The method used for the QI initiative was the Plan, Do, Study, Act (PDSA) cycle. This method served as a guide for the project’s timeline and for planning data collection, as well as analysis and implementation of the change. The group spent about half the time in the Plan phase, a quarter of the time in the Do phase, and the remainder divided between the Study and Act phases.
A variety of tools were used throughout the initiative. The team began with quantitative and qualitative data collection. For the qualitative data collection, the team facilitator conducted interviews with WIC participants. She interviewed both WIC participants who had a great benefit pickup history and who had never had their benefits terminated and clients who had their benefits terminated in the past. The results were compiled and presented to WIC staff at a meeting in which they provided their feedback on the interviews. This information was valuable to the staff because they were surprised by some of the themes and results from the interviews. The second part of the data collection piece was the quantitative data collection. RiverStone employees retrieved the retention rates, but for further demographic data and data on appointment types missed, etc., they partnered with the Montana DPHHS, which provided the raw data needed for further analysis of the WIC clients.
Flowcharts were used to examine the current process. This tool is much more visual than brainstorming and was used to help identify areas in which WIC employees were not performing duties uniformly. Many employees helped draft the flowcharts, including WIC staff who were not part of the QI team.
The brainstorming tool required creativity, given the multidisciplinary nature of the team. The QI team consisted of the director of Population Health Services, the director of WIC, the director of Family Health Services, a WIC educator, a past WIC participant, a home visiting nurse, the WIC program specialist for the Montana DPHHS, and the facilitator for the team—a prevention health specialist from Population Health Services. Many of these individuals were not accustomed to working together regularly; therefore, some were reserved and did not readily express their ideas and opinions. In addition, the time constraints of their schedules allowed the team to meet only once every other week for 1 hour. To make use of the time, the following technique was used to brainstorm the QI technique to implement: Each team member started with a blank sheet of paper, and for 4 minutes, they jotted down their ideas in silence. They then passed the paper to the person to their left, and that person had the option to add more ideas or build on ideas that already existed. This exercise lasted until the papers made it back to the original person. The exercise allowed for efficient time management and for focused and effective brainstorming.
Multivoting was also used. Once the team narrowed down several potential changes, each member was e-mailed a sheet with these options listed. The team members were given 250 points to divide among the options and were asked to rate them based on their importance. The best option could be given most or all of the points. The sheets were e-mailed, which allowed the members to vote in private and take their time deciding.
Meeting evaluations became a crucial part of the biweekly team meetings. At the end of the meeting, the facilitator would ask each member to verbally rate how they thought the meeting went. Did the team accomplish what it set out to do? Was time used effectively? How did the team members feel about the project's progress after the meeting? Did the team members have any concerns that were not addressed in the meeting? Participants could answer these questions and rate the meeting on a scale of 1–10, with 10 being the best. The team identified many concerns in this short time. Biweekly meetings also became a time to give congratulations and kudos to team members for their efforts.
Another way to engage not only the QI team members but also the WIC staff was to create a bulletin board display that gave monthly updates on the project and explained the aim statement of the project and data behind it.
The team reviewed all the data, and based on multivoting results, chose the following change: Schedule clients for their next appointment before they leave the office. This change was chosen after reviewing data provided by DPHHS. When studying the appointment types missed by those with terminated benefits, the team discovered that 68% of those with benefits terminated did not have an appointment scheduled. Further investigation into the current processes in WIC identified that an inconsistency in appointment scheduling may have contributed to these numbers. If clients are in fact scheduled for an appointment before leaving the office, their names go into the computer and administrative assistants are alerted to call and remind the client of his or her upcoming appointment. If the client misses the appointment, staff call to reschedule. However, if the client chooses not to schedule an appointment before leaving the office, no reminder system is in place to call and remind the clients that they need to call to schedule their next appointment before their benefits expire.
The simple change that was implemented was that all clients were scheduled for their next appointment before leaving the office, instead of being given the option to call back and reschedule. WIC administrative assistants and WIC nutrition educators implemented this change. In addition to the staff who were exposed, all clients who visited the clinic were exposed to the initiative. Staff were given prompts to remind them of this change when it first started, because it was habit to give the client an option to call back to reschedule. The initiative took place from mid-April through August 2013. This period was needed to track the data that were being collected to identify whether an improvement was being made.