1. 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 Chlamydia Quality Improvement Workgroup (CTQI)

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

5. 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 Plan: Define the opportunity 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. 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 Plan 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. 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 Plan: What data or information is needed 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. 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 Plan 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=2 N=3 Hospital HD PPCom/Mig OB/GYNOther

9. 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 Do: Select and develop a theory for improvement 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. 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 Study: Study the results 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. 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 Study: Study the results 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. 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 Study: Conclusions 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. 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 Act 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. 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 Act: Lessons learned 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