Cathy Bambrick – Administrator Bonnie Corns – Community Health Services Director

1. Chlamydia Quality ImprovementWorkgroup (CTQI) • 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

2. 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

3. Plan • 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 • 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

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

5. Plan: Define the opportunity • 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 • 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%

6. Plan • 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 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

7. Plan: What data or information is needed • 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 • 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

8. Plan • 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 • Hypothesis: emergency departments responsible • for most untreated cases • Finding: EDs not a big player in Skagit County, • 1 of 3 big players in Kitsap N=2 N=1 N=1 N=3 N=1 N=1 N=2 N=2 N=2 Hospital HD OB/GYN Other PP Com/Mig

9. Do: Select and develop a theory for improvement • 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 • 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

10. Study: Study the results • 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 • 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

11. Study: Study the results • 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 • 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

12. Study: Conclusions • 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 • 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

13. Act • 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 • 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

14. Act: Lessons learned • 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 • 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