cathy bambrick – administrator bonnie corns – community health services director linda navarre...

• Cathy Bambrick – Administrator

• Bonnie Corns – Community Health Services Director

• Linda Navarre – Public Health Nurse

• Sage Park – Former Environmental Health Director

• Sara Burnet – Assessment Coordinator / Health Promotion Manager

LPHI Improvement

• Skagit County Public Health Department Mount Vernon, WA Population: 115,300 people

• Kitsap County Health Department Bremerton, WA Population: 244,800 people

• Washington State Department of Health Sexually Transmitted Disease Olympia, WA

Chlamydia Quality ImprovementWorkgroup (CTQI)

Workgroup Members

• Mark Aubin, STD Section Manager, DOH• Dana Brainerd, Nurse Epidemiologist, Kitsap County• Kerry Dobbelaere, Clinical Services Program Manager, Kitsap County• Katherine Gudgel, Infertility Prevention Project, DOH• Alba Gutierrez, PA, Skagit County • Marni Mason, Consultant, MCPP Healthcare Consulting• Hilary Metcalf, Regional Surveillance Coordinator, Kitsap County• Sandi Paciotti, CD Supervisor, Skagit County• Beth Phipps,RN, BSN Outreach Education, Kitsap County• Cathy Smith, ARNP, Skagit County• Kim VanEpps, Health Educator, Skagit County






Plan

• State and local public health experts defined 32 local public health indicators

• Two of these dealt with chlamydial infection (CT), a common communicable disease

• Indicator: % reported CT infections documented as being treated among 15-24 year old females; selected because it is easily measurable and could change quickly (as opposed to disease incidence rate)

• 2004-06 data: 89% of Skagit County cases treated, 94% of Kitsap County cases treated

• Made fishbone diagram of possible factors contributing to failure to treat






Plan: Analyze the reasons +CT clients aren’t treated

TREATMENT Not given free

Not treated medication TESTING with appropriate antibiotic Not testing high risk and dose Providing prescription clients 15 – 24 yrs. only Not offering Do you have easy method standard Not medicating suspects UA testing orders Treating culture positive only

_________________________________________________________________________________________

What do you do Do you charge if you can’t for follow-up visit contact Improper or no client education at time of Not rescreening testing and treatment at 3 months Who completes How many times you try EDUCATION case report to contact them FOLLOW-UP

UNTREATED POSITIVE CHLAMYDIA PATIENT






Plan: Define the opportunity

• We are seeking to improve the proportion of CT cases that are treated by the providers responsible for 43% (Kitsap) or 64% (Skagit) of untreated cases by 20% in Kitsap and Skagit counties by January 2008

• If these 4 providers increase the proportion of cases treated to 20% the overall treatment rate will improve by 18% in Skagit County and 10% in Kitsap County

• Therefore, revise AIM statement to increase the proportion of cases treated by 60%






Plan

Health Issue/Goal Short Term Goal Mid range Goal Long Term Goal “Process” “Results” “Outcome”

• Improve % of Chlamydia (CT) cases receiving treatment by specific provider type

• Assess & educate providers through survey

• Develop a model to educate providers

• Document # targeted providers “educated”

• Monitor % of cases missing treatment reported by target providers

• Increase % of patients and partners treated

• Decrease rates of Chlamydia

• Decrease rates of infertility






Plan: What data or information is needed

• State generated data of reported and treated cases by provider

• Project designed interview script to learn about provider treatment protocols

• Skagit and Kitsap counties picked two providers who were excellent performers and two weak performers in CT treatment and queried them for patient treatment protocols

• Improvement will be evaluated using state statistics for July1, 2008 - June 30, 2009 once provider education has occurred






Plan

• Hypothesis: emergency departments responsible for most untreated cases

• Finding: EDs not a big player in Skagit County, 1 of 3 big players in Kitsap

0

2

4

6

8

10

hospital PP OB/GYN

SkagitKitsap

Number untreated cases by provider type 07/ 06 - 06/ 07

N=2

N=2

N=1

N=1

N=1

N=1

N=2 N=2

N=3

Hospital HD PP Com/Mig OB/GYN Other






Do: Select and develop a theory for improvement

Round 1• P – Plan for analysis of determining what clinics are not treating

• D – Conduct analysis

• S – Review data – who is responsible for most missing data

• A – Identify target population and small scale

Round 2• P – Plan interviews to understand current procedures of each provider type

• D – Conduct interviews

• S – Collate and review interview/survey results

• A – Design education/ intervention






Study: Study the results

Skagit County

• All providers used the phone to contact positives

• Poor performers charged patients for follow up visit

• Poor performers usually gave Rx instead of medications

• Providers do not call pharmacy to see if Rx was filled

• 50% of providers had standing orders

• All providers suggest re-screening at 3 months

• Providers assumed HD was following up on all untreated cases






Study: Study the results

Kitsap County

• All use the phone to contact positives

• All reported charging for follow up visits and treatment (and all had exceptions)

• Providers gave a mix of Rx or medications

• None reported contacting the HD if they weren’t able to contact the patient for treatment

• 50% do not have standing orders for medications

• 75% do not re-screen all positive patients after 3 months

• Providers assumed HD was following up on all untreated cases






Study: Conclusions

We were successful in identifying the following target points for providers:

• Treat with medications, not prescriptions

• Develop a system for contacting patient if clinic is unable to follow up

• Treat without charging for follow up visit

• Encourage standing orders

• Re-screen patients at 3 months

• Treat partners

• Test every patient age 15-24






Act

• An education card for providers was developed and highlights treatment pitfalls discovered through survey

• Education card will be piloted with providers who were already surveyed

• If found to be useful, education card will be distributed to all internal medicine, OB/GYN, pediatric and family practice providers






Act: Lessons learned

• We pooled our abilities to analyze data and develop interventions

• We learned how to apply QI tools including Pareto charts and fishbone diagrams and learned that RCI works well to address the highly measurable type of change we sought

• Was imperative to apply tools immediately and have access to experts to assure we were applying principles correctly

• Scale (DOH + 2 counties) was just right for the timeline desired by funder; new teams could easily be formed and achieve success

cathy bambrick – administrator bonnie corns – community health services director linda navarre...

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