An Initiative to Improve a Local Health Department's Lyme Disease Case Report Process

Summary

Impact Statement:

Responding to case reports of Lyme disease, the most common tick-borne infection in North America represented a very large time burden for a local health department in northwest New York state. The department used QI tools to decrease the number of steps and amount of time to respond to case reports by using a completely electronic process. This time savings will allow for greater RN time to educate the public and patients about Lyme disease.

Summary:

The aim of Jefferson County Public Health Service’s quality improvement (QI) project was to reduce the number of possible steps in the Lyme disease case report process from 41 to 18, to transition from a combined paper and electronic process to a purely electronic process, and to reduce the types of staff involved in the process from two to one. The project began on January 2, 2013, and concluded on July 31, 2013, with adoption of the new process.

The QI team achieved significant process improvement. The improvement theory was tested across two cohorts of Lyme disease case reports. The number of days it took for staff to process a Lyme disease report decreased by 20%. Time (in minutes) to process a Lyme disease report showed similar improvement. In testing the first cohort, the process was made fully electronic, and the need for secretarial staff was completely eliminated. Time (in minutes) was reduced by 51.9%. In testing the second cohort, time was reduced to 5.68 minutes.

The improvement in time, based on comparison of the old approach with the new approach, represents a 73.3% reduction in minutes that registered nurses (RNs) worked per Lyme disease report. Although the team met its goal of reducing total possible steps in the process, actual total steps were reduced by 73.5% on average.

Organization that conducted the QI initiative:

Jefferson County Public Health Service

Citation:

Jennings, S. Public Health Quality Improvement Exchange. An Initiative to Improve a Local Health Department's Lyme Disease Case Report Process. Mon, 01/29/2018 - 14:27. Available at https://www.phqix.org/content/initiative-improve-local-health-departments-lyme-disease-case-report-process. Accessed September 15, 2024.

Background and Aim

Aim statement:

By July 31, 2013, reduce the number of possible steps in the Lyme disease report process from 41 to 18, transition from a combined paper and electronic process to a purely electronic process, and reduce the types of staff involved in the process from two to one (RNs and secretaries to RNs only).

Need For The QI Initiative:

Lyme disease impact and incidence have grown substantially between 2006 and 2011. For 2012, the department case report volume was in line with 2011 experience. Using the completed year 2011 as a baseline, there were 199 Lyme disease case reports per the department’s communicable disease case log. The total includes some individuals who had more than one case report during the year because of repeat testing by area physicians. It is unknown whether repeat cases were the result of additional blood testing over time as managed and directed by the patient’s provider or whether the case was truly patient symptom–driven. Per the New York State Department of Health Communicable Disease Electronic Surveillance System (CDESS), 69 (35%) individual cases in 2011 met case definition, whereas 130 (65%) did not meet case definition. Of the cases who met case definition, approximately half had an erythema migrans (EM) rash, a symptom that automatically diagnoses Lyme disease. The public health nurses and secretarial staff are overwhelmed by the volume of Lyme disease case reports occurring in spring, summer, and fall. RNs responsible for Lyme disease monitoring reported frustration with the critical need for patient education, but they lack time and resources to provide it individually to patients because of the burden of case report activity. The health promotion unit, responsible for public health education, reported frustration that despite considerable efforts at outreach, efforts did not seem either to arrest or reverse growth in the volume of Lyme disease cases. The department's preventive services clinical staff chose Lyme disease rather than another communicable disease to work on because of the administrative burdens associated with the time it takes to diagnose Lyme disease, the time it takes to work with physician practices, and the substantial growth in volume of cases from previous years.

Area for Improvement:

Lyme disease is the most common tick-borne infection in North America. The volume of Lyme disease case reports received by the Jefferson County Public Health Service was greatly exceeding department capacity to process, let alone appropriately monitor treatments, educate patients, educate the public, and control and mitigate population-wide disease incidence. Some patients receive multiple blood tests over time to monitor progress, which generates reported and repeat cases. Many patients exhibiting symptoms similar to those of Lyme disease are making frequent visits to physicians' offices, which also generates reported and repeat cases. Of all case reports in 2011, 35% met case definition, and 65% did not meet case definition. Of additional concern is the fact that babesiosis cases in New York State are spreading north and westward from the New York City and lower Hudson Valley area and will likely further adversely impact the department’s capability to manage these tick-borne infections in the near future.

Root Cause:

The following root causes were identified: • nurse-driven environment, • staggered data collection methods (six data pieces were required for moving a case report forward, leading to significant manual work time by RNs), • misappropriation of staff time and duties between RNs and secretaries, and • lack of feedback from the New York State Department of Health when it revokes a case.

Planning and Execution Details

Attachment	Size
NNPHI QI MEETING AGENDA.doc	27 KB
NNPHI QI MEETING AGENDA17.doc	26.5 KB
01 07 2013NNPH QI MEETING NOTES.doc	44 KB
07 30 13NNPHI QI MEETING NOTES.doc	55 KB
LYME REPORT PROCESS STEPS GRID.xls	72.5 KB
LYME REPORT TEST THEORY PROCESS STEPS GRID.xls	91 KB
LYME REPORT TEST THEORY 2 PROCESS STEPS GRID.xls	72 KB
NNPHI QI GRANT PROCESS AND THEORY CHART.docx	23.65 KB

Results

Measurable QI Outcomes:

The measurable results of this QI project were based on laying out all possible steps of the old process in the Plan phase and examining the process over 20 cases. The team then laid out revised steps for a new process in the Do phase, testing the new process and discerning the difference between the two approaches. The QI team achieved significant improvement. The improvement theory was tested across two cohorts (20 cases in the first cohort and 10 cases in the second cohort) of Lyme disease case reports. Time for staff to process a Lyme disease report decreased from an average of 17.5 days in the old process to an average of 14.58 days, a 20% reduction. Time (in minutes) to process a Lyme disease report showed similar dramatic improvement. In examining the old approach, secretarial and RN staff took 21.28 minutes to process paper and electronic components of a Lyme disease report. In testing the first cohort, the process was made completely electronic, and the secretarial piece was completely eliminated (except for an occasional returned fax from a physician office; once faxes are received, secretaries have to retain or file them). Time was reduced to 10.23 minutes, a 51.9% reduction. In the test of a second cohort, time was reduced to 5.68 minutes. This was a result of ironing out difficulties with the electronic local area network (LAN) fax function. The time in the second cohort indicates actual, current adopted process. The improvement in time, based on comparison of the old approach with the new approach delineated in the second cohort, represents a 73.3% reduction in minutes that RNs worked per Lyme disease report. Although total possible steps to process a Lyme disease case report were reduced from 41 to 18, actual total steps used in the examined cohorts numbered between 34 (old process) and 9 (new process), a 73.5% reduction in steps on average.

Other QI Outcomes:

RNs noted additional time to work one on one with two patients over the telephone regarding Lyme disease prevention. RNs want to have greater time to educate patients. Time savings realized by case report process improvements should allow for greater RN education time with the public.

Lessons Learned, Observations and Insights:

The starting aim for this project was to decrease the percentage of Lyme disease patient case reports and the number of patients who meet case definition for Lyme disease. Work actually began by mapping case report and definition processes separately and creating a separate map for the Lyme disease community education process. Although these remain desired aims, it was quickly determined that the real problem from the department process perspective was not the numbers of patients, but how work is accomplished. The aim had to be changed to reflect this reality. Considerable time was spent examining the current process. It was complex to map it, monitor it, make modifications to it, and so forth. Staff members were found to be performing processes differently. There were not barriers per se, but there were challenges. The team envisioned a completely electronic process, but some were reluctant to fully jump in. In early visioning, staff imagined that nursing time would be measurably reduced and clerical time would greatly increase. Many of the nursing tasks were nonclinical. In the end, what really underscored the efficiencies created was the process becoming 100% nurse-controlled and electronic; now, all steps are completed at the nurse’s computer. It was great to witness staff empowerment as they implemented the solutions they developed.

Future Plans:

As of July 31, 2013, the initiative was standardized and uniformly implemented. As an outgrowth of the Lyme disease initiative, all communicable disease report processes will be examined to ensure continued improvement. Some of the process lessons learned from the Lyme disease report process are already being applied to other disease-reporting processes.

Training and Preparation

Information about the Community

Population Size:

100,000 to 249,999

Population Characteristics:

Jefferson County is located in the northwest corner of New York State, approximately 60 miles north of Syracuse. The county borders Lake Ontario to the west, the St. Lawrence River to the north, St. Lawrence County to the northeast, Lewis County to the east, and Oswego County to the south. Included within the Jefferson County borders are eight large islands, three of which are located in the St. Lawrence River and five in Lake Ontario. The entire northwestern and western edges of the county are bordered by water. The county's population, according to the 2010 U.S. Census, is 116,229. The major population center within the county is the city of Watertown, with a 2010 population of 27,023. Between 1980 and 1990, Jefferson County experienced a 26% increase in population and was the fastest-growing county in New York State. The largest factor for this growth was the activation of the U.S. Army 10th Mountain Division (Light Infantry) at Fort Drum, which is located in the northeastern portion of the county and occupies 107,625 acres. Since 2010, Fort Drum has experienced further population growth, which has been the key contributor to the increased 2012 U.S. Census population estimate for Jefferson County (120,262). The county contains approximately 43,967 households and 30,038 families. The median age is 32.8 and is expected to increase to 33.3 by 2016. Compared with New York State and the nation as a whole, Jefferson County’s population and number of households are expected to grow over the short term at a faster rate. Comparatively, the median age in Jefferson County, 32.8 years, is lower than that of New York State or the nation, which are both around 37. The lower median age in the county is low, largely due to the demographics of Fort Drum soldiers and their families. The median household income in Jefferson County is $41,811. The average household income is more than $10,000 greater than the median at $53,827. Per capita income is about $20,438. By 2016, the median household income in the county is expected to increase by about 18% and reach approximately $50,000. Both average household income and per capita income are expected to increase by about 10% by 2016. Compared with New York State and the United States, Jefferson County’s per capita income is anticipated to grow more slowly over the next few years. Furthermore, the income data show a continuation of lower income levels in Jefferson County compared with New York State and the United States.

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Submission Status:

Completed

Comments

I very much appreciate your

I very much appreciate your "lessons learned" section. So often with public health QI projects, we go into them thinking we know what the problem and solution are, but then the data and QI methods lead us to realize something different. This is a great example of how you let the data and QI process guide you to make real improvements. I also loved your comment about staff empowerment. Nice work!

Cindan Gizzi, MPH
Community Assessment Manager
Tacoma-Pierce County Health Dept.
cgizzi@tpchd.org

Truly outstanding results -

Truly outstanding results - thanks so much for your submission!

It's great to read that the

It's great to read that the process improvements are being applied in other disease-reporting processes. Fantastic! Keep up the good work!

Link to the resource where this submission is also published:

This submission is not published anywhere else on the Internet.

An Initiative to Improve a Local Health Department's Lyme Disease Case Report Process

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

I very much appreciate your

Truly outstanding results -

It's great to read that the

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An Initiative to Improve a Local Health Department's Lyme Disease Case Report Process

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

QI Spotlight