Author: jaustin

Getting Started
The Sexually Transmitted Disease (STD) program wanted to evaluate and conduct a Continuous Quality Improvement (CQI) project on their current survey process. The STD program had only a four percent survey return rate for 2009. If changing the current survey process increases the amount of surveys returned, the data collected would have statistical significance. Program changes could occur related to client input/data thus increasing client satisfaction/ program efficiency and cultural awareness to provide appropriate services. The hope of this project was that if the STD team could get client input then program changes that occurred might reduce re-infection rates and allow the STD team time to provide additional outreach services. By providing additional outreach services more clients would be educated and reached; which would improve population health in relation to undetected or untreated STDS including HIV.

Allegan County
Health Department (ACHD)
29 Employees
Located in rural Allegan County
Population Served: 113, 449
30% urban, 70% rural

Team Members:
Team Leader: Angelique Joynes, RN, BSN, Director of Personal Health
Rashmi Travis, MPH, CHES, Health Officer
Kathy Yonkers-Wright, RDH, MS, Director of Health Education
Cynthia Stiles, RN, STD/HIV Coordinator
Jackie Skelton, RN, BSN, STD Nurse
Vicki Weaver, STD/HIV Support Staff

Quality Improvement Story Board

Act

Plan

The Sexually Transmitted Disease Client Survey Process:
Standardizing the Process to Increase Survey Return and Client Input

Study

Do

Plan
Identify an Opportunity and Plan for Improvement

2. Assemble the Team
The second step was to put in place a CQI team that consisted of interdepartmental personal to include representation of the STD program, the Health Education department, and the Administrative department; to implement a new survey and process that is standardized yet culturally individualized for each client. It was important to include representation from each area of the STD program to ensure that input was received from different perspectives. A work-plan and timeline were created and regular meetings were scheduled. An Aim statement was developed to define what the team hoped to accomplish with this improvement.
Original Aim Statement:
Between September 01, 2010 and November 30, 2010 fifty percent (50%) of STD clients presenting for care at Allegan County Health Department will complete and return an individualized culturally appropriate survey to STD staff.
The CQI team developed a demographic checklist to audit the STD records of those clients served during May 2009– May 2010. This checklist data collected created a demographic profile of the population served during that period.. A sample of those demographics are listed below:

Identify Potential Solutions
The STD team members developed a process map to standardized the process.
The MLC-3 team sent out a survey on the STD survey process to all local health departments in Michigan via Survey Monkey( an electronic survey) to evaluate other health departments current practice.
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A process map was created from a local health department with a survey return rate of 75% or better.

Develop an Improvement Theory
Predictions:
If the STD program stabilizes the process and develops a process map that all STD team members can refer to; then there will be an increase in staff awareness and compliance to the standardized STD survey process.
If STD staff follow the STD stabilized process and incorporate time into the appointment itself, then there will be an increase in the survey return rate .

Data from Survey Monkey was analyzed and compared to Allegan County’s STD survey process that was implemented during the “Do” stage of this project. There were two areas where Allegan County’s process differed from the majority of the survey responses.
Allegan County STD program gave their survey to the client during the appointment and only 9.1% of the respondents did the same.
Allegan County STD program incorporated time into the appointment itself to allow the client to complete the survey and only 40% of the respondents allow time as well.
Allegan County STD program’s total client STD survey return rate during the “Do” stage of the CQI project was 75%.

Act
Standardize the Improvement and Establish Future Plans

8. Standardize the Improvement or Develop a New Theory
The Allegan County STD program has adopted the survey process that was implemented during the “Do” stage of the PDSA.
Allegan County STD program has developed a process which produces a statistically significant return rate for client surveys.
The STD team now needs to evaluate the current survey; does the current survey give us the demographics and knowledge the team need to move towards developing a culturally appropriate client centered approach?
Allegan County STD program will evaluate the client survey return rate quarterly to ensure the process remains effective.
Allegan County STD program will evaluate why 100% of clients opted for the paper survey over the electronic. The MLC-3 team was able to purchase a year subscription to Survey Monkey; and will utilize CQI tools to evaluate how to make this a client friendly option.

Examine the Current Approach
The evaluation of the current approach was explored utilizing a process map. This map presented a pictorial representation of the existing sequence of actions that comprise the process of conducting the client satisfaction survey..

The current approach was analyzed using a cause and effect fishbone diagram . After evaluating the Fishbone Diagram the MLC-3 team identified that the process was not standardized between the STD Public Health nurses working in the program. An STD nurse often did not know if it was an STD survey month. Others did not address the survey with the client . The process needed to be standardized first ; to increase survey return rate. For the team to be able to provide culturally appropriate services the STD program needed to get back more surveys. An AIM Statement revision needed to occur. A new AIM Statement was developed; Between September 01, 1010 and November 30, 2010 fifty percent (50%) of STD clients at Allegan County Health Department will complete and return a STD survey.

