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If you need technical assistance please email naccho@commpartners.com The primary means of listening to this webcast is via streaming audio through your computer speakers. If you are unable to access streaming audio through your computer, please dial (800) 817­8874 and enter passcode 8025542# . Quality Improvement and Accreditation Preparation: Quality Improvement 101

Speaker Introductions

• Marlene (Marni) Mason, BSN, MBA, MCPP Healthcare

Consulting

• Stacy Baker, MSEd, Public Health Foundation

Quality Improvement and Accreditation Preparation: Quality Improvement 101

• Marni Mason: Overview of Quality Improvement
• Tacoma­Pierce County Health Department Quality Improvement (QI)

Initiative – Rapid Cycle Improvement Example

• Rapid Cycle Improvement: Genesee County, Michigan Example
• Stacy Baker: Tools and Resources for Public Health
• Questions and Answers
• Evaluation

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Webcast Agenda

Quality Improvement and Accreditation Preparation: Quality Improvement 101

POLL:

Have you applied quality improvement methods in your public health work? Yes – in the last 6 months Yes – but it was more than 6 months ago No, not yet Not sure

Overview of Quality Improvement

Marni Mason, BSN, MBA, Healthcare Management Consultant, MCPP Healthcare Consulting

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Performance Management has many components How do they work together?

QI Plans & Councils Business Process Analysis P u b l i c H e a l t h I n d i c a t

• r

s Standards for Public Health P e r f

• r

m a n c e A s s e s s m e n t Improving PH processes QI Methods & Tools Quality Improvement and Accreditation Preparation: Quality Improvement 101

Performance Management System

There are four important components of performance management: Performance Standards Performance Measurement Quality Improvement Process Reporting of Progress

Guidebook for Performance Measurement, Turning Point National Program Quality Improvement and Accreditation Preparation: Quality Improvement 101

Performance Standards

• We have standards for capacity and process/outcomes,

AND

• We have standards for results through health status and

health determinant indicators

• Both types of standards for performance are important and

are needed for successful performance management and improvement

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Performance Measurement

• Monitoring of Performance through Local and State Standards
• Monitoring of Indicators

Core Health Indicators Program Evaluation Data

• Requires regular analysis and review to tell you if you are achieving

your agency goals and objectives

• Provides the basis for deciding on QI efforts and the baseline

information for measuring the impact of quality improvement activities

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Principles of Quality Improvement

• 1. Know your stakeholders and what they need
• 2. Focus on processes
• 3. Use data for making decisions
• 4. Understand variation in processes
• 5. Use teamwork to improve work
• 6. Make quality improvement continuous
• 7. Demonstrate leadership commitment

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Quality Improvement Process

• Use data to identify opportunities for improvement and to make decisions
• Choose an improvement method targeted at a specific opportunity for

improvement: Plan­Do­Study­Act cycle Improvement Collaboratives Adapting or adopting Model Practices Establishing QI Councils, Plans, and Teams Logic Models, Rapid Cycle Improvement (RCI), Business Process Analysis (BPA)

Quality Improvement and Accreditation Preparation: Quality Improvement 101

The PDSA Cycle for Learning and Improvement

Act

• What changes

are to be made?

• Next cycle?

Plan

• Objective
• Questions and

predictions (why)

• Plan to carry out the cycle

(who, what, where, when)

• Plan for data collection

Study

• Complete the analysis of

the data

• Compare data to

predictions

• Summarize what was

learned

Do

Small scale test Series of tests Wide­scale tests Implementation

• Carry out the plan
• Document problems

and unexpected

• bservations
• Begin analysis of the

data

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Rapid Cycle Improvement (RCI)

Model for Improvement

W hat are we trying to accomplish? How will we know that a change is an improvement?

Act P lan Do S tudy

The idea behind RCI is to be very clear about the focus of the improvement and to first try a change idea on a small scale to see how it works, and then modify it and test it again until it demonstrates real improvement. Then, and only then, should the change be implemented.

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Some Quality Improvement Tools

• Choose the conceptual or numerical tool needed to analyze

your data

• Work Process Analysis
• Fishbone Diagram and other tools for identifying root cause

like the 5 Why’s

• Pareto Diagrams to identify the “vital few”
• Variation analysis; common cause and special cause

Quality Improvement and Accreditation Preparation: Quality Improvement 101

More QI Tools

• Check Sheet
• Bar Chart
• Histogram
• Pareto Chart
• Control Chart
• Run Chart
• Affinity Diagram
• Brainstorming
• Process Flow Chart
• Interrelational Diagraph
• Matrix Diagram
• Tree Diagram
• Cause and Effect Diagram

Numerical Tools Conceptual Tools Great descriptions of tools in Goal/QPC’s Public Health Memory Jogger

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Putting the pieces together

Health Indicators Performance Standards Quality Improvement Efforts

Identify the weak spots in public health practice. One Problem: Program evaluation is weak , so we do not routinely measure program impact son health. One Example: We have not systematically evaluated immunization efforts. Our immunization rates for 2 year olds appear low for the 4

th DTAP. We have

seen increased pertussis. Can we improve the effectiveness of this service? Change what is not working Response: Provide training and tools on evaluation and apply to specific

• services. Implement strong evaluation. Use the results to make services

more effective. Example: Outreach to medical providers, parents and day care to address

• immunization. Better data collection. Increased outreach to parents.

Monitor Results Track rates: Determine if strategies are working Example: Did the strategies work? Immunization rates up? Pertussis down? If not – why not? Was success achieved one place – and why?

Quality Improvement and Accreditation Preparation: Quality Improvement 101

“Plan – Do – Study – Act” Example: Immunization

Plan Act Do Study

Completing the full DTAP immunization series protects children and others from pertussis Goals and targets are set Outreach to health providers, parents and day care can increase attention and follow through. Rates are monitored to see if they

• increased. Surveys may be used to

gather data. What worked? What did not work? Materials are improved, Tracking system is made easier to use. Return to Plan step, above, and set new targets.

• 1. Plan
• 2. Do
• 3. Study
• 4. Act

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Tacoma­Pierce County Health Department Quality Improvement (QI) Initiative – Rapid Cycle Improvement Example

Quality Improvement and Accreditation Preparation: Quality Improvement 101

TPCHD Sexually Transmitted Disease Reporting Project

• Assessment identified that STD reports did not contain

accurate race/ethnicity information

• STD team wanted to customize their follow­up based on

race/ethnicity

• Identified this as an opportunity for improvement
• Chose Rapid Cycle Improvement as method to create

improvement

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Rapid Cycle Improvement Project

• Form workgroup

Supervisor/manager Front line staff Assessment staff

• Conduct just­in­time training
• Complete a three­month RCI project

Multiple PDSA cycles

• Mid­term and final reports to Quality Improvement Council

Quality Improvement and Accreditation Preparation: Quality Improvement 101

STD Reporting of Race/Ethnicity

• 1. Collected data to

identify “root cause” of problem

• 2. Pilot tested an

education intervention

Percent of STD Case Reports That Include Race Data (Among Pilot Providers)

74 55

10 20 30 40 50 60 70 80 Pre Post Percent

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Change versus Improvement

• W. Edwards Deming stated “Of all changes I’ve observed, about 5%

were improvements, the rest, at best, were illusions of progress.” We must become masters of improvement We must learn how to improve rapidly We must learn to discern the difference between improvement and illusions of progress

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Another Rapid Cycle Improvement Example Genesee County, Michigan

Quality Improvement and Accreditation Preparation: Quality Improvement 101

What are We Trying to Accomplish?

• Increase complete reporting of CD to 80% or more of all reports by

10/07, and more than 95% by 2/08 with clear definition of complete

• reports. We do this in order to provide valid data for planning and

program improvement.

Quality Improvement and Accreditation Preparation: Quality Improvement 101

How Will We Know When We Get There?: Measurements

• Data analysis showing trend of completed reports moving in

direction of “goodness”

• Actual decrease in staff time to input incomplete information
• Trend in overall measures in right direction

CD reporting Program measures

Quality Improvement and Accreditation Preparation: Quality Improvement 101

What Changes Can We Make?

• Data analysis of reasons for incomplete reports.

Identify reasons with definitions Assure that database can capture each reason Initiate data collection process Train staff and providers in definition and reporting process

• Address lack of knowledge of providers
• Create plan to identify high volume providers and target for extra

training

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Data Analysis­ Pareto Chart

N o n ­R ep o rtin g F acilities b y S ch o o l T yp e

10 20 30 40 50 60 70 80 90 100 C H ILD C A R E /P R E S CHO O L Total P U B LIC Total P R IV A TE Total C H A R TE R Total 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Data Analysis­ Pareto Chart

Non­Reporting Schools By District

62 11 8 8 5 4 4 4 3 3 3 3 2 2 1 1 1 1 1 7 10 20 30 40 50 60 70 F L I N T G R A N D B L A N C C A R M E N ­ A I N S W O R T H S W A R T Z C R E E K C L I O A T H E R T O N B E E C H E R B E N T L E Y F E N T O N D A V I S O N L A K E V I L L E L I N D E N W E S T W O O D H E I G H T S L A K E F E N T O N M T M O R R I S B E N D L E F L U S H I N G G O O D R I C H K E A R S L E Y M O N T R O S E G E N E S E E G I S D 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Results – Error Rate

