Tuberculosis Rate Improvement Project
Tuberculosis is difficult to eradicate, it can have devastating health impacts, and one active TB case can result in budget-breaking expenses for small-to-medium local health jurisdictions. A local health department in Washington state implemented a quality planning and quality improvement project to increase the percentage of high-risk clients with latent TB infection (LTBI) who are seen by staff and start treatment through two interventions: (1) reducing the time staff spent with low-risk LTBI clients; (2) improving one-to-one communication and follow-up with high risk LTBI clients.
Whatcom County Health Department's (WCHD's) initial quality improvement (QI) aim statement was as follows: “By July 1, 2013, the TB program will increase the percentage of high-risk clients with latent tuberculosis infection (LTBI) who start treatment by 5%.” This aim statement was revised to read, “By July 31, 2013, the TB program will increase the percentage of high-risk clients with LTBI who start treatment by 5%." As the project progressed, the team realized the layers of complexity in the TB program, which resulted in an additional focus on quality planning. The following aim statement was developed: “By July 31, 2013, the TB program will increase the percentage of high-risk clients with LTBI who are seen by WCHD staff from 75% to 90%. This goal will be accomplished by decreasing the number of low-risk clients with LTBI who are seen by WCHD staff.” To move forward on this goal, the team researched TB programs in several health departments; all had screening criteria. Because WCHD lacked criteria, the team concluded that screening guidelines should be developed that limit clients seen to those at high risk for active TB. The root cause of the problem was spending too much time on screening low-risk referrals. The team drafted LTBI screening guidelines and a timeline. Instituting the screening guidelines is ongoing and scheduled for completion by December 2013. The team then focused on the QI effort. The team identified the root cause of clients not starting treatment as a lack of one-to-one contact with staff. Identifying the problem resulted in improving communication and follow-up with clients. The team also realized that TB client data collection was inaccurate and not automated. An improved data collection system will be an ongoing focus.
Organization that conducted the QI initiative:
Simmons, A. Public Health Quality Improvement Exchange. Tuberculosis Rate Improvement Project. Tue, 05/26/2015 - 08:17. Available at http://phqix.org/content/tuberculosis-rate-improvement-project. Accessed December 1, 2020.
Background and Aim
QI: The initial aim statement was as follows: “By July 31, 2013, the TB Rate Improvement Project will increase the percentage of high-risk clients with LTBI who start treatment by 5%.” WCHD staff sought to improve start rates for high-risk clients with LTBI. Staff expected this goal would improve efficiency in the TB screening processes as well. Using 2010 data, out of 199 clients for whom treatment was recommended, 104 clients (52%) refused treatment. This treatment refusal rate was of particular concern, and the team sought to improve it. Quality planning: An additional aim statement was as follows: “By July 31, 2013, the TB Rate Improvement Project will increase the percentage of high-risk clients with LTBI who are seen by WCHD staff from 75% to 90%.” This goal will be accomplished by decreasing the number of low-risk clients with LTBI who are seen by WCHD staff.” WCHD staff realized that many of the TB clients seen were at low risk for active TB, and with limited resources, WCHD needed to focus on clients who are at high risk for active TB. The team decided this was a quality planning component, because completing this objective entailed a complete redesign of the TB program.
Need For The QI Initiative:
This project sought to accomplish two important organizational goals: (1) Reinforce QI skills in staff who have recently received QI training and who need further QI project experience, and (2) draw in other staff members with QI experience who have not had the opportunity to use their knowledge. A professional, cross-divisional team met to review TB program processes and data. WCHD staff created a funnel diagram in which the large funnel opening represents the entire TB population, the next layer represents those who are tested for TB, the next layer represents positive referrals to WCHD, the next layer represents those who receive treatment, and finally, the narrow spout represents those who have completed treatment. Based on the team discussion, staff identified at least three questions that relate to improvement: 1. Are those at highest risk for TB being tested? 2. Are staff as efficient as they could be in screening positive referrals, and how do inefficiencies in screening impact staff resources available for provider education? 3. How could staff improve treatment start rates and completion rates? The team does not have easily accessible data to answer the first question. The team did know that about 50% of positive referrals who were screened were not at high risk for TB, so it seemed that there was room to improve the efficiency of these screenings and perhaps reduce the number of low-risk referrals made by providers. Finally, WCHD had treatment start rates of only 48% (n=95), which is unsatisfactory.
