Stories from the QI Award Program:
Using QI to Guide and
Support Your Work
June 2013
Presented by Nicole Charon-Schmitt, MPH
Director, 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
Administration
and Finance
Prevention and
Risk Reduction
Planning and
Program
Development
Treatment and
Recovery Support
Community
Prevention and
Mobilization
Specialized
Outpatient
Treatment
Risk Reduction
and Overdose
Prevention
Opioid Treatment
Family Residential
Access to Care
PAATHS
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 time
SAMHSA, 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
Brainstorming
Problem
Solving
• Formed QI Team
• Introduced staff to QI concepts and goals for project
• Engaged staff in identifying challenges and opportunities
for improvement
• Developed sub-aims
• 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
clarification
Voting
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 NGT

What 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

After first meeting with coach, agreed to develop
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
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
PDSA

PDSA 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
Lessons Learned

QI 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 Forward

QI 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, CHES
Donna Walsh, RN, BSN, MPA
Florida Department of Health, Seminole County
June 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 & 9/09-12/09
In 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, FL
In 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.
What is Required?
 Access to PRISM (for sending texts & call backs)
 PRISM training within 30 days of implementation
 Negative and positive labs attached
 Enter 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.
31
And So It Begins…
 County adoption of texting*:
Clay – 11/10/11
Seminole – 1/20/12
Duval – 1/26/12
Escambia – 11/8/12
Miami-Dade – 11/20/12
Orange – 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
# Days (field record add to treatment
7.0
6.0
5.0
6.4
6.1
6.0
5.1
5.0
5.2
4.2
4.0
Non-Texters
2.8
3.0
Texters
2.0
1.0
0.0
All
Clay
Duval
Seminole
Timeframe = lab add date to treatment date, excludes presumptively treated and those treated past 30 days.
Call Me!
# Days (field record add to treatment
Time to Treatment Comparing Call Back Status
10
9
8
7
6
5
4
3
2
1
0
8.9
7.0
6.9
5.0
3.9
3.6
3.5
2.6
All
Clay
Duval
Called Back
Didn't Call Back
Seminole
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
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.
Activities
Brainstorming
 Discuss models for
implementation.
Feedback Sessions
 How did we do?
 Process improvements.
Analysis
 Develop process maps
 PDSA cycles
 Metrics
 Surveys
QI Project PDSA Cycles
Cycle Stage
1
2
3
Plan
Check
Act
a) Initiate text option in FP clinic a) QI team to meet for evaluation
on 3/4/13.
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.
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.
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.
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.
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.
4
5
Do
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.
PDSA RAMP
Update survey,
tabulate responses,
evaluate feedback &
plan next steps
Begin offering text option to
PN clients
Begin collection of metrics &
develop client survey
QI team evaluation, revisions &
finalize materials for Team
Meeting
Train staff & begin offering
text option to FP clients
Change Strategy Cycle 1
Revised Process Map due to
discrepancies
Train staff & begin offering
text option to FP clients
Developed uniform script for
staff to counsel clients
Created sample text
Process Map
Family Planning Flow Chart
Sample Text
Consent Form
Script
Change Strategy Cycle 2
Revise policy to reflect
updates
QI team evaluation,
revisions & finalize
materials for team
meeting
Revise client
information cards
Clarify metrics for data
analysis
Text Message Instruction Cards
Change Strategy Cycle 3
Distribute client survey to
all clinics
Begin collection of metrics &
develop client survey
Received and distributed
new message cards and
consent forms
Client Survey for Texting Project
Program Code: 02
Strongly
Disagree
I am satisfied with the
texting option that I chose.
Texting provided me with
the opportunity to receive
my results quickly.
I feel comfortable calling
the Health Department if I
had questions about my
results.
I felt confused about the
text message I received.
In the future, I would rather
come to the Health
Department for the results.
Somewhat
Disagree
23
Neither
Agree nor
Disagree
25
Age:___________
Somewhat
Agree
Strongly
Agree
Change Strategy Cycle 4
Text option only offered at
Prenatal initial visit
Begin offering text option to
Prenatal clients
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
Adjust clinic schedule
according to service type
requested
Update survey, tabulate
responses, evaluate
feedback, plan next steps
Produce report reflecting
cost savings attributed to
texting option
Consider adjusting staffing
model to reduce cost per
service
Metrics
Clients
Tested
Clients
Opting In
Clients
Opting Out
Texts
Sent
STD
Family
Planning
197
109
88
126
55%
117
*
*
*
*
Prenatal
128
*
*
*
*
Total
442
109
88
126
*
STD
Family
Planning
184
133
51
128
72%
112
*
*
*
*
Prenatal
93
*
*
*
*
Total
389
133
51
128
*
STD
Family
Planning
177
114
63
112
64%
114
79
28
72
69%
Prenatal
*
*
*
*
*
Total
291
193
91
184
*
STD
Family
Planning
207
169
38
103
81%
145
128
18
60
88%
Prenatal
69
35
2
28
50%
Total
421
305
175
191
*
STD
Family
Planning
155
101
45
103
65%
69
60
9
82
87%
Prenatal
31
19
12
25
61%
255
180
66
210
*
Program
Jan
Feb
Mar
April
May
Total
Program
CHD
OPT IN % OPT IN %
25%
34%
66%
71%
71%
Percentage of Clients Opting In For
Text Messaging By Program
100%
90%
80%
STD
70%
Family Planning
60%
50%
Prenatal
40%
30%
CHD
20%
10%
0%
JAN
FEB
MAR
APR
MAY
Clients Tested By Month
STD
Survey Results
I FEEL COMFORTABLE CALLING THE HEALTH
DEPARTMENT IF I HAVE QUESTIONS
TEXTING PROVIDED ME WITH THE
OPPORTUNITY TO RECEIVE MY
RESULTS QUICKLY
I AM SATISFIED WITH THE
TEXTING OPTION I CHOSE
1
1
6
5
6
12
13
13
I FELT CONFUSED ABOUT THE MESSAGE I
RECEIVED
1
IN THE FUTURE I WOULD RATHER COME TO THE
HEALTH DEPARTMENT FOR MY RESULTS
1
2
7
6
8
8
Strongly
Agree
Somewhat
Agree
1
Neither
Agree nor
Disagree
Somewhat
Disagree
4
Strongly
Disagree
Lessons Learned
Limitations
Challenges
Access to PRISM
requires rights
Increase workload
on existing staff to
send texts
Texting cannot
reach those w/o
cell phone
Determine costsavings benefit
DIS notify clients
with positive
results often
before text sent
One staff trained on
text messaging in
PRISM
Introduction of
Clearview rapid
HIV test in STD
Administering
surveys
Buy-in
Discoveries
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
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