Step 4: Develop a Solution and Action Plan

“Control and influence” was an important concept introduced to the team by the teams consultant, which helped the team prioritize what causes they could most directly affect.


■ Analyzed maps of current processes to pinpoint areas for improvement.

■ Identified three priority areas for action plan to address root causes for turnover: lack of useful training, lack of good candidates, and low morale.

■ Analyzed each area of the fishbone and categorized potential solutions within the team’s control or influence.

■ Selected strategies the team could easily control that would affect programmatic processes or environment.

■ Submitted proposal for additional vehicles.

■ Requested help from HR and outside organizations on behavioral interviewing.

■ Submitted a proposal to human resources to increase salary grade.

■ Collected information on strategies effective in other jurisdictions.

■ Reviewed evidence and recommendations for controlling syphilis in MSM populations.

QI tools used in this step: Multi-voting, Sorting tool, Benchmarking, Control/Influence/Concern Chart

Step 5: Implement the Solution

The team implemented changes by dealing with easily addressed problems first. Among their first successes, they reorganized space and made supplies more readily available to decrease preparation time for field blood draws.

Next, the team implemented several other solutions, such as enhanced DIS training and coaching, recognition of staff accomplishments, obtaining vehicles for the unit, increasing the base rate of pay for DIS, and creating a consistent process for data gathering.

Action registers helped the team track progress (Table 7.6).


■ Changed assignments for orientation training and initiated regular case review sessions for continuous on-the-job learning.

■ Health department approved unit request for three new vehicles.

■ DIS workers sent to national STD meeting for training.

■ Implemented new interviewing process for DIS candidates.

■ Trained newly hired people using improved process maps.

■ Clarified and eliminated unnecessary steps in procedures:

  • - Centralized location of forms.
  • - Made supply cabinet unlocked for all DIS.
  • - Eliminated use of certain forms in the preparation process.

■ Reorganized space for better work environment.

■ Started recognizing DIS workers for their work and contributions.

■ Increased base rate of pay for DIS 10%.

QI tools used in this step: Action Register

Table 7.6 Sample from Action Register: "Lack of Good Candidates"






1. Improve Interview/ Hiring Process




To include: review people first, information/job specific description/ requirements/etc., qualifying questions, interview questions

2. Conduct informal survey of current field staff



Ask how DIS found out about job, what would make you stay

Step 6: Review and Evaluate Results of the Change

By the end of the nine-month project, new early syphilis cases leveled off and began to decline (Figure 7.6). During the same period, syphilis increased in Florida peer counties.

  • 1. 100% of DIS conformed to minimum blood draw standards for the last two months.
  • 2. Achieved cluster index above CDC standard for four consecutive quarters: attributed by team members to better interviewing skills.
Measures of project success after 9-month process improvement efforts

Figure 7.6 Measures of project success after 9-month process improvement efforts.

3. Contact index target was improved but target not met - needs additional action.


■ Gathered data and charted progress on the indicators.

■ Revisited Fishbone Diagram on turnover, and identified that most causes had been addressed, or were being addressed, by the team.

QI tools used in this step: Control Charts, Fishbone Diagram

Step 7: Reflect and Act on Learnings

Secondary Effects of QI Effort: In addition to advances made in their indicators, the team also reported the following successes which grew out of the QI initiative:

■ Stopped DIS staff turnover (a root cause)

  • - Zero DIS left the unit in the first half of 2006; 6 left in 2005.
  • - Fully staffed for the first time in group memory.

■ Improved morale and teamwork

  • - Increased job satisfaction: STD employee satisfaction surveys show an 18% increase in 2006 compared to the last survey in 2004 (significant at the p = .05 level).
  • - More cohesiveness and trust in team.
  • - Better morale and teamwork translated into a better ability to work with the community.

The community is more accepting and receptive to our team because of the improvements we’ve made within our unit.

- Jim Hinson

Team success strengthened OCHD ability to request other project funds. Implementing QI: Since this was the health department’s first QI initiative using this approach, the team learned what support needed to be in place for a successful project. While some team members had previous

QI training, most learned new methods by carrying out the project. One of the most important assets was having a consultant who could be neutral, provide expertise from other fields, and help keep the team focused. The team also identified other practices and expectations they saw as necessary to successfully carry out the QI process; however, they also found that establishing these practices and expectations proved to be a challenge.

Some challenges identified by the team:

■ Dedicating staff to full attendance at all team meetings.

■ Staying focused on priority issues.

■ Scheduling subject matter experts for process drill down documentation.

■ Using quality tools effectively.

■ Securing imbedded consultant with required support skills.

Other Team Lessons: The project gave the team many other insights, such as:

■ Most useful tools: Affinity Diagram, Fishbone Diagram, Process Mapping.

■ Biggest surprise: The problem is not necessarily what you think it is.

■ Maintaining focus on quantitative measures requires discipline and time commitment.

■ Barriers and gaps must be documented for action.

■ QI projects must be aligned to organization’s goals.


■ Completed evaluation using interviews, quarterly questionnaires, and data review.

■ Recognized team members with letters of commendation from the local health officer, certificates of accomplishment, and a placard with team members’ photos in the lobby.

■ Shared successes through agency presentations, newsletters, and milestone meetings.

■ Other units became interested in QI and requested project participation.

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