Area for Improvement:
TB is a difficult disease to eradicate, and even one active TB case can result in budget-breaking expenses. Whatcom County experienced this issue in 2010–11, when the costs to manage one case of multidrug-resistant TB were more than $53,000 for staff time and $20,500 for treatment medication, for a total of $73,500. Reducing LTBI in the population is a crucial public health issue with widespread health and cost implications. Although WCHD had a robust TB program, it still had far to go in identifying those most at risk for TB, testing them, screening positive referrals efficiently and thoroughly, and ensuring that treatment is started and ultimately completed. Staff know that about 50% of positive referrals who were screened were not at high risk for TB, and they needed to focus more effectively on high-risk clients. WCHD also had treatment start rates of only 48% (n=95). This start rate is unsatisfactory, and the team sought to increase it.
The initial quality planning issue identified was “too much time spent on low-risk referrals.” Root causes that contributed to this issue were as follows: • referrals that were accepted from all community sources; • screenings were completed equally on all referrals (whether high- or low-risk clients); • workflow was continually interrupted by phone calls and walk-in clients; • providers lacked knowledge about TB, resulting in phone calls and patient referrals to the WCHD TB program; • the work culture included staff who were resistant to program change; and • the program lacked a formal guidance document detailing clear screening and referral criteria. The primary root cause was determined to be the lack of screening and referral criteria. This root cause was identified through researching TB programs in health departments (some of comparable size) in Washington and California. In April, the team identified the key QI issue as “high-risk clients not starting treatment.” Potential root causes included the following: • client perceptions of LTBI treatment as a low priority, • inadequate client knowledge regarding LTBI, • clients' fear of LTBI treatment, • clients' concerns regarding treatment costs, • clients' possible lack of trust in WCHD staff, and • limited staff one-on-one contact with clients after screening results were determined. The team identified “limited staff one-on-one contact” as the primary root cause. The team identified this cause by surveying the recent client population and analyzing results. Written communication processes were also identified as problematic. In particular, the follow-up letter providing screening results to clients needed extensive improvement, and staff needed to be more proactive in following up with clients.
Planning and Execution Details
The following specific QI methods and tools were used: a process flowchart, a cause-and-effect diagram, and surveys. Initially, the initiative sought to increase the treatment start rate for high-risk clients with LTBI. This initiative was chosen because TB is a difficult disease to eradicate, it can have devastating health effects, and it is communicable. Also, even one active TB case can result in budget-breaking expenses for small-to-medium–sized local health jurisdictions. At the first QI meeting, team members were given various assignments including researching LTBI treatment in low-risk clients and current triage practices in various similar-sized health jurisdictions in Washington and California. A web search resulted in research on additional TB QI projects. A fishbone diagram was constructed based on the problem statement, “Too much time is spent on low-risk referrals." This diagram identified possible root causes in the current process. In April, LTBI guidelines were developed for screening, treatment, and possible referral of clients to outside providers. The guidelines were created so the TB program can focus limited resources on the screening and treatment of high-risk clients and the seamless referral of other LTBI clients to community providers. The guidelines included criteria for client acceptance to the WCHD TB program and criteria for client referral to outside providers. A timeline for implementation of the guidelines was also created. The TB medical consultant participated in the final draft of the guidelines and guideline implementation. Currently, the TB medical consultant is developing TB education information for the website that will help community providers to recognize TB and to better understand the treatment of TB. As this component of the project has not yet been completed, the team continues to implement improvements that it will then study and evaluate. As this initiative developed, team members realized that it included a data system improvement component. This need was identified as staff were forced to do hand counts to obtain data that should be legitimately automated within the data collection system. Therefore, toward the end of the project, the team began to meet with an information technology specialist to find key data elements that need to be added to the data system, automated reports that staff need for day-to-day work and work on continuous QI, and ways to ensure that data are entered accurately. Thus, this project covered all three quality dimensions: quality planning (developing screening guidelines), QI (increasing high-risk LTBI treatment success), and quality assurance/control (ensuring accurate and useful data for monitoring the program). The following people were exposed to the QI initiative: • LTBI clients; • TB program staff including clerical staff, nurses, the TB medical consultant, and the division manager; • the WCHD performance management team; • Whatcom County council members; • the Public Health Advisory Board; and • private providers (when the screening guidelines and educational materials are provided).
