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Chlamydia Quality Improvement Workgroup (CTQI) • Cathy Bambrick – Administrator LPHI Improvement • Director Bonnie Corns – Community Health Services • Skagit County Public Health Department Mount Vernon, WA Population: 115,300 people • Linda Navarre – Public Health Nurse • Kitsap County Health Department Bremerton, WA Population: 244,800 people • Sage Park – Former Environmental Health Director • Washington State Department of Health Sexually Transmitted Disease Sara Burnet – Assessment Coordinator / Olympia, WA • Health Promotion Manager 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 • Cathy Bambrick – Administrator • State and local public health experts defined 32 local public health–indicators Bonnie Corns Community Health Services • Director • Two of these dealt with chlamydial infection (CT), a common communicable disease • Linda Navarre – Public Health Nurse • Indicator: % reported CT infections documented • Sage • Health as being treated among 15-24 year old females; selected because it is easily measurable and could Park – Former Environmental Health Director change quickly (as opposed to disease incidence rate) Sara Burnet – Assessment Coordinator • 2004-06 data: 89% of Skagit County /cases Promotion 94% Manager treated, 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 • Cathy Bambrick – Administrator TESTING • Bonnie Corns Not testing high risk Director TREATMENT Not treated with appropriate antibiotic – Community and dose Not given free medication HealthProviding Services prescription clients 15 – 24 yrs. Not offering easy method UA testing only Do you have standard orders • Linda Navarre – Public Health Nurse Not medicating suspects Treating culture positive only UNTREATED _________________________________________________________________________________________ POSITIVE CHLAMYDIA PATIENT What do you do Do you charge if you can’t for follow-up visit – Former Environmental contact Health Director Improper or no client education at time of Not rescreening testing and treatment at 3 months • Sage Park • Sara Burnet – Who Assessment Coordinator / times you try completes How many Health EDUCATION Promotion Manager case report to contact them FOLLOW-UP Plan: Define the opportunity • Cathy Bambrick – Administrator • Director • We are seeking to improve the proportion of CT cases thatCorns are treated by theHealth providers responsible for Bonnie – Community Services 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 • Linda Navarre Public Health Nurse treated to 20% the overall treatment rate will improve by 18% in Skagit County and 10% in Kitsap County • Sage Park – Former Environmental Director • Therefore, revise AIM Health statement to increase the proportion of cases treated by 60% • Sara Burnet – Assessment Coordinator / Health Promotion Manager Plan • Cathy Bambrick – Administrator Health Issue/Goal • Short Term Goal “Process” Mid range Goal “Results” Bonnie Corns – Community Health Services • Assess & • Monitor % Director • Improve % of Chlamydia (CT) cases receiving treatment by specific provider –type Public • Linda Navarre • Sage Park – Former • educate providers through survey • Develop a Health Nurse model to educate providers of cases missing treatment reported by target providers • Increase % of • Document # Director Environmental Health patients targeted and providers partners “educated” treated Sara Burnet – Assessment Coordinator / Health Promotion Manager Long Term Goal “Outcome” • Decrease rates of Chlamydia • Decrease rates of infertility Plan: What data or information is needed • Cathy Bambrick – Administrator • State generated data of reported and treated cases by provider Bonnie Corns – Community Health Services • Director • Project designed interview script to learn about provider treatment protocols • Linda Navarre – Public Healthcounties Nurse • Skagit and Kitsap picked two providers • Sage • Health who were excellent performers and two weak performers in CT treatment and queried them for Park – Former Environmental Health Director patient treatment protocols • Improvement will be evaluated using state Sara Burnet – Assessment Coordinator / statistics for July1, 2008 - June 30, 2009 once Promotion education Manager provider has occurred Plan • Cathy Bambrick – Administrator • Hypothesis: emergency departments responsible for most untreated