Improving the Timeliness of Salmonella Investigation

Summary

Impact Statement:

Rapid response to new Salmonella cases is critical to decreasing the spread of disease and reducing the likelihood of an outbreak. The Santa Clara County Public Health Department in California used the Define, Measure, Analyze, Improve, Control (DMAIC)/Six Sigma approach to identify the root causes of “slow down” in the response time for Salmonella cases, cutting the time to investigation in half.

Summary:

Beginning in January 2015, the Santa Clara County Public Health Department initiated an employee development program in Six Sigma. Four project teams implemented DMAIC/Six Sigma methodology. They selected projects uniquely positioned to support the department's strategic vision, goals, and objectives. This project focused on the department's strategic priority of strengthening prevention and response to current and emerging infectious diseases. The Communicable Disease Prevention & Control program in the department wanted to decrease its time to investigation for Salmonella cases, an established program performance measure.

From September 2014 to March 2015, the program’s process for Salmonella case investigation was not as controlled as it needed to be to securely meet the performance measure of initiating the investigation within 48 hours of receipt by the program. The program saw some improvement to its process from January to March 2015 but decided to test three significant factors associated with barriers for timely Salmonella investigation based on its process from September 2014 to March 2015. Only one of the three factors was still a significant barrier from January to March 2015. The program’s process for Salmonella case investigation is now much more tightly controlled.

This Six Sigma project began shortly after another similar project, which was started out of the county’s Center for Leadership & Transformation (CLT), began in the Communicable Disease Prevention & Control program. The CLT project was pushing rapid change to transform county operations. The data from the Analyze phase of DMAIC supported the changes being driven by CLT project team members. Had the data not supported the interventions being tested, the Six Sigma and CLT members would have needed to decide about how to use the data to guide the changes within the program.

The following changes were implemented in April 2015: (1) the staffing assignment to the advice desk was shortened from weekly to daily, (2) notification of the clinician before initiating the phone call to the patient was discontinued, and (3) reports were distributed at time of receipt as opposed to the nurse manager batching the assignments. As a result, the average time to investigation for Salmonella cases decreased by 50%.

Organization that conducted the QI initiative:

Santa Clara County Public Health Department

Citation:

Webber, W. Public Health Quality Improvement Exchange. Improving the Timeliness of Salmonella Investigation. Mon, 10/12/2015 - 10:00. Available at https://phqix.org/content/improving-timeliness-salmonella-investigation. Accessed May 31, 2023.

Background and Aim

Aim statement:

Decrease the time to investigation for Salmonella cases to fewer than 48 hours by May 31, 2015. The time to investigation is defined in hours as the difference in the time a report of Salmonella reaches the program office and the time the patient is contacted by phone.

Need For The QI Initiative:

This project focused on a department strategic priority. The Communicable Disease Prevention & Control program wanted to decrease its time to investigation for Salmonella cases, which was an established program performance measure that was not consistently meeting its target. It is important that the Communicable Disease Prevention & Control program meet the Salmonella investigation guideline of 48 hours for reporting and surveillance purposes to prevent further transmission from cases and sources of ongoing transmission and to identify outbreaks.

Area for Improvement:

Salmonellosis is a common foodborne illness caused by the bacteria Salmonella. Individuals with salmonellosis infection may experience diarrhea, fever, and abdominal pain, usually within 12 to 72 hours after exposure. The symptoms can last from 4 to 7 days and generally resolve without medication. For some individuals, illness can be more severe and require antibiotics and/or hospitalization. The salmonellosis incidence rate in Santa Clara County in 2014 was 19.7 per 100,000 population. Santa Clara County is among the top 10 counties with the highest salmonellosis incidence rate in California. Populations with the highest rates of salmonellosis in the county are children younger than age 5 (66.8), particularly among Asians/Pacific Islanders (101.8).

Root Cause:

After closing out each case, staff document the time to investigation and barriers in an online reporting system via SurveyMonkey. Staff brainstormed the following barriers to Salmonella investigations: • No physician information is listed on the report. • Staff are unable to locate the physician on the same day that the investigation was initiated. • Information on the reports is inadequate or wrong. • The public health nurse (PHN) is saturated with the workload. • There is a staff shortage. • Volume of the reports has increased. • A previous case is highly complex or acute. • PHNs were assigned to advice calls. From September 2014 to March 2015, barriers that were significantly associated (p < 0.05) with time to investigation for Salmonella cases included problems locating the physician, the volume of reports, and staff assigned to advice calls. From January to March 2015, problems locating the physician were the only barriers significantly associated with time to investigation for Salmonella cases.

