYING QI TO COMMUNICABLE DISEASES: INITIAL STORIES FROM THE NNPHI QI AWARD PROGRAMJanelle Elza, Red Cliff Community Health Center

Pamela Davis, South Carolina Department of Health and Environmental Control

Linda Navarre, Kittitas County Public Health Department

Applying QI to Communicable Diseases

Red Cliff Community Health CenterBayfield, WI

Jenelle Elza, RN

• The reservation is approximately one mile wide and 14 miles long, located at the top of the Bayfield Peninsula, on the shores of Lake Superior in northern Wisconsin. The village of Red Cliff, the location of tribal offices and businesses, is three miles north of Bayfield Wisconsin, a popular tourist community adjacent to the Apostle Islands National Lakeshore. The reservation population is 924, primarily Native American.

Red Cliff Community Health Center•Alcohol and Other Drug Abuse Services (AODA) and Mental/Behavioral Health•Clinic (Family Practice, Women’s Health, Pediatrics, Laboratory, X-ray) •Contract Health Care (CHS) and Medical Benefits •Community Health (Immunization, Disease Prevention) and Environmental Health & Maintenance •Dental •Pharmacy •Maternal Child Health and WIC

The IPC program strives to stimulate the desire and optimism for improvement and intolerance of the status quo; promote wide-spread adoption of best practices that will lead to improvement; test and adapt ideas and knowledge for the Indian health system; help grow a vibrant health care workforce; and ensure that quality is a way of life for future generations.

American Indians and Alaskan Native (AI/AN) people face high rates of illness, disability, and death from chronic and preventable diseases. The IHS, Tribal, and Urban health programs participating in the Improving Patient Care (IPC) program aim to reduce these health disparities among AI/ANs by:•Ensuring access to primary care for all AI/AN people;•Providing high-quality primary care;•Coordinating care across the continuum or integrating primary care, inpatient care, and the community.•Making real and measurable improvements in care.

•DM Comprehensive•Cancer Bundle •Health Risk Screening Bundle•Physical Activity•3rd Next Available Appointment

Public Health Quality Improvement

• Wisconsin’s Public Health Quality Initiative– Developed a team, which consists of CH Nurse

Supervisor, CH Nurse, QI Nurse, and Environmental Health.

– Completed public health self-assessment– Defined communicable disease reporting along

with other areas, as weaknesses. – Participated in weekly webinars related to Public

Health QI: QI 101, performance measures and management.

Strengthening the Community of Practice for Public Health Improvement.

•Assessment of the Public Health Department lead us to communicable disease reporting as our weakness. •Currently Bayfield County Health Department does our reporting.

•This is not being done accurately •Double reporting. •No reporting

•We do not know what and how many diseases from the reservation are being reported.

•Red Cliff wants to take back communicable disease reporting so we can focus on surveillance, control, and prevention.

SMART AIM

SPECIFIC - Is the statement precise about what the team hopes to achieve?

MEASURABLE - Are the objectives measureable? Will you know if the changes resulted in improvement?

ACHIEVABLE - Is this doable in the time you have? Are you attempting too much? Could you do more?

REALISTIC - Do you have the resources needed (people, time, support?)

TIMELY - Do you identify the timeline for the project - when will you accomplish each part?

AIM Statement

The Red Cliff Community Health Center will assume responsibility of reporting all communicable diseases to the Wisconsin State Health Department by November 30, 2012

The Public Health staff will have knowledge in all areas of the reporting process as measured by completing a knowledge test with a score of 95% or better by September 30, 2012.

Steps….

•Team in place-Roles defined.

•Training- QI process, Reportable diseases, Investigation, computer systems, etc…

•Meeting- Designating time! Weekly team meetings.

Plan-Do-Study-Act

Select your change- All improvement requires making changes, but Not all changes result in improvement.

Test your change- planning it, trying it, observing the results, and acting on what is learned.

Implement your change - After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team can implement the change on a broader scale.

Spread your change- After successful implementation of a change or package of changes for a pilot population or an entire unit, the team can spread the changes to other parts of the organization or in other organizations.

Key Lessons Learned

Slow Down! Do PDSA cycles

Spread the wealth- don’t do it all yourself

Get Organized!

Be transparent

Celebrate success!

It’s about the process not the people

Communication

Share senselessly and steal shamelessly!

What gets measured gets managed

The goal for the Red Cliff Community Health Center is to have a functional and reliable count of all communicable diseases in our community. This is necessary for program development to help

control spread and work towards prevention of all communicable diseases. We are working towards a healthier community!

National Network of Public Health Institute

Open Forum Meeting for Quality Improvement in Public Health

Apply QI to Communicable Diseases: Initial Stories from the NNPHI QI Award ProgramJune 19, 2012

Pamela DavisSouth Carolina Department of Health and Environmental Control

STD/HIV Division

Background

• December, 2006 - Missed Opportunities Research– HIV testing practices in South Carolina failed to identify a

substantial proportion of HIV-infected persons early in the course of their infection.

– Among the persons identified in this report as late testers (i.e., persons who received an AIDS diagnosis within 1 year of HIV diagnosis), approximately three fourths had visited a South Carolina health-care facility before having HIV diagnosed.

– Most of the late testers made multiple visits, and most of their visits occurred 1 year or more before diagnosis of HIV infection.

