Step 1: Describe the Problem

Problem Statement: Early syphilis is increasing in Orange County.

Reason Selected: Surveillance data showed significant increases in early syphilis over the previous 4 years. If not rapidly controlled, early syphilis could become a larger epidemic, costing the community hundreds of thousands of dollars in health-related costs for early, late, and congenital syphilis cases, in addition to potential costs resulting from syphilis-associated HIV transmission.

Measures of project success:

  • 1. Reduce new early syphilis cases by 25% compared to the previous year (Outcome measure).
  • 2. 100% of Disease Intervention Specialists (DIS) will test a minimum of four associates per month for syphilis through DIS-initiated field work.

Table 7.1 Cluster and Contact Index and CDC Goal (situation 2006)


Team baseline (previous 6 mos.)

State average (previous 6 mos.)

CDC goal

Cluster Index




Contact Index




  • * Team target
  • 3. Increase the quarterly cluster index to 1.0 on early syphilis cases among MSM.
  • 4. Increase the quarterly contact index on all early syphilis cases, including MSM cases, to 1.41.

The team identified four measures of its success: one outcome measure and three performance measures for processes important to reaching the outcome goal. Two process measures - the contact index and cluster index (process measures related to eliciting partner names and testing at-risk individuals) - were identified as areas for improvement because the team performed below the state average and Centers for Disease Control and Prevention (CDC) goals. See Table 7.1 for contact and cluster index measures. The third process measure was a new internal standard for “field blood draws,” which could be tracked monthly (Table 7.2).

Step 2: Describe the Current Process

There are six major processes involved in field blood draws: preparation, acquiring vehicle, field work, field recording, blood handling, and post-test procedures (Figure 7.3 and Table 7.3).

Table 7.2 STD team members and milestones

STD team members


  • • Jim Hinson - Team Leader
  • • Earl Boney-QI Lead
  • • Anne Marie Strickland - Ql Support
  • • Donna Bouton - Dept Admin Ass't
  • • Preston Boyce - DIS Supervisor
  • • Barbara Carroll - Operations Manager
  • • Shonda Mitchell -Surveillance Supervisor
  • • Rajendra Hiralal - DIS Supervisor
  • • Scott Fryberger- DIS Staff
  • • Isabel Hudson - DIS Staff
  • • Team committed to problem statement
  • • Identified national and state standards
  • • Defined measures and targets
  • • Completed first working/ learning session
  • • Drafted expectations for members on Ql team

Figure 7.3 Sample process map for field blood draws: preparation.

Table 7.3 Interpretation of flow chart, milestones, and Ql tools used in this step

  • 1. Examination of the current process for doing blood draws revealed areas of inconsistent DIS practices and inefficiencies in the way the process was currently carried out.
  • 2. The DIS field preparation process took too much time - estimated as much as two hours each time.
  • 3. The two areas that consumed the most time for field preparation were getting the key to unlock the supply cabinet and getting permission to use a vehicle (involving several permission steps).


  • • Completed 7 process maps (1 overall, 6 detailed) related to carrying out blood draws.
  • • Identified opportunities for cutting down time in 2 major areas of field preparation, as well as improving other processes.

Ql tools used in this step

  • • Process Mapping,
  • • Brainstorming,
  • • Discussion.

Step 3: Identify Root Cause(s) of the Problem

Problem: Early syphilis is increasing in Orange County.

  • 1. After conducting an initial root cause analysis examining the possible reasons for the increasing rate of early syphilis in Orange County, the DIS saw that an overlapping issue in various categories was high staff turnover (Figure 7.4).
  • 2. By delving deeper into the issue, the team concluded that staff turnover affected their performance indicators.
  • 3. The rate of turnover for DIS workers was high at OCHD, where the average length of stay for DIS new employees was six months or less.
Cause and Effect ("Fishbone") Diagram

Figure 7.4 Cause and Effect ("Fishbone") Diagram: root causes for rising syphilis cases.

The contact index relies on information provided from clients, and this is where the experience of DIS workers helps in pushing the contact index up ... It takes some time and exposure to develop these relationships [with clients],

- Scott Fryberger

The STD QI Team located most of their turnover problems in four main

areas (see Figure 7.5):

  • 1. Lack of training
  • 2. Low morale
  • 3. Office environment (including space and interpersonal issues)
  • 4. Lack of good candidates
Initial Fishbone Diagram for staff turnover

Figure 7.5 Initial Fishbone Diagram for staff turnover.


■ Completed initial Fishbone Diagram showing major factors in addressing the syphilis problem and identified that staff turnover was underlying most of these causes.

■ Created detailed Fishbone and Affinity Diagrams on staff turnover with co-worker input.

■ Decided to focus on staff turnover and programmatic processes that are within departmental control.

■ Repeated a department SWOT (Strengths, Weaknesses, Opportunities, and Threats) Analysis to take stock in what they had accomplished since the last analysis and identify strengths they could use to address future STD unit needs.

QJ tools used in this step: Brainstorming, Affinity Diagram, Management Survey, SWOT Analysis, Fishbone Diagram, Process Maps/Drill Downs, Priority Setting Matrix (Tables 7.4 and 7.5).

Table 7.4 Sorting activity: "Lack of Useful Training"

To tackle staff turnover, the team found that there were multiple areas members could work on. Because of this, they had to focus their attention first on the areas they felt were most important. Through multivoting, the team determined that the three most important areas to address were the following (from most to least important):

  • • Training
  • • Finding good candidates
  • • Low morale

In addition, the team set aside time in weekly meetings to improve the processes that were hindering the unit's success.

Identified cause from Fishbone Spine

What is to be done first? *

What do we


Can't do job = Skill









Logical Decision Making


Skills needed = Y







Result of multi-voting on priority to address Lowest number = Highest priority

Table 7.5 C/l/C Chart: Staff Turnover

Things within our:



(Have) Concern

  • • Gossip
  • • Training
  • • Recognition
  • • Process
  • • Hiring
  • • Inter-departmental relations


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