Stories from the QI Award Program:

Using QI to Guide and Support Your Work

June 2013

Presented by Nicole Charon-Schmitt, MPHDirector, Programs and Planning

Addictions Services, Boston Public Health Commission

Goals of Presentation

Provide background and overview of our QI Project including key activities and QI tools utilized

Describe our experience as Cycle 2 QI Award Grantee including key challenges, successes, and lessons learned

Project Overview Implementation is taking place within

Boston Public Health Commission's (BPHC) Addiction Services’ Bureau PAATHS Program

Original AIM Statement◦ By July 31, 2013, increase by 25% the percentage

of PAATHS clients connected to their primary service need (s) within four days of intake

Goals for Project◦ Increase access to substance abuse and

recovery support services

◦ Promote recovery from substance abuse

What is BPHC?

Serves as the City of Boston’s local health department

Mission: Protect, promote, and preserve the health and well being of all Boston residents, particularly the most vulnerable.

Provides public health programming and other services across six bureaus:

Addictions Prevention, Treatment and Recovery Support Services

Child, Adolescent and Family Health

Community Initiatives

Emergency Medical Services (EMS) and Public Health Preparedness

Homeless Services Infectious Disease

Bureau of Addictions Prevention Treatment

and Recovery Support Services

Prevention and Risk Reduction

Community Prevention and

Mobilization

Risk Reduction and Overdose

Prevention

Treatment and Recovery Support

Specialized Outpatient Treatment

Opioid Treatment

Family Residential

Access to Care

PAATHS

Administration and Finance

Planning and Program

Development

What is PAATHS? Providing Access to Addictions Treatment Hope and Support

One-stop shop for individuals and families looking for information about, or access to, substance abuse treatment and other recovery support services

Serves approximately 2500 individuals annually

Developed in response to an identified need to improve the way people in Boston affected by substance use disorders are connected to a wide range of services (APTRSS Bureau Strategic Plan, 2009)

Expansion project began in 2012 by building off existing service component

Applied for and received QI grant in Fall 2012

Why QI?How to transform existing program?

◦ Existing culture reflected a resistance to change◦ Struggling with how to create a culture of change

while honoring the expertise and experience of staff

Identified QI as a vehicle to help us get from Point A to Point B and to help us meet the growing demands of healthcare reform

Previous experience with QI work through NiaTx was positive and had been used to address similar challenges in other program areas

Why Our Aim? Of the 15 largest metropolitan areas, Boston ranks

5th highest in reported rates of illegal substance use and 3rd in reported binge alcohol use.

These reported rates are at least 25% higher than any other region of the state.

Of the 106,301 admissions to substance abuse treatment programs statewide in FY 2010, 16.72% (17,775) were from Boston.

Drug abuse mortality in Boston increased sharply from 1999-2007 with age-adjusted substance use mortality more than doubling, from 11.3 per 100,000 to 23 per 100,000 during this timeSAMHSA, Office of Applied Studies, The NSDUH Report: Substance Use in the 15 Largest Metropolitan Statistical

Areas 2002-5.SAMHSA, Office of Applied Studies, Massachusetts State Treatment Planning Areas.

Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Substance Abuse Treatment Fact Sheet FY 2010 – Boston.

Boston Public Health Commission. Substance Abuse in Boston. 2011

Major Activities

Forming •Formed QI Team•Introduced staff to QI concepts and goals for project

Brainstorming •Engaged staff in identifying challenges and opportunities for improvement•Developed sub-aims

Problem Solving •Utilized process mapping•Piloted PDSA Change Cycles

Forming Our Team

What is typically recommended vs. what we did

Challenge: Do we include everyone?

Considerations: ◦ Small team; only 7 staff in total◦ Clear division between existing staff and new hires◦ Felt we needed buy-in from existing staff to truly

be successful

Brainstorming Utilized tools called nominal group

technique (NGT)

◦ Structured method for group brainstorming that encourages contributions from everyone.