Other QI tools:
10/1/12 to 5/19/15
Greater than 24 months
Methods of evaluation:
The QI and quality planning components will be measured by collecting data and evaluating client charts reviewed by the TB medical consultant during 2014 and comparing these data with data collected during 2010 (the best and most complete full year of data). The quality assurance component will be measured by improved efficiency and improved methods (new automated analysis and reporting versus current hand counts) of data collection. In addition to evaluating the success of programmatic changes, the team also surveyed members quarterly regarding their QI experience. Team members were asked to respond to six questions using a Likert-type scale, in which 1="not at all” and 5="extremely.” One measure remained the same at 4.6, and one measure decreased from 4.8 to 4.6. Average (mean) scores increased for the following four out of six measures over the course of the project: • To what extent was the discussion open, with sharing of diverse ideas and perspectives? (Increase from 4.6 to 4.8). • How valuable were the goals compared to other things the team needed to accomplish? (Increase from 4.6 to 4.8). • Overall, how effective was the group in meeting its goals? (Increase from 4.2 to 4.4). • To what extent did I say or contribute what I thought was important to achieving the team's goals? (Increase from 4.0 to 4.4).
WCHD Final TB QI Return on Investment Report - August 28, 2013 and May 15, 2015
Measurable QI Outcomes:
The QI and quality planning components used 2010 baseline data and the outcomes were measured using 2013 and 2014 data. Overall our QI outcomes were: • Decreased screening of TB clients: There was 54.35 percent decrease in the total number of TB clients that were seen by the TB medical consultant. (2010=199, 2014=91) This translated into a 53.5 percent decrease in cost from 2010 to 2014. (2010=$61,969, 2014=$28,649) In addition, from 2013-2014, there was a 41.6 percent decrease in the total number of TB clients that were seen by the TB medical consultant. (2013=156, 2014=91) This decrease is attributed to referring clients who were potentially a Class 0 and clients who were a Class 2 (but were at very low risk to activating to Class 3) to providers in our community. This allowed staff to focus on Class 2 clients who are at higher risk of activating to Class 3. • Improved Treatment Starts: From 2010-2014, there was a 25 percent increase in the percentage of Class 2 clients who started treatment for latent TB infection by WCHD staff. (2010=48%, 2014=60%) • Improved Treatment Completion: From 2010-2014, there was an 11.9 percent increase in the percentage of Class 2 clients who completed treatment at WCHD. (2010==74%, 2014=82.8%) • Return on Investment: For every $1 invested in the quality planning component, WCHD realized a return of $1.31 after costs. In order to measure our QI outcomes, we needed to establish a method to track our work (quality assurance). We decided to use an excel data base to establish a standardized, and objective method to categorize our clients who are evaluated by the TB nurses and TB medical consultant. By using an excel database, we were able to use Epi Info and conduct a more in depth data analysis. Using excel, we classified the clients according to standard TB classifications (0=no TB exposure; 1=TB exposure, no infection; 2=latent TB infection, no TB disease; 3=active TB disease; 4=previous TB disease, not clinically active; 5=TB suspect), treatment recommendation, treatment start, treatment completion and the referral source. In the process we discovered that many clients who were referred and evaluated by the TB medical consultant were class 0. Our screening guidelines were further refined, resulting in a 58% decrease in the number of class 0 clients seen from 2013-2014 (2013=50, 2014=21). By tracking the referral source, it allowed the staff to focus TB education on the top referring sources. The results of this effort was from 2013-2014, the top two referring sources (42 referrals) decreased by 74% (11 referrals). With the decrease in clients evaluated by staff, the staff is able to focus on the higher risk clients and educating and acting as consults with providers, clinic staff and others in the community. This has increased TB awareness, knowledge and partnership between the health department and the community.
