CorrectCare

Staff Health Fair Celebrates Quality Improvement
By Debbie Raab, Lisa DeBilio, PhD, and Carl Ausfahl, MS, RN, CPHQ

On June 16, 2007, something strange was happening at the New Jersey Department of Corrections headquarters. There were balloons, juggling, colorful posters, prizes and great food. The crowd was a potpourri, with some people in business attire, some in casual office wear and others in corrections uniforms. All were engaged in lively discussions, celebrating a job well done.

The event was the second annual Performance Improvement Fair. The theme was CQI—Data Mining & Minding Data. Overall, 29 performance improvement teams, representing the work of more than 180 staff, exhibited their work at this festive event. Fourteen correctional facilities proudly displayed examples of their quality improvements at the PI Fair, which provided a forum to share the efforts, the struggles and the results with their colleagues.

The Quality Mission
While continuous quality improvement is a requirement for accreditation by the National Commission on Correctional Health Care, it also is a critical practice for any health care program striving for excellence. NJDOC, like many other correctional departments, has the responsibility to ensure a constitutionally sound health care system in a complex setting that includes a diverse mixture of players and multiple service providers. To this end, the NJDOC is attempting to make PI everyone’s business through multidisciplinary PI teams.

In 2005, the NJDOC’s director of medical services restructured the statewide QI program, emphasizing the partnering of the NJDOC, Correctional Medical Services and University Correctional HealthCare, a component of the University of Medicine and Dentistry of New Jersey. This restructuring took existing programs from the two service providers and placed them under the NJDOC umbrella, incorporating elements from both.

This new endeavor also resulted in an expanded QI/PI mission, one that fosters a genuine curiosity in staff to seek opportunities to improve services; dedication to data-driven improvement efforts; and effective dissemination of relevant, accurate and timely information to management and staff. One major outcome of this new focus was the PI Fair.

An important element of this new system is frequent staff training on QI concepts and practices. A general plan/design, measure, assess and improve model was agreed upon by the QI directors for NJDOC, CMS and UCHC. Since 2005, two statewide trainings have been held for CQI participants, presenting key concepts of the model, use of various PI tools and an experiential approach to learning. Small, multidisciplinary groups worked through the steps of the QI model using different tools to develop their own PI initiatives.

The QI directors also attend many facility-based CQI meetings to offer guidance and support, and they periodically meet with individual PI team leaders to help them through their specific team or project difficulties. Another valuable resource is a step-by-step PI Workbook and Reference Guide, created in collaboration with University Behavioral Health Care (a subsidiary of the University of Medicine and Dentistry).

A Fair Is Born
With more than 1,200 clinical care providers and some 10,000 staff in the state’s 14 correctional institutions, a way to acknowledge PI teamwork and achievements and to share information was needed. The PI Fair was the answer.

This event was adapted from a similar program developed at UBHC. The idea was to create a forum for staff to exchange improvement ideas, share their successes and learning experiences, and network with colleagues from other sites. The NJDOC modified and implemented the concept in 2006. Appropriately, the fair theme in the transition year was PI, A Team Approach.

The PI teams keep accurate documentation of their efforts, planning sessions and selection of interventions and implementation, as well as monitoring the results. Using guidelines developed by the statewide committee, teams that submit projects will assemble a 36"-by-48" poster to display their efforts. A one-page written summary of each entry is also required to provide an overview of the process and status of the PI activity. This summary is available as a handout at the fair.

A panel of judges representing the three organizations (NJDOC, CMS and UCHC) reviews each poster and assigns scores for eight elements: clear planning process, sound and explicit data-gathering design, evidence of use of the QI model, appropriate use and analysis of data, evidence of a follow-up plan, visual appeal of the poster, reflection of the NJDOC mission statement (“Protecting the Public—Changing Lives”) and a clearly written project summary.

The rating is done independently by each judge and then tallied to identify the best performers. The five highest scores determine the winners who receive plaques and ribbons at the event. Afterwards, all posters and awards are displayed at each of the sites and are used for ad hoc training for staff.

On the day of the fair, visitors receive a brochure outlining the day’s activities and projects on display. Senior leadership of NJDOC, CMS and UCHC as well as the PI team members celebrate accomplishments by attending the affair. To keep the event festive, door prizes are raffled off, decorations abound and refreshments are served.

The ceremony acknowledges all staff who worked on PI projects, and all team participants receive a certificate of appreciation.

And the Winners Are...
This year’s first-place team focused on the use of universal precautions in the prison laundry in response to an increase of staph/MRSA infection cases in 2005. Interventions included use of protective garments for inmates working the soiled-linen line, procedures to protect inmates when changing smocks and washing hands, and ongoing education of laundry workers.

The team reduced MRSA incidence by 36% over a 12-month period. The multidisciplinary team included the director of nursing, the infection control nurse, NJDOC administrator, NJDOC health services manager and the facility laundry supervisor. Positive clinical outcome, multidisciplinary collaboration and use of data were the high points of this group.

The second-place team explored the effectiveness of group versus individual therapy at a youth correctional facility. Using a patient self-report outcome measure (BASIS-24), the team found no advantage to one type of treatment over the other. The team concluded that increasing group treatment options might be beneficial because it is a more efficient way to provide treatment and apparently leads to the same patient outcomes. This team was most notable for appropriate use of data.

Increasing “out-of-cell” clinician therapy contacts in administrative segregation was the focus of the third-place PI team. They found that only 50% of administrative segregation inmates had participated in out-of-cell contacts during a three-month period. The team sent brochures to inmates explaining the importance of out-of-cell contacts and letters to escort officers explaining the policy requirement for out-of-cell contact and thanking them for their assistance in achieving compliance with the policy. The team also consulted with custody officers about initiating the use of flexible cuffs.

These interventions resulted in 100% compliance with the out-of-cell contact policy. This PI project highlighted the cooperative efforts of administration, custody and mental health staff. Outstanding accomplishment of positive outcome and inclusion of custody staff are noteworthy.

Other PI teams’ projects include:
• Increasing the number of behavioral health inmates successfully transitioning from different levels of care
• Identification of variables impeding the start-up of therapy groups
• Effectiveness of smoking-cessation programs
• The effect of exercise groups on reducing obesity in inmates taking atypical antipsychotic medications

Still other examples are collaborative efforts to manage diabetes through inmate education, decreasing the use of low-dose Seroquel as treatment for insomnia and reducing the number of inmates returning to the “security threat management” unit.

On the Right Track
After the event, we solicit feedback through a brief survey. Insights gleaned from the results help us to develop better PI fairs and educational offerings for the future. Feedback on this year’s fair was very encouraging, with positive responses for all categories surveyed. The poster presentations were rated on average even higher than the program format, which will change next year to have winning teams give short presentations on their projects.

 — About the author: The authors are the quality improvement directors at their respective institutions: Debbie Raab at the New Jersey Department of Corrections, Trenton; Lisa DeBilio, PhD, at University Correctional Health Care, Trenton, NJ; and Carl Ausfahl, MS, RN, CPHQ, at Correctional Medical Services, Ewing, NJ. To reach them, e-mail deborah.raab@doc.state.nj.us.

[This article first appeared in the Summer 2007 issue of CorrectCare.]