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Results – Time Study

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Performance Management & Quality Performance Management & Quality Improvement Improvement Tools and Resources for Public Tools and Resources for Public Health Health Stacy Baker, MSEd Director of Performance Improvement, Public Health Foundation 202­218­4416 • sbaker@phf.org

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Remembering Why We Are Here

• Achieving better outcomes
• “Vital few” priorities
• New ways of solving

complex problems

Quality Improvement and Accreditation Preparation: Quality Improvement 101

• 1. Unit or team
• 2. Program or division
• 3. Local health agency
• 4. District or region

5. State public health agency 6. State public health system 7. National public health system

Performance Management is the “30,000 foot view”

• f Results for Any Level of Public Health

Source: Turning Point Performance Management Collaborative, 2003.

Quality Improvement and Accreditation Preparation: Quality Improvement 101

What performance will we manage? What matters most?

Quality Improvement and Accreditation Preparation: Quality Improvement 101

• 1. Human Resource Development
• 2. Data and Information Systems
• 3. Customer Focus and Satisfaction
• 4. Financial Systems
• 5. Management Practices
• 6. Public Health Capacity
• 7. Service Delivery
• 8. Health Status

Managing what matters:

What Might Be on Your “Dashboard?”

[Eight Areas Recommended by Turning Point]

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Managing What Matters:

What Might Be on Your “Dashboard?”

(Eight Areas recommended by Turning Point)

Poll:

Does your organization have a performance management system that integrates all four components: standards, measures, reporting of progress, and quality improvement? Yes No Not sure

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Puts QI in the larger context of managing performance across public health activities

• Self­assessment tool
• Guidebooks for public health
• 30­min. training DVD
• Performance management case

stories, examples, and documents

Performance Management Resources from Turning Point & the Public Health Foundation

www.phf.org/infrastructure/PMtools Quality Improvement and Accreditation Preparation: Quality Improvement 101

Some QI Tools to Help Teams Define Problems & Identify Potential Solutions

Quality Improvement and Accreditation Preparation: Quality Improvement 101 See page numbers in

Problem (Effect)

5 Why’s

Why? Why? Why? Why? Why?

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Half of my new shrubs die

Why? Why? Why? Why? Why? I didn’t water them Too much hassle Hose is hard to use Too far from new plants Only hose at back of house

Problem (Effect)

5 Why’s

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Why can’t we make progress on ______________?

Is it because of: – Methods / procedures – Motivation / incentives – Materials / equipment – People (personnel, partners, providers, or patients) – Information / feedback – Environment – Policy

Successful Improvement Efforts Analyze and Address “Root Causes”

Quality Improvement and Accreditation Preparation: Quality Improvement 101

3 steps you can use on any problem – even complex public health problems

Quality Tools Help Organize Ideas on Problems and their Causes

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Generate Ideas About Causes (Brainwriting or 6­3­5 Method)

Build on their idea (Dig deeper – What causes that?) Let it trigger a related idea Start a new idea

1 2 3 1 2 3 3 Ideas Per Row Yours Your neighbor’s

(pass paper to right)

1

(p. 21)

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Group Ideas into Categories (Affinity Diagram)

2

Category Name Category Name (p. 12)

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Diagram Relationships

(Cause & Effect or “Fishbone” Diagram)

3

Category Category Category Category Category Category

Problem (Effect)

(p. 23)

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Close­up on one “bone”

Mistrust

Poor experience

Don’t know status

Inconvenient

Disparities in HIV infection

Don’t want test Fear Don’t see benefit

Counseling not client centered

Not offered every visit

Staff not respectful

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Plan–Do–Check–Act Do Act Plan Check

Plan Plan changes aimed at improvement, matched to root causes Do Carry out changes; try first

• n small scale

Check See if you get the desired results Act Make changes based on what you learned; spread success

Quality Improvement and Accreditation Preparation: Quality Improvement 101

POSSIBLE PROBLEMS PROBLEM DEFINED POSSIBLE CAUSES ROOT CAUSE IDENTIFIED POSSIBLE SOLUTIONS SOLUTION CHOSEN TO TEST

EXPAND FOCUS

“Expand­Focus Sequence,” p. 3, Nancy R. Tague, The Quality Toolbox, 2

nd Edition. 2005.