Do
Test the Theory for Improvement

Test the Theory
ACHD STD Public Health nurses implemented the new STD survey process from September 01, 2010– November 30 2010.
The MLC-3 team and STD team noted that the October rates were significantly lower. The charts were reviewed and it was discovered that one Public Health nurse did not follow the process map. The nurse did not allow the client time to complete the survey during the appointment . The local health departments that did incorporate time into the appointment had the highest percentage of return rates per the survey sent out via Survey Monkey. In November our STD Public Health nurses ensured that they followed the process map and the client had time during the appointment to complete the survey.
The STD team discovered an unintended consequence of incorporating time into the appointment; the nurse was able to complete her charting while the client completed the survey. This decreased charting time after the appointment which increased efficiency.

Study
Use Data to Study Results of the Test

7. Study the Results
STD SURVEY PROCESS AT LHDS IN MICHIGAN (Survey Monkey)
*Allegan County STD program during the “Do” part of this project gave the
survey to the client “During the appointment”.
*Allegan County STD program during the “Do” part of this project offered “Both”.
*Allegan County STD program during the “Do” Stage gave “time during the appointment to fill out the survey”
*Allegan County STD program survey return rate during the “Do” stage of this project was 75%
overall. The STD survey return rate for the 2009 was 4%.

9. Establish Future Plans
The MLC-3 team did a literature review on survey instrument design-quality assurance measures. A form was created to objectively measure the current survey from the literature review data.
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The MLC-3 team plans to look at the “bigger picture” on the survey implementation: the team created a process map from literature review outcomes.
Allegan County STD team plans to evaluate the current survey and make changes; changes will put demographics, cultural awareness, and client input/needs into perspective. To identify the clients needs and make changes in the STD program that will reduce re-infections, increase treatment of partners, educate clients on decreasing risk of transmission, and improve population health in Allegan county. This will be another CQI project .
This project’s outcomes will be shared at the Legislators and County Commissioners Orientation, a regional STD meeting, other Public Health conferences, 2011 Public Information Session, and with the LHDs that participated in the electronic survey.
Share the outcomes of this project with ACHD staff and continue to foster the use of CQI tools and implement a culture of CQI throughout the health department. Environmental Health and Personal Health have an interdivisional CQI project between Communicable Disease and Food Inspection program on identifying and communicating possible food borne illness outbreaks.

Survey Instrument Design-Quality Assurance Measures
Does this instrument measure the five domains? (Weston, Dabis, Ross 2009)
Convenience of clinic location	met unmet
Availability of appointments	met unmet
Staff attitude to patients	met unmet
Effective delivery of information	met unmet
Confidentiality within the clinic	met unmet
Does the instrument measure dissatisfaction levels opposed to satisfaction to allow for social determinants? (Sitzia, Wood, 1997)	met unmet
Is the instrument coded to measure demographic? (Hall, Dornan, 1990)	met unmet
Does the instrument measure age and gender? (Fox, Storms 1981)	met unmet
Are the questions all formatted as either using positive or negative questions; not varied between the two. (Stump, Dexter, Tierney, Wolinsky, 1995)	met unmet
Do the structured questions have five point scales? (NCQA)	met unmet
Does the instrument use visuals to compliment the five point scale? / Great Good Fair OK Poor / (HRSA, 2010)	met unmet
Has the instrument been pre-tested to forestall psychometric influences? (Stump, Dexter, Tierney, Wolinsky, 1995)	met unmet
Does the instrument have structured questions followed by unstructured at the end? (locker, Dunt 1978)	met unmet
Is the instrument controlled against “provider-led” errors? (Carr-Hill 1992)	met unmet
Does the instrument control the “halo effect” of nurses? / (College of Health, 1994)	met unmet
Does the implementation of the instrument control for the time and location of its completion? / (Carl-Hill, 1987)	met unmet

How to Administer the Survey Flowchart

Create a survey
administration plan

Select staff to offer survey

Develop Script

Develop signage for waiting room and clinical areas.

Purpose of the survey
“We would like to know feel about the quality of your care at ACHD. Your answers to the questions will help us understand what works and what does not, and how we can improve our services to you and others”.

Role Play: Assume role of client and ask a staff member to approach you with the survey. Give feedback to each team member.

Anonymity
“If you choose to participate, your survey will remain completely anonymous”.

Question and Ask: Review each survey question together as a staff, in order to surface any questions/or difficulties that clients may have with certain question types.
Correct areas indentified in the survey.

Option to decline-Yes/No
“Your participation in this survey is completely voluntary. If you choose not to participate it does not affect the services you

Administer the survey

What is your current survey return rate?	Response Percent	Response Count
< 10%	18.8%	3
10-24%	6.3%	1
25-50%	31.3%	5
51-74%	12.5%	2
75-100%	31.3%	5

Does your STD clinic incorporate the survey into the appointment process itself? (give time during the appointment)	Response Percent	Response Count
Yes	40.0%	8
No	60%	12

What types of surveys does your STD program offer?	Response Percent	Response Count
Paper	76.2%	16
Electronic	0.0%	0
Both	14.3%	3

When does the STD client receive the survey?	Response Percent	Response Count
During the check-in process	36.4%	8
At the beginning of the appointment	4.5%	1
At the end of the appointment	27.3%	6
During the appointment	9.1%	2
Other	36.4%	8

Multi-State Learning Collaborative 3 - Funded by the Robert Wood Johnson Foundation.