• These health-care encounters represent missed opportunities for earlier HIV diagnosis

Background

• In 2007, CDC implemented a new HIV testing program, CDC-RFA-PS07-768: – Expanded and Integrated Human Immunodeficiency Virus

(HIV) Testing for Populations Disproportionately Affected by HIV, Primarily African Americans, aimed at significantly increasing the number of persons tested each year in jurisdictions with a high incidence of HIV among disproportionately affected populations affected by HIV – African Americans, Hispanics, MSM, and IDUs, primarily in healthcare settings

• Testing efforts were sustained with CDC FOAs– PS10-10138 (2010-2011)– PS12-1201 (2012-2014)

Goal• To increase the number of persons who receive HIV testing,

and the number and proportion of HIV-infected persons who are aware of their infection by:– Providing routine HIV screening in healthcare settings serving

these populations.

– Expanding targeted HIV testing in non-healthcare settings or venues where high-risk members of these populations can be accessed.

– Ensuring that persons testing positive for HIV infection (new positives and previously diagnosed positives not in care) receive HIV test results, prevention counseling and linkage to medical care, Partner Services, and HIV prevention services.

Plan

Do

Study

Act

PLAN

Planning Phase• QI Team formed

– Health department (HD) QI Team Assembled • Expanded Testing Staff

– Latasha Robinson– Jarvis Carter– Pamela Davis

• HD 1st QI team Meeting– Revisited AIM statement

• By December 31, 2012, the identified hospital ED will implement routine opt-out rapid HIV testing where 80% of patients that present in the ED and meet testing criteria will receive HIV screening.

– Discussed HIV testing process in ED• Current Process• Collection of Data• Identified Problems• Identified Potential Improvements

Planning PhaseHospital/Outreach Rapid and Conventional HIV Testing Data Collection and Testing Flow Chart

Contact Healthcare or Non-Healthcare ETC

within 48 hours

Documents: DHEC/Hospital

General Consent Form

DHEC Demographic Form

DHEC Testing Log Client Test Result

Card

Client Information Collection on General Consent and Demographic form

Test Results document on testing log

Rapid HIV Testing

Rapid/ Conventional Test Negative

Rapid/Conventional Test

Positive

Document TR on testing log

Document TR on testing log

Enter testing and pt. information into Evaluation Web

Testing logs are retained in testing facility for 2 years as required by CLIA.

Abbreviation Key: ETC - Expanded Testing Coordinator SW - Social Worker DIS - Disease Intervention Specialists TR - Test Results PS - Partner Services

• Give pt. TR • Explain Result & Answer pt.

questions. • Explain blood draw procedure • Explain linkage procedure to pt. • Give TR card to patient. Linkage & Referral Process Begins

See L&R flowchart

Complete & Send 1610- Referral

& 1129 Dz rpt. card to

ETCs

Due within 3 day to ETCs

/DIS Copies:

White: SW Pink: SW

Yellow: ETCs

Pt info entered on (+)/Prev (+) spreadsheet

1610 Pink Copy Due w/i 30 day.

Completed with Linkage and PS contact info.

Yes

No

Document TR. Give TR; Get retested in 1yr

Identify High Risk

Behaviors

Send Completed DHEC 1610 Referral for

Intervention (white & pink) to Social

Worker

Document are due within 3 days.

Send DHEC 1610 Yellow copy to

ETCs.

Special Note: Client information for completion of

intervention can be on the Quarterly Narrative

Report.

Planning Phase• Met with QI Coach to discuss QI project

• Identified Site for QI Project– Medical University of South Carolina (MUSC)

• Identified key staff at QI Project Site– Site QI Team

• Dag Shapshack, MD – Assistant Professor Department of Medicine, Division of

Emergency Medicine• Roberta Navarro, RN

– HIV Early Intervention Program Coordinator• Michael Green

– Research Assistant

Planning Phase• QI Team Meeting (HD & MUSC QI Team)• Meeting outline

– Purpose of QI project– AIM Statement– Discussed HIV testing process in ED

• Current Process• Collection of Data• Identified Problems• Identified Potential Improvements• Developed an Improvement Theory• Developed an Action Plan

Lessons Learned

• Be sure to involve everyone (internally/externally)Identify a “Project Champion”

• Keep focused on project goals– Everyone on the same page

• Team consensus of problem and plan for improvement

• Be sure to include the input of stakeholders

Barriers/Challenges

• Getting the buy-in of the QI project from:– QI team– Administrators– Front-line staff

• Ensure QI project does not interfere and/or interrupt patient care and daily operation.

What Do We Expect to Achieve?

• Develop a model program for routinizing HIV testing during a healthcare visit.

APPLYING QUALITY IMPROVEMENT TO

COMMUNICABLE DISEASES: QI IN ACTION

Total population: 40,50014.5 FTEs

Team Members

Linda Navarre, Community Health Services Supervisor, Project Lead

Tiffany Beardsley, Public Health Nurse

Julia Karns, Community Outreach Worker

Why focus on hepatitis C testing?

• Dramatic decline in hepatitis C testing

• One in four tested in the 2010-2011 time period were positive for hepatitis C

Initial Steps

What are we really trying to improve?

What more do we need to know?

How will we obtain this information?

AIM STATEMENT

By November 1, 2012, KCPHD will have a 50% increase in the number of ADDS

(Alcohol and Drug Dependency Services) referred clients who follow

through with hepatitis C testing.

What do we hope to achieve?

A sustainable referral process

“Know your status” awareness

Develop useful tools to share with others

QI stepping stone for staff

Successful QI Method or Tool

Top three QI tools used:•Process mapping•Affinity diagram•Surveying stakeholders

Survey Results

n=8

The Reward

Challenges

“Fix it Now” mentality

Difficult barriers to overcome

Balancing workload

QI Lessons Learned Administrative support

Utilize your staff’s strengths

Find your champion

Acknowledge and praise

Reward your partners

Recommended Resources

Embracing Quality In Public Health, Second Edition

The Public Health Memory Jogger II

Thank you

A special thank you to the NNPHI QI Awards team and our quality improvement coach, Jim Butler.