cases Bonnie Corns – Community Health Services • Director • Finding: EDs not a big player in Skagit County, 1 of 3 big players in Kitsap • Linda Navarre – Public Health Nurse Number untreated cases by provider type 07/06 - 06/07 10 • Sage Park – Former Environmental Health Director N=2 Skagit Kitsap 8 • N=1 Sara Burnet – Assessment Coordinator / 6 N=1 Health 4Promotion Manager N=2 N=3 N=1 N=1 N=2 N=2 2 0 Hospital hospital HD PP PP Com/Mig OB/GYN Other OB/GYN Do: Select and develop a theory for improvement • Cathy Bambrick – Administrator • • • • Round 1 Round 2 • P – Plan for analysis of • Health P – Plan interviews to Bonnie Corns – Community Services determining what understand current Director clinics are not treating procedures of each provider type • D – Conduct analysis Linda Navarre – Public Health Nurse • D – Conduct interviews • S – Review data – who is responsible for most • S – Collate and review Sage Park – Former Environmental Health Director missing data interview/survey results • A – Identify target Sara Burnet – Assessment• Coordinator / education/ population and small A – Design Health Promotion Manager scale intervention Study: Study the results • Cathy Bambrick – Administrator Skagit County • Bonnie Corns Community Services • All providers used –the phone Health to contact positives Director • Poor performers charged patients for follow up visit • Linda Navarre – Public Health Nurse • Poor performers usually gave Rx instead of medications • Sage Park – Former do Environmental Health Director • Providers not call pharmacy to see if Rx was filled • SaraofBurnet – Assessment Coordinator • 50% providers had standing orders/ Health Promotion Manager • All providers suggest re-screening at 3 months • Providers assumed HD was following up on all untreated cases Study: Study the results • Cathy Bambrick – Administrator Kitsap County • Bonnie Health Services • All use theCorns phone –toCommunity contact positives Director • All reported charging for follow up visits and treatment (and all had exceptions) • Linda Navarre – Public Health Nurse • Providers gave a mix of Rx or medications • Sage • None reported contacting the HD if they weren’t Park – Former Environmental Healthfor Director able to contact the patient treatment • 50% do not have standing orders for medications • Sara Burnet – Assessment Coordinator / Health • 75% do not re-screen all positive patients after 3 Promotion Manager months • Providers assumed HD was following up on all untreated cases Study: Conclusions • Cathy Bambrick – Administrator We were successful in identifying the following for providers: Bonnietarget Cornspoints – Community Health Services • Director • Linda • Treat with medications, not prescriptions • Develop a system for contacting patient if clinic is Navarre Health unable –toPublic follow up Nurse • Treat without charging for follow up visit • Sage Park – Former Environmental Health Director • Encourage standing orders • Re-screen patients at 3 months • Sara Burnet – Assessment Coordinator / Health • Treat partners Promotion Manager • Test every patient age 15-24 Act • Cathy Bambrick – Administrator • Director • An education card for providers was developed and highlights treatment pitfalls discovered Bonnie Corns – Community Health Services through survey • Linda • Education card will be piloted with providers who were already surveyed Navarre – Public Health Nurse • Sage • If found to be useful, education card will be distributed to all internal medicine, OB/GYN, Park – Formerand Environmental Health Director pediatric family practice providers • Sara Burnet – Assessment Coordinator / Health Promotion Manager Act: Lessons learned • Cathy Bambrick – Administrator • We pooled our abilities to analyze data and develop Bonnieinterventions Corns – Community Health Services • Director • Linda • Sage • Health • We learned how to apply QI tools including Pareto charts and fishbone diagrams and learned that RCI works well to address the highly measurable Navarre – Public Health Nurse type of change we sought • Was imperative to apply tools immediately and Park – Former Environmental Directorwe were have access to expertsHealth to assure applying principles correctly Sara(DOH Burnet Assessment Coordinator / for the • Scale + 2 –counties) was just right Promotion desired Manager by funder; new teams could timeline easily be formed and achieve success