◦ Takes brainstorming a step further by adding a voting process to rank ideas that are generated

Silent idea generation

Recording of ideas

Discussion and

clarificationVoting

Benefit of NGT Focuses on identifying problems first rather

than solutions

Allows team members to contribute their own experience and expertise

Silent group generation provides everyone with an opportunity to contribute

Voting promotes shared decision making and helps with prioritization

Results of NGTWhat is/are the biggest barriers for you to

be able to connect your clients to the resources they request in a timely manner?

◦ Amount of time it takes for clients to be seen at first visit

◦ Too much paperwork that is redundant and/or not necessary for what the client is requesting

◦ Need to build capacity, and better understand processes and requirements, for referring to expanded referral network

◦ Limited staff knowledge of available resources

Development of Sub-Aims

Original AIM: By July 31, 2013, increase by 25% the percentage of PAATHS clients connected to their primary service need (s) within four days of intake

Sub-aim #1:

Reduce amount of time it takes clients to be seen at first visit from 25 to 8 minutes

Sub-aim# 2:

Reduce the number of incomplete applications

Sub-aim #3:

Increase number of individuals accepted into post detox programs

Sub-aim #4:

Increase outreach efforts to referral agencies

After first meeting with coach, agreed to develop sub-aims

Process Mapping

Documented current process from when client arrives until when they leave

Discussed and identified problem areas◦Redundant/unnecessary paperwork◦Bottlenecks

Agreed on areas for improvement/change

Original Intake Process

1st PDSA Cycle: Reducing Wait Time in the Waiting

Room

PDSAPDSA cycles

◦ Plan the change◦ Do the plan◦ Study the results◦ Act on the new knowledge

Rapid cycle changes ◦ Changes should be doable in 3

weeks

Sub-aim Change Cycles Results

Reduce amount of time it takes clients to be seen at first visit from 25 to 8 minutes

Streamlined intake process including reducing number of forms and addressing redundancy across forms

Reduced time for each visit, on average, from approximately 25 to 13 minutes

Developed specialized care teams

In progress; awaiting results

Reduce the number of incomplete applications

Developed a checklist for staff and system for auditing/QA

Achieved 100% compliance

Increase number of individuals accepted into post detox programs

Adopted universal intake form for post detox services

Increased number of individuals placed in post detox by 20%

Increase outreach efforts to referral agencies

Began conducting site visits and sending follow up thank you cards to referral agencies who accepted new referrals

Completed 17 site visits and sent 12 thank you cards to new partners

Developed 3 new referral sources as a result of efforts

Successes

Challenges

Staff Development

and Team Building

Increased Client

Satisfaction

Created Culture of Change

Overcoming Initial

Resistance

Keeping the

Momentum Going

Lessons LearnedQI is an ongoing process that

needs constant attention

No one size fits all model for how to implement QI – need to pick and choose what works for you

Staff buy-in is key

Moving ForwardQI Team continues to meet

regularly

Continue to identify opportunities to improve our service delivery and be more efficient and effective

Exploring potential opportunities to generate revenue for work

Q&A

Expanding STD Text Messaging Services Using QI Processes

Kathleen Yeater, RN, BSN, MS, CHESDonna Walsh, RN, BSN, MPA

Florida Department of Health, Seminole CountyJune 12, 2013

Why Texting?

From 2007-2011, STD cases in FL increased by 18%.

Closure of STD clinics and reductions in staff due to budgetary constraints.

Traditional methods of client notification may delay treatment.

The mHealth Solution

Mobile phone use high in the United States.

High-risk groups receptive to mobile health programs.

Many advantages of mobile health programs.

Mobile phone-based pilot projects have shown promise.

Goal

Offer text messaging of STD results (gonorrhea, chlamydia, and syphilis reports) to improve timeliness of STD diagnosis, treatment, and reduce clinic burden.

Pilot Projects

Peoria County – 12/08-5/09 & 9/09-12/09In 2009, STD clients could opt in to receive

chlamydia and gonorrhea test results via coded text messages.

