All Performance Improvement Committee members, including:

• Dan Sendzik, team leader and Director of the PATH Center
• Angela Douglas, Senior Staff Nurse at the PATH Center
• Leonard Berkowitz, Chief of Infectious Diseases at Brooklyn Hospital

Increase the percentage of charts documenting PPDs placed and read from 68 percent to 85 percent.

Percentage of Charts Documenting PPDs Placed and Read

Planning:

We performed an investigation of our existing PPD placement and reading process using brainstorming, run charts, and cause and effect diagrams, and identified three primary problem areas:

• No individual staff person was clearly assigned responsibility for tracking and following up on PPDs.
• The house staff of the hospital rotate through the PATH Center and are not familiar with the PPD requirement for patients with HIV.
• Patients often do not return in 48 hours for the reading.

We tested and implemented two rounds of changes to help address these issues.

First-Round Changes:

• We assigned HIV Clinical Case Managers the responsibility of flagging the charts of patients that were due for PPD.
• Senior Staff Nurses were given responsibility for planting the test and giving each patient a reminder card.

The rate of PPD placement and reading increased from 68 percent to 81 percent by March 1999. A decision was made to implement these changes permanently and on a system-wide basis.

We then implemented a second round of changes in an effort to further improve PPD performance.

Second-Round Changes:

• The Senior Staff Nurse called patients on day two to remind them to return on day three.
• By the end of day three, the Senior Staff Nurse called "no shows" asking that they return on day four.

These two additional interventions increased the rate of PPD placement and reading to 88 percent by the end of April 1999.

• Project work is enhanced by a high level of staff motivation, open lines of communication, and excellent relationships between patients and staff.
• Add PPDs to a list of indicators monitored every quarter, with results reported to the Performance Improvement Committee for evaluation.