Quality Improvement Redesign a Tool in Pandemic Planning and Response

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The University of Chicago needed to act quickly in late April 2009 when it discovered a Medical Center staff member was diagnosed with H1N1 as cases of the virus were appearing in California and Mexico. Lacking complete knowledge about the scope of the outbreak and the morbidity and mortality rate, Student Care Center (SCC) director Dr. Kristine Bordenave and other public health planners responded with a strategy to address this threat with limited resources to the large population of the University of Chicago campus.

The University of Chicago and the University of Chicago Medical Center have separate emergency preparedness plans. While the University of Chicago plan focuses mainly on students, staff and faculty, the Medical Center focuses on the community at large. The Bio-Outbreak Task Force, a committee of the Medical Center, allowed for rapid planning by having all of the hospital administrative staff at the table regularly to discuss updates and approve plans. An H1N1 management team from the university also met regularly to address the rapidly changing outbreak and subsequent recommendations for students. The emergency preparedness plans along with the administrative teams created the environment necessary to implement rapidly changing redesign projects and measures.

With a small clinic, five providers and five nurses, and a need to triage and care for an unknown number of cases, Bordenave and her team sought a partnership with the University Medical Center. Health planners began early triage of students and staff for influenza-like illness (ILI) in a ventilated parking garage located on campus, then shifted to screening and testing students, faculty and staff in the Student Care Center while transferring the standard student healthcare needs to a clinic within the medical center that I typically used for primary care services for community members. The willingness of the University Hospital, the Primary Group and the Student Care Center to work together, reassign space and redistribute the workload made it possible to meet the needs of the entire university community while continuing to meet the needs of the hospital and the population of the surrounding area, Bordenave said.

Bordenave attributes early successes of triage and patient care to a strategy she dubbed "Quality Improvement and Healthcare Redesign," an area in which she is expert. She said this can be effective in caring for large populations using limited resources.

With 3,600 square feet of space and a small clinical staff, the SCC had to design a system to address a large number potentially infected and exposed individuals, so it adapted the Agency for Healthcare Research and Quality (AHRQ) redesign concept. According to Bordenave, the university has the smallest clinical staff per student of the Big 10 + 2 schools: three nurse practitioners, two medical doctors, five nurses, (two LPNs and three RNs) and five front office and administrative support staff.

"That is the entire staff available to care for 15,000 students," she said.

Redesign of services was necessary to provide surge capacity and meet the triage and testing needs of students, faculty and staff while attempting to limit disease spread.

Bordenave said she and her team learned to be efficient when doing other redesign projects designed to engage students in healthcare activities with limited resources and space.

"We also used redesign concepts with respect to vaccine distribution," Bordenave said. "We concluded it was best to take vaccines to people rather than people coming to the clinic for vaccines so that sick contacts were limited and individuals didn't have to hunt us down for vaccine."

Bordenave said the SCC saw far more faculty and staff than students early in the campaign. Techniques designed for seasonal influenza campaigns were adapted for screening processes. Peer health educators handed out forms and information so that nurses could rapidly triage and test those meeting criteria. The SCC performed nasal swabs on-site, which made testing easier because of its proximity to the medical center. U of C moved the general services offered by the Student Care Center (SCC) to the general internal medicine clinic and used the SCC for screening and caring for ill people. That approach “allowed us to evaluate plans for greater surge capacity should it be needed it in the future," Bordenave said. SCC staff members welcomed the peer health educators' help and the additional space to handle the demand. Students were swabbed until mid-June 2009 and medical staff until mid-fall 2009. The center measured the number of people that came in for testing and test results by territory or department.

During the first weeks of the outbreak, the SCC staff prescribed prophylaxis to people in close contact with those who were infected, such as roommates and workmates. They ended this approach as more information became available through the CDC.

As vaccine arrived, public health workers focused their limited vaccine resources on highest risk individuals first, and then broadened their efforts as supplies allowed. The medical center and the university have expressed interest in Bordenave's redesign techniques because of the effectiveness of the SCC project. While the SCC traditionally has cared only for students, it is now jointly leading efforts with the Director of Environmental Health and Safety for screening of university community-related outbreaks and health prevention strategies on campus.

Bordenave urges her colleagues at other Big 10 + 2 universities to embrace the redesign philosophy and become familiar with the AHRQ's website and its planning steps. Combined with Institute of Heathcare Improvement (IHI) concepts, she said redesign methodology and quality hinges on consistency; the more consistent you are with any single process, the less variation there is to measure, the higher the likelihood of quality. The result is a process that moves more rapidly because it is repetitive and easily replicated.

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