Results: - 46%opted in - Texters received treatment significantly sooner - Health department costs were reduced

Pilot Projects

Clay County, FLIn 2010, Clay adopted Peoria’s texting process and

began offering service to STD clients.

Results: - 56% opted in - Time from notification to treatment decreased - Cost savings in staff time

How Did They Do That?

Use of existing resources:PRISM (Patient Reporting Investigating Surveillance

Manager) – Florida’s electronic STD database which houses client records and labs of “all” STD clients.

Disease Intervention Specialists (DIS) – Responsible for tracking clients to refer for treatment and solicit exposed partners.

No additional state funding.

31

What is Required?

Access to PRISM (for sending texts & call backs)PRISM training within 30 days of implementationNegative and positive labs attachedEnter 4 pieces of information from consent form*Record call backs immediately in PRISM

* Cell number, cell carrier, date authorization form was signed, and date the form expires.

And So It Begins…

County adoption of texting*:Clay – 11/10/11Seminole – 1/20/12Duval – 1/26/12Escambia – 11/8/12Miami-Dade – 11/20/12Orange – 1/30/13

*9% of FL counties

Success!

* 55% of clients under the age of 25 opted in for texting across all texting counties.

Time to Treatment Comparing Texters to Non-Texters

6.0

2.8

6.46.1

5.0 5.1 5.2

4.2

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

All Clay Duval Seminole

# D

ays

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ord

ad

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rea

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nt

Non-Texters

Texters

Timeframe = lab add date to treatment date, excludes presumptively treated and those treated past 30 days.

Call Me!

3.62.6

3.9 3.5

6.9

8.9

7.0

5.0

0123456789

10

All Clay Duval Seminole

# D

ays

(fie

ld r

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Time to Treatment Comparing Call Back Status

Called Back

Didn't Call Back

Timeframe = lab add date to treatment date, excludes presumptively treated and those treated past 30 days.

I Have an Idea!

Success of pilot project in Seminole County prompted proposal for expansion to other clinics reporting STD results: Family Planning and Prenatal.

Plan: Use QI processes to document best practices and access tools for further implementation.

QI Project

The Seminole County Health Department seeks to improve the timely treatment of clients who test positive for Sexually Transmitted Diseases (STDs) and reduce exposure of partners and contacts by utilizing more efficient and technologically advanced methods of notification.

The health department is looking to expand the usage of text messaging for reporting STD results to our Prenatal and Family Planning clinics in an effort to provide timely treatment and reduce partner, congenital, and newborn exposures.

AIM Statement

The Florida Department of Health, Seminole County will increase the number of clients opting in for text messaging by 20 percent for STD reporting by July 31, 2013.

Logic Model

Building Our Team

Activities Brainstorming

Discuss models for implementation.

Feedback Sessions How did we do? Process improvements.

Analysis Develop process maps PDSA cycles Metrics Surveys

Team Selection

QI Proposal Committee Edited proposal for

submission. Agreed on AIM statement.

QI Project Team Provided opportunity for

staff to learn QI tools and process through webinars.

QI Workgroup Team members directly

involved in providing services.

QI Project PDSA CyclesCycle Stage Plan Do Check Act

1

a) Begin Offerring text message option in the Family Planning Clinic on 3/4/13. b) Inservice training for staff in FP and Prenatal clinic on counseling for text message service on 2/28/13.

a) Initiate text option in FP clinic on 3/4/13.

a) QI team to meet for evaluation of first day test service offered in FP clinic. b) Identified process map discrepancies. c) Identified need for uniform message/script for staff counseling.

a) Contact PRISM administrator for sample text. b) Assign messaging/script composition to Patrice. c) Request revised process map to be completed using appropriate software and sent electronically to team members.