Other QI Outcomes:
Non-measurable outcomes included Screening Guidelines, excel data collection, improved client communication and increased staff quality improvement capacity. The QI project also increased the awareness and knowledge of TB in our community and developed sustaining partnerships with providers, clinics and others. In addition, our TB web page was revised to include information and references for medical providers.
Lessons Learned, Observations and Insights:
As the team delved into this QI project, the project's scope increased from a QI project to include quality planning and finally to include quality assurance. As the project expanded, the timeline extended, and staff time on the project will continue until staff follow through on completing all components. Overall, the QI project allowed the TB program staff to take a break from their normal work duties, to be objective, to research options, to study the options, and to plan for a more focused, client-centered program. This process improved staff morale and sparked and renewed interest in other program areas and in work life. The project was a success in many ways.
The TB QI Initiative is fully incorporated into the TB program. We established an excel data base for gathering client information and for tracking outreach and educational opportunities in the community. The data we collect will be evaluated regularly and the program adjusted accordingly.
Training and Preparation
Technical Assistance Received:
This QI project was conducted as part of the National Network of Public Health Institutes (NNPHI) QI Award Program, a competitive initiative that provides a small financial award and 15 hours of distance-based and in-person coaching from a designated QI consultant. The program is part of the Community of Practice for Public Health Improvement (COPPHI), supported by the Robert Wood Johnson Foundation.
QI Related Training Received:
The Public Health Performance Management Centers for Excellence at the Washington State Department of Health provided webinars on the following topics. These trainings were offered to all WCHD staff, although not all staff were able to attend the trainings. • Overview of Performance and Quality Management • Communicating with Data • Monitoring Quality Improvements: Introduction to Variation Theory • Quality Tools Training Also, the National Network of Public Health Institutes (NNPHI) and COPPHI provided webinars to the TB QI team on the following topics: • Getting Started on the Right Foot with Your QI Project • Engaging Customers, Team Members, and Partners in the QI Process • Understanding Your Customer, Understanding Your Process: QI Essentials • Submitting Your Project to PHQIX: A QI Award Program Participant’s Guide • Sustaining the Gains: Building a Culture of QI
Information about the Community
Whatcom County is located in the northwest corner of Washington State and the United States. The county population is 203,500. Of the residents, 43% live in unincorporated areas; the remaining residents live in one large city (n=83,210) and six small cities. Of the population, 85% identifies as white, 8% as Hispanic, 4% as Asian, 3% as American Indian, and less than 1% as black. Whatcom County data demonstrate strong associations between income and self-reported health status of adults, with a significantly greater percentage of people in households at lower income levels reporting poorer health status than those with higher household incomes. Whatcom County also has pockets of vulnerable populations. Pockets of poverty are distributed throughout the county; however, percentages of families living in poverty are higher in the eastern part of the county and in central northern Bellingham and the city of Ferndale.
Information about the Health Department
Local Health Department Governance:
Local Governance - all LHDs in the state are units of local government
PHAB Accreditation Status:
Submitted statement of intent for accreditation
Annual QI Initiative Frequency:
QI activity level:
QI Staff Information
Total number of Staff on QI Team:
Total number of FTEs on QI Team:
QI team members:
Role in the Initiative:
Project manager and facilitator
Role in Organization:
Performance Management Specialist and Accreditation Coordinator
Role in the Initiative:
Role in Organization:
Role in the Initiative:
Team sponsor and epidemiology consultant
Role in Organization:
Role in the Initiative:
Topical lead and co-facilitator
Role in Organization:
Public Health Nurse (PHN) in TB Program
Role in the Initiative:
Best practice researcher
Role in Organization:
PHN in Immunization Program
Domain 2: Investigate health problems and environmental public health hazards to protect the community
Other Partner Organization Types:
No partner organizations.
Contact Information of the Submitter
Link to the resource where this submission is also published: