This project consisted of several rapid-cycle improvements (RCIs). After the steps of the PDSA process, the team evaluated the current process using a flowchart and fishbone diagram. Further analysis of the baseline data was completed by surveying clients to determine why they were not enrolling in the program. The results of this process indicated many root causes. Based on these results, the first intervention was to simplify the referral process by merging three forms into one and using a QuitLine fax referral to enroll clients who indicated they were ready to quit within 30 days.
The flowchart tool was used with a WIC staff focus group to identify the steps during a typical clinic visit and to determine how tobacco cessation fits within the clinic visit. The QI team learned that staff were expected to accomplish a large amount in the short clinic visit and that clinic procedure are inconsistent.
The fishbone cause-and-effect diagram was used with a WIC staff focus group to identify barriers to low enrollments in the WIC Quit Tobacco cessation program.
The WIC focus group brainstormed and prioritized solutions. The QI implementation team then researched and discussed the feasibility of the top three solutions. The most viable solution was presented to WIC staff, and the following tools were developed and secured to support the implementation of this solution: revised chart documentation form, one-page "barriers to quitting" handout, and the QuitLine fax referral form.
A flowchart outlining the new tobacco cessation referral process was created, used for staff education, and posted in the clinic as a visual reminder.
Goal of the project: Using the QI process, CDHD’s goal was to analyze the current approach of enrolling pregnant WIC clients in the smoking cessation program and to improve the process to increase enrollment. As smoking rates are higher among the younger population, CDHD would conduct focus groups for pregnant WIC clients in the following age groups: 15–19, 20–24, and 25–29 years. Approximately six women representing each age group would participate in each focus group. Discussion would elicit information about barriers and solutions to enrollment and participation in currently offered smoking cessation programs.
On February 21, 2013, tobacco cessation case studies were included in WIC staff training on participant-centered counseling conducted by a WIC-registered dietitian to prepare staff to guide clients toward meaningful goals based on identified risk factors.
On March 4, 2013, and April 2, 2013, two facilitated discussion and verbal survey client focus groups were conducted by a trained professional to determine reasons clients are not enrolling in the WIC Quit Tobacco cessation program. From January through April, WIC staff recruited clients to participate in the client focus groups. Invitations were first sent via postal mail. Invitations were sent via text messaging after little response from mailings and phone messages. The initial QI project proposal included offering several age-specific WIC client focus groups. Based on clients' limited availability, the focus groups became multi-age and were reduced to two. Even with dinner and a $40 gift card incentive, the number of clients who showed up for the focus groups was discouraging. Three were invited and confirmed attendance to the first focus group, and one attended. Eleven were invited and confirmed attendance to the second focus group, and only one attended.
Although it was not initially in the QI project plan, it became apparent that the QI team needed to include the WIC staff in the process of identifying why enrollment into the WIC Quit Tobacco cessation program was low. WIC staff focus groups, facilitated by the health promotion program manager and tobacco policy analyst, completed multiple QI tools: on January 17, 2013, a flow chart of the tobacco cessation counseling process within the WIC clinic visit; and on February 21, 2013, a fishbone cause-and-effect diagram for why enrollment numbers are low. On April 8, 2013, the WIC staff brainstormed and prioritized solutions.
The three-member QI implementation team, which included the health promotion program manager, the tobacco policy analyst, and the WIC program manager, used information gathered from the WIC client focus groups and WIC staff focus groups (QI tools) to develop an improvement theory.
During the June 6, 2013, WIC staff meeting, the tobacco policy analyst gave a QI project update and discussed the identified improvement plan. The staff received training on the identified improvement plan, which included reducing paperwork by merging three separate forms into one to make enrollment more streamlined, having WIC staff focus their counseling on barriers to quitting tobacco use, and referring clients within 30 days of readiness to quit to the Idaho QuitLine using a fax referral system.
During the June 2013 RCI and the Do, Study, Act phases of the PDSA process, several modifications were made to the initiative, including identifying the need to provide more training to help the staff understand the two parts of the project: clinic counseling of barriers to quitting and referral into QuitLine if a client is within 30 days of quitting. Other improvements were identified and implemented, including condensing three enrollment forms into one merged form, merging five separate barriers handouts into one, and creating a script that staff could use to engage clients.
From June 8 to July 24, 2013, weekly "huddles" with WIC staff took place to discuss implementation and to receive feedback on concerns, ideas, and observations.
Data collection proceeded as follows:
• In May 2013, pre-pilot data were gathered.
• In June 2013, pilot project data were captured.
• In July 2013, the procedure was finalized and data continued to be captured.
The following people were exposed to the QI initiative:
• WIC staff: 21 Boise staff members, 6 Mountain Home staff members, and 1 McCall staff member;
• 5 additional CDHD staff members: Jaime Harding, Joanne Graff, Rob Howarth, Russ Duke, and Hilary Flint-Wagner; and
• 14 WIC clients were invited to focus groups, and 28 pregnant tobacco users were introduced to the program.