2

a) Forward all the assigned material to QI team members for evaluation or revision. b) Make any revisions suggested. Finalize and print materials for next team meeting.

a) Completed script/message distributed to QI team. b) New process flow map distributed to team. c) A screen shot of text messages sent to clients was obtained and distributed to the team for clarification.

a) Revise policy to reflect accurate text message information. b) Revise cards given to clients that opt in for text messaging to reflect proper language. c) Clarify metrics to be collected for data analysis.

a) Draft policy and procedure revised for ELT approval. b) Cards for clients redesigned to include proper language and new FDOH logo. c) Metrics that are to be collected, defined, and responsible team member identified.

3

a) Begin collection of metrics data. b) Develop a survey for client feedback on text messaging option.

a) Training for staff scheduled for 3/28/13 at 2:30. b) QI team solicited for questions for client survey. Deadline to submit COB 3/22/13. c) Established point of contact for data collection in all clinics: FP - Noemi PN - Joyce STD - Betty

a) Meet 4/1/13 4:00 for brief evauation of first day in prenatal clinic. b) Discussed and agreed that FP will conduct phone surveys with clients that have already opted in for texting. c) PN will conduct survey while offering texting service.

a) Distribute client survey to all clinics. b) Received and distributed new message cards and consent forms.

4

a) Go live in Prenatal clinic. a) Conducted training for Prenatal nurses on 3/28/13. b) Implemented text messaging option in prenatal clinic 4/1/13. c) Met to review and discuss first day in prenatal clinic.

a) Decided text message option is only appropriate for new prenatal clients as those in second and third trimester RTC every 2 weeks and get test results at that time. b) Re-evaluated how to conduct client satisfaction survey. c) Identified need for program code and age to be identified on survey form.

a) Test option only offered to prenatal intial visit clients. b) Nurse of Day will conduct survey with clients when they return for HIV results. c) Surveillance counselor conducts survey in Specilaty Clinic when clients return for HIV test. d) Survey form updated with program and age information.

5

a) Update survey form with suggested info. b) Tabulate responses to survey in STD. c) Evaluate client feedback. d) Vidoeconference with coach to plan next steps in grant reporting.

a) Continue survey in STD b) 4/8/13 started survey in FP and PN. c) Update metrics chart. d) Distribute new survey forms. e) Compile initial survey data.

a) Group identified additional data to collect and evaluate in regards to return visits for test results. b) Develop measurement criteria for financial impact on clinic with fewer appointments for test results (cost savings, clinic schedule availability.)

a) Adjust clinic schedule according to type of services requested. b) Produce report reflecting cost savings attributed to texting option. c) Consider adjusting staffing model to reduce cost per service if less demand for general visits.

PDSA RAMP

1

2

3

4

5

Train staff & begin offering text option to FP clients

QI team evaluation, revisions & finalize materials for Team Meeting

Update survey, tabulate responses, evaluate feedback &

plan next steps

Begin offering text option to PN clients

Begin collection of metrics & develop client survey

Change Strategy Cycle 1

Train staff & begin offering text option to FP clients

Revised Process Map due todiscrepancies

Developed uniform script forstaff to counsel clients

Created sample text

Process Map

Family Planning Flow Chart

Sample Text

Consent Form

Script

Change Strategy Cycle 2

QI team evaluation,revisions & finalizematerials for team

meeting

Revise policy to reflectupdates

Revise clientinformation cards

Clarify metrics for dataanalysis

Text Message Instruction Cards

Change Strategy Cycle 3

Begin collection of metrics &

develop client survey

Distribute client survey to

all clinics

Received and distributed

new message cards and

consent forms

StronglyDisagree

Somewhat Disagree

Neither Agree nor Disagree

Somewhat Agree

Strongly Agree

I am satisfied with thetexting option that I chose.

Texting provided me withthe opportunity to receivemy results quickly.

I feel comfortable callingthe Health Department if Ihad questions about myresults.

I felt confused about thetext message I received.

In the future, I would rathercome to the HealthDepartment for the results.

