Improving STD Prevention and Control by Implementing a Formalized Plan for Managing Increased STD Cases or Decreased STD Staff

Direct Observation by an Evaluator during the TTX Objective 1: By November 30, 2012, Sexual Health Program staff will demonstrate the ability to manage a mock outbreak by using the STD ORP during a TTX. Measures 1.1 Was the STD ORP activated? Achieved The activation of the ORP was discussed during a one-on-one meeting between the program manager and the affected personnel at that time. During the team meeting, it was not evident to the evaluator that the participants had been clearly told that the plan had been activated and had been given an explanation of the next steps. 1.2 Do staff members know their specific roles in relation to the TTX scenario? Improvement Needed Nursing staff knew what was expected of them and what their roles were. Nonnursing staff and the designated lead did not appear to have a clear understanding. 1.3 Were there adequate resources to manage the outbreak without overtime? If yes, until what level? Achieved The Community and Clinical Health Services division and TTX participants were willing to change directions on assignments to manage the outbreak. Using the assumptions that staffing levels were normal, the outbreak was manageable internally until Level 3. Objective 2: By November 30, 2012, the Sexual Health Program staff will demonstrate the ability to involve WCHD partners into the scenario based on the TTX that focuses on outbreak response. Measures 2.1 Did the staff appropriately integrate internal and external partners as the TTX progressed? Achieved This was a major strength of the TTX. Participants continually discussed which internal and external partners should assist with the outbreak. There was a clear understanding of the role of the Nevada Division of Public and Behavioral Health and the potential involvement of CDC. Additional outside partners were identified that were not previously considered during the TTX design. Objective 3: By November 30, 2012, the Sexual Health Program staff will demonstrate the ability to assess and evaluate the trigger points, as laid out in the STD ORP. Measures 3.1 Did staff notify the proper agencies of the increase in syphilis cases? Achieved Throughout the TTX, communication with outside agencies was discussed. Communication to outside partner organizations consisted of simulated telephone calls, e-mails, and use of Epi-News and Epi-Updates. 3.2 Did staff reach out to the public information officer to inform the media? Area for Improvement Two staff meetings were held during the TTX, and media was not discussed. The TTX included a call from a local media station to try to verify a rumor, and there was no follow-up to that media inquiry. 3.3 Did staff communicate effectively internally to ensure agency awareness of the outbreak and the change of assignments to manage the outbreak? Achieved The communication tools used during the TTX mirrored those that would be used during a real response. The level of activation was discussed either at the team meeting or in a follow-up e-mail. Objective 4: By November 30, 2012, the Sexual Health Program staff will demonstrate the ability to coordinate and communicate during a TTX. Measures 4.1 Were the levels discussed and adequately executed? Achieved Except for the actual discussion of the plan's activation, progression through the levels was discussed at each trigger. Pre-Test and Post-Test Participants were asked to rate themselves on a 1 (low) to 5 (high) scale before and after participating in training and the TTX: Seven of eight (staff) participants completed both tests. Results of Pre- and Post-Tests: Percentage Answering 4 or 5 • Overall knowledge of your role in an outbreak: pre-test = 14%, post-test = 85%, improvement = 61% • Ability to effectively perform duties likely to be assigned to you during an outbreak: pre-test = 57%, post-test = 100%, improvement = 43% • Comfort level to perform duties likely to be assigned to you during an outbreak: pre-test = 7%, post-test = 100%, improvement = 43% • Belief that the syphilis ORP is realistic and will be useful in an outbreak: pre-test = 71%, post-test = 100%, improvement = 29% Since putting the STD ORP into effect, WCHD has experienced a syphilis outbreak and has had multiple opportunities to use the plan. Staff found that they were able to handle, and even exceed, 12 cases for a rolling 3 months.

Other QI outcomes included the following: • The initiative and implementation of the STD ORP increased interdivision communication and collaboration. • Ideas generated during the TTX for creative uses of staff outside the program, nursing students, and volunteers will be explored to lessen the impact of staff shortages on STD service provision. • Completion of the TTX increased Sexual Health Program staff members' confidence and understanding of how a syphilis outbreak can be managed with assistance from other programs. • As a result of implementing the STD ORP, staff ultimately decided to move a nurse full time into the disease intervention specialist position to better handle the increased demand related to the ongoing syphilis outbreak. • Also, this project definitely changed how the program and division viewed QI projects, and much of what staff learned can be applied daily in small-scale, rapid-cycle PDCA.

Key successes were as follows: • The TTX was realistic and a great way to test the new plan. • Arizona outbreak response information was instrumental in understanding how quickly an outbreak situation can occur. • University of Nevada, Reno, nursing students participated in planning and the TTX, which benefited both the students and WCHD. • Working with the Strike Teams (subcommittees) was a great time saver and allowed project pieces to progress simultaneously. Areas for improvement included the following: • A dry run for the TTX planning team before the exercise would help the leads have a better understanding of what would happen during the exercise because this was the Community and Clinical Health Services division's first exercise. • The TTX focused too much on the numbers of an outbreak rather than on the fluidity between the levels and involvement of other WCHD staff. • The team that the staff started with during the planning process was too large.

The Community and Clinical Health Services division had never used a TTX to pilot a new policy or procedure. QI team members and other participants found the TTX to be invaluable and will incorporate it into other projects. The use of Strike Teams is a lesson learned that will be used in future projects and added to the QI plan. To maintain gains, the STD ORP is being used to address staffing challenges and to evaluate increases in STD cases in day-to-day program management. A corrective action plan was developed to address areas needing clarification and/or additional training. The program manager supports the STD ORP and will monitor completion of recommended corrective actions. Training identified as required for staff to perform expanded roles during an outbreak will be provided during periods of downtime and incorporated into staff duties. The STD ORP will be updated, and training will be provided annually.