Cover Sheet for Example Documentation for PHAB Domain 9 Standard 2 Measure 1

Transcription

1 Cover Sheet for Example Documentation for PHAB Domain 9 Standard 2 Measure 1 The following documentation has been submitted to ASTHO for the Accreditation Library as a potential example of Health Department documentation that might meet the PHAB Standard and Measure 9.2.1A. This document is not intended to be a template, but is a reference as state health agencies develop and select accreditation documentation specific to the health department's activities. Please note that the inclusion of documentation in this library does not indicate official approval or acceptance by PHAB. Document Title: Document Date: RI Quality Improvement Plan June 2013 Version of Standards and Measures Used: 1.0 Related PHAB Standard and Measure Number Domain: 9 Standard: 2 Measure: 1 Required Documentation: 1 Short description of how this document meets the Standard and Measure s requirements: Measure requires a QI Plan Submitting Agency: Staff Contact Name: Staff Contact Position: Staff Contact Staff Contact Phone: Rhode Island Department of Health Magaly Angeloni Performance Improvement and Accreditation Manager Magaly.angeloni@health.ri.gov

2 RHODE ISLAND DEPARTMENT OF HEALTH QUALITY IMPROVEMENT PLAN Michael Fine, MD Director JUNE 30, 2013 health.ri.gov

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4 Table of Contents I. EXