The specific QI methods and tools were used as follows:
• A root cause analysis was used to identify the causes. The team used the affinity diagram to cluster and identify the main topic areas.
• The team members brainstormed what they wanted to accomplish, how they will know they accomplished it, and changes they would see. The answers to the first question (What are we trying to accomplish?) were serve more people, serve all people who need it, and provide quality customer service. Team members then answered the second question (How will we know that a change is an improvement?) An improvement would be recognized so the client caseload numbers will increase (measurable monthly).
• A flowchart was made, and it documented two processes: the process of a client enrolling in the WIC program and the staff process for the program components.
• The team members identified potential points of the process that could be changed to impact caseload. These points included attending and networking at outside events (understaffing at these events could lead to missed opportunities); on-site enrollment (this is an important process to catch otherwise missed potential clients; it could be a place to focus improvement); WIC staff appointment scheduling (a lot of time is spent scheduling appointments; show-up rates are 40%–50%); intake process (could potentially engage clients in the waiting room and speed up the intake process; mobile triage could potentially help retain clients; potential ideas: group certification, kiosks for clients to self-enter intake info, online appointment process; having clients do work before arriving may speed up process); giving nutritional education; notes by WIC staff (it becomes a customer service issue when clients are left waiting while staff finish notes); assessment, tools, and baby behavior training process; increase languages on website; track website hits (new URL, link to public health homepage). An important decision was needed to focus either on the staff process or client process. This question was put to the team members, who overwhelmingly wanted to focus on staff inputs.
• An affinity diagram was created after using the 5-Whys technique to identify the reasons for the decreased number of WIC enrollees. The nine broad categories include change in demographics, access to appointments, logistics, stigma, fear of government, food security, lack of knowledge of the WIC program, poor experience with WIC, and staff behavior.
• The team used a control versus influence chart to plot the areas for improvement and identified those that the team could control and influence. Six potential solutions were identified as being beyond the team’s ability to influence and to control.
• The team members used ranking/voting to identify the solution. The items were then ranked using a nominal voting procedure. The results were as follows (in order of highest priority):
1. WIC hours vary and are not always from 8 a.m. to 5 p.m.
2. Taking new appointments (calls and walk-ins).
3. (tie) Bad reputation of WIC.
3. (tie) Change awareness that WIC is easy to obtain (versus food stamps).
4. (tie) Staff not “selling” WIC to clients.
4. (tie) Staff have unwilling attitudes.
5. Lack of WIC knowledge and services.
6. Change the attitude of clients who do not think they need WIC.
The team describes the QI initiative as follows:
• The team chose one main strategy initiative, which was to implement changes to increase the number of walk-in clients to the clinics. The initiative was chosen after prioritizing bringing new clients into the system as the focus rather than trying to sustain current clients (clinics that took appointments had already started calling clients who had missed their appointments and would continue this approach to maintain those client caseload numbers).
• To increase the number of walk-in clients to the clinics, the team relied on the data analysis of client intake and flow provided by the Office of Epidemiology. Specifically, the team looked at the peak hours for appointments and walk-ins and at the average number of walk-ins or appointments per clinic for January 2013. A second round of analyses was conducted for four clinics for an additional month, June 2013.
• Findings included higher intake volume on Tuesday through Thursdays and the peak hours of client arrival times are 8 a.m., lunch time, and afternoon.
• The results were data-driven decisions to
1. change staff working hours to the hours the clinics were open, which would include staggering staff schedules and heavier staffing during lunch time (11 a.m.–1 p.m.) and on Mondays and Fridays;
2. change the walk-in versus appointment ratio schedules in the clinic; and
3. change one clinic to a walk-in only system.
The QI team implemented the initiative in the following ways:
• Clinic supervisors have started changing staff hours so that more staff were available when clients walk in, and staff are able to take more walk-in clients.
• Two clinics have changed to seeing only walk-in clients, and a third handles mostly walk-in clients (near or around the time of the initiative).
The following people were exposed to the QI initiative:
• All the WIC clinic supervisors have been involved in this initiative. Information from the initiative was presented at all supervisor meetings. Every clinic supervisor was invited to participate in an interview to assess program concerns and to identify solutions to the decreasing caseload problem (interviews with 11 supervisors were completed).
• More than 400 clients who had appointments but did not show up for their appointment were called and asked why they did not keep their appointment.
• Seven staff members from the Office of Epidemiology participated in the project in some way. Two project supervisors and three interns were most heavily involved in the database creation, data inputting, and analyses.
• Six other staff members attended at least one QI team meeting to offer input into the process. These stakeholders included the Community Health Action Division director, the program manager for the Office of Vital Registration, a WIC manager from ADHS, two county WIC regional managers, and the WIC trainer.