Client Survey for Texting ProjectProgram Code: 02 23 25 Age:___________

Change Strategy Cycle 4

Begin offering text option to

Prenatal clients

Text option only offered at

Prenatal initial visit

Nurse of Day to conduct

survey at return visit for

HIV results for FP clients

Survey conducted by

Counselor in Specialty Clinic at return for HIV results

Survey updated with program

and age information added

Change Strategy Cycle 5

Update survey, tabulate

responses, evaluate

feedback, plan next steps

Adjust clinic schedule

according to service type

requested

Produce report reflecting

cost savings attributed to

texting option

Consider adjusting staffing

model to reduce cost per

service

MetricsProgram

Clients Tested

Clients Opting In

Clients Opting Out

Texts Sent

Program OPT IN %

CHD OPT IN %

Jan STD 197 109 88 126 55% 25%Family Planning 117 * * * *

Prenatal 128 * * * *

Total 442 109 88 126 *

Feb STD 184 133 51 128 72% 34%Family Planning 112 * * * *

Prenatal 93 * * * *

Total 389 133 51 128 *

Mar STD 177 114 63 112 64% 66%Family Planning 114 79 28 72 69%

Prenatal * * * * *

Total 291 193 91 184 *

April STD 207 169 38 103 81% 71%Family Planning 145 128 18 60 88%

Prenatal 69 35 2 28 50%

Total 421 305 175 191 *

May STD 155 101 45 103 65% 71%Family Planning 69 60 9 82 87%

Prenatal 31 19 12 25 61%

Total 255 180 66 210 *

JAN FEB MAR APR MAY0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

STD

Family Planning

Prenatal

CHD

Percentage of Clients Opting In For Text Messaging By Program

Clients Tested By Month

STD

Survey Results

Strongly Agree

SomewhatAgree

NeitherAgree norDisagree

SomewhatDisagree

Strongly Disagree

13

5

1

I AM SATISFIED WITH THE TEXTING OPTION I CHOSE

13

6

TEXTING PROVIDED ME WITH THE OPPORTUNITY TO RECEIVE MY

RESULTS QUICKLY

12

6

1

I FEEL COMFORTABLE CALLING THE HEALTH DEPARTMENT IF I HAVE QUESTIONS

1 1

2

8

7

I FELT CONFUSED ABOUT THE MESSAGE I RECEIVED

6

41

8

IN THE FUTURE I WOULD RATHER COME TO THE HEALTH DEPARTMENT FOR MY RESULTS

Lessons Learned

Limitations Challenges Discoveries

Access to PRISM requires rights

Increase workload on existing staff to send texts Texting cannot

reach those w/o cell phone

Determine cost-savings benefit Introduction of Clearview rapid HIV test in STD Administering surveys

DIS notify clients with positive results often before text sent

Buy-in

Prenatal Clinic may not need text option due to frequency of visits Presentation of text option matters! Need to customize benefit of text option Paperwork lost in the process with Prenatal Clients

One staff trained on text messaging in PRISM

Next Steps Sustainability

Provide PRISM access to additional staff and train on text messaging process Consider eliminating option in Prenatal Clinic (conduct needs analysis)

Expansion of use of text option beyond test results State Texting Workgroup

Develop standard statewide policy Identify further uses for text option:

Health education/prevention messages (WIC, Healthy Start, TEXT4Baby, Epidemiology), appointment reminders, broadcasting versus dialog

Measuring outcomes Opt-in percentage for STD, Family Planning, and Prenatal Clinics Treatment timeframes with texters and non-texters Impact on clinic burden STD morbidity in newborns and fetal complications (birth defects, stillborns,

miscarriages)

Acknowledgements

Patrice Boon, RN Willie Brown Betty Chillon Anne Symecko, RN Joyce Pellar, RN Noemi Flores, RN Mashell Moss Mary Ann Rosenbauer, MPA Sara Warren, MPA Gloria Rivadeneyra, MS

Mike Napier, MS William Riley, PhD Cristina Rodriguez-Hart, MPH Sandra Zow-Johnson

Questions