Planning and Execution Details

QI Implementation:

The project team used the DMAIC improvement cycle to decrease the time to investigation for Salmonella cases. Implementation occurred with the following steps: Define • The Six Sigma project team identified a project and developed the project charter (March 2015). • A process map in Microsoft Visio was finalized to document the steps in Salmonella case investigation (March 2015). Measure and Analyze • The Six Sigma project team created control charts using JMP® software to establish a baseline for time to investigation (March 2015). Improve • Changes were implemented in April 2015 as part of the CLT. These were (1) the staffing assignment to the advice desk was shortened from weekly to daily, (2) notification of the physician before initiating the phone call to the patient was discontinued, and (3) reports were distributed at the time of receipt as opposed to the nurse manager batching the assignments. Measure and Analyze • The Six Sigma project team analyzed the barriers significantly associated with time to investigation, which supported changes implemented by the CLT. The team used the Fit Model platform in JMP® to run the analysis. • The Six Sigma project team examined follow-up data in the control chart to evaluate the degree of improvement in time to investigation (May 2015). Control • The next steps are to standardize a process for Salmonella case investigation and to identify what additional information is needed and how to collect it. The program continues to collect and monitor data on time to investigation and barriers to investigation.

Focus activities

Data collection, Epidemiology and Surveillance:

Communicable/infection diseases

QI Methods:

QI Tools:

QI Tool Documentation:

control chart.pdf

process map.pdf

survey.pdf

Initiative Dates:

3/5/15 to 5/31/15

Initiative Duration:

Less than 6 months

Methods of evaluation:

The project team created control charts by plotting the time to investigation for each Salmonella case throughout the project. This was the main measure and was compared before and after the three changes to the process were implemented in April 2015. Changes in staff and variations in data reporting may have affected the precision and accuracy of the measure.

Results

Measurable QI Outcomes:

The average time to investigation for Salmonella cases was 46.5 hours at the start of this project (September 2014 to March 2015). From January to March 2015, the average time to investigation was 23.8 hours. At the end of this project (May 2015), the average time to investigation for Salmonella cases was 11.7 hours, a 50% decrease in time.

Other QI Outcomes:

The successful completion of the project also included identification of process improvements, increased employee productivity, and increased capacity of staff to use quality improvement (QI) tools and methods.

Lessons Learned, Observations and Insights:

Key successes included having front-line staff participate in identifying the process and barriers, staff and managers providing insight into some of the issues, using data to substantiate a change, and empowering staff to be part of that change. Challenges included the time it took to go through the process, competing efforts with the CLT process, some inconsistencies with staff and manager participation in meetings, and encouraging staff to have a voice. Because of the other changes occurring with CLT, the QI project team needed to track when limitations occurred and their impact. This will need to be monitored over time to see whether the improvements continue. The team especially wanted to test it during the typically busier summer months. However, summer 2015 has been an exceptionally quiet summer for Salmonella. Standardization of processes was one reason for the difference between the observed and expected outcomes. The team found that different nurses were initiating their investigation in different ways. By observing them, the team identified the most efficient ways and addressed the need for more time-consuming processes. The team reduced redundancies (referrals waiting to be assigned, entering the case manager right away to avoid the manager having to look up a second report) and deleted unnecessary processes (extra database, calling the physician before contacting the patient). The method was standardized to inform the physician without delaying case investigation. The team needs to continue to monitor the initiative. The initiative addressed health equity or disparity by changing from assigning cases to nurses to distributing them as the reports came in. This eliminated assigning cases based on language skills. Staff were transitioned from assigning cases based on nurses’ language skills to using translation services, which may have resulted in faster investigation of cases involving non-English-speaking clients.

Future Plans:

Members of the project team observed all three PHNs who are involved in Salmonella investigations. Individual processes were shared with management to develop procedures and make decisions regarding program needs. The next steps are to standardize a process for Salmonella case investigation and to identify what additional information is needed and how to collect it. The program continues to collect and monitor data on time to investigation and barriers to investigation.

Improving the Timeliness of Salmonella Investigation

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Contact Information of the Submitter

Comments

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Improving the Timeliness of Salmonella Investigation

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Contact Information of the Submitter

Comments

QI Spotlight