(American Society for Quality, Quality Press, 2005)

EXPAND FOCUS Do we need to Expand or Focus our thinking? Are we working with ideas or numbers? What will be the easiest tool that will do the job? EXPAND FOCUS

Choosing the Right Tool

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Review

Remember why we’re here “Press pause” before attempting to fix Take a system view Why? Why? Why?... Go for highest impact Tip: Look inside and outside your team for information

Quality Improvement and Accreditation Preparation: Quality Improvement 101

http://www.phf.org/infrastructure/performance

Getting Started Guide with 5 minute tutorial QI tools and methods from industry, healthcare, and public health QI case examples Supplements to the Public Health Memory Jogger II™ Links to evidence

Public Health Infrastructure Resource Center (PHF)

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Example: To improve self­care among community members with diabetes, your team wants to see what articles have been published on effective strategies.

Resources: Finding Outside Evidence to Improve

Quality Improvement and Accreditation Preparation: Quality Improvement 101

To find relevant articles with best practices, you could try on your own to string together the right search terms. A librarian (you are a librarian, right?) would formulate the search like this:

Resources: Finding Outside Evidence to Improve

Diabetes Mellitus[mh] AND Blood Glucose Self­Monitoring[mh] AND (united states[mh] OR USA[ad]) AND (community health services[mh] OR health education[mh] OR patient education[mh] OR knowledge, attitudes, practice[mh] OR risk reduction behavior[mh] OR health promotion[mh] OR public health[tw] OR public health[mh] OR public health administration[mh] OR population surveillance[mh] OR program evaluation[mh] OR health policy[mh]) AND journal article[pt] AND english[la]

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Resources: Finding Outside Evidence to Improve

Increase the proportion of adults with diabetes who perform self­blood­glucose­monitoring at least

• nce daily. (Objective 05­17)

OR…you could click 1 button on the “Healthy People 2010 Information Access Project” site:

Resources: Finding Outside Evidence to Improve

…and find relevant articles faster:

www.phpartners.org/hp

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Resources: Learning From Healthcare

www.phf.org/infrastructure (What’s New)

New Institute for Healthcare Improvement page with resources relevant for Public Health

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Resources: Learning From Many Industries

• Quality tools for government, service, industry, and many

fields: – American Society for Quality, www.asq.org – GOAL/QPC, www.goalqpc.com – including Public Health Memory Jogger™ II

• Institute for Healthcare Improvement, www.ihi.orgw
• More links at:

www.phf.org/infrastructure/performance www.naccho.org/topics/infrastructure/accreditation.cfm

.

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Poll:

What do you see as the biggest barrier to applying quality improvement methods routinely in your organization? Not a priority Leadership Not built into work processes Resources: $, time, people Staff skills/expertise Resistance Something else Not sure

Quality Improvement and Accreditation Preparation: Quality Improvement 101

• Press *1 on your touch­tone phone to ask a

live question OR

• Type your question in the “questions” box

located on the lower left side of your screen

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Question and Answer Section

Please complete a brief evaluation by clicking on “Evaluation” in the LINKS box. If you have additional questions, email If you have additional questions, email

• jovanovic@naccho.org
• jovanovic@naccho.org

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Thank you for joining today Thank you for joining today’ ’s webcast! s webcast!

The causes of many public health problems may not be what you think.

“Could Syphilis Be Linked to Office Gossip?”

Quality Improvement Application:

Reducing syphilis in Orange Co., FL

Quality Improvement and Accreditation Preparation: Quality Improvement 101

To find out how addressing STD staff turnover (and its root causes) and work processes helped a local health department team reduce syphilis by

• ver 25%, download the storyboard

at: http://www.phf.org/infrastructure/ OCHDstoryboard.pdf

Quality Improvement and Accreditation Preparation: Quality Improvement 101

• Syphilis declined more than 25% in 2006
• Improved and controlled processes underpinning the team’s

effectiveness – Achieved 100% conformance for field blood draw standards in two consecutive months – Increased and maintained a cluster index above the CDC standard (1.0) for four consecutive quarters

• Stopped DIS staff turnover (a root cause)

– Achieved zero employee turnover in the first half of 2006; 6 persons left the STD team in 2005 – Achieved full staffing for first time in group memory

• Improved morale and teamwork

STD Team Results

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Another Quality Improvement Application: Improving Media Capacity

• Tested strategies to:

– Reduce time to edit – Increase deadlines met RESULTS

• Increased frequency of articles,

awareness

• Tracking service impact
• Plan to spread to other areas of

department

See Michigan resource link:

Quality Improvement and Accreditation Preparation: Quality Improvement 101

Another Quality Improvement Application: Improving Media Capacity

• Berrien County, Michigan
• Two related improvement
• pportunities:

– Public awareness of services and programs – Department media capacity

• Used QI methods to study current

situation – Frequency of articles – Reasons – Internal processes

See Michigan resource link:

Quality Improvement and Accreditation Preparation: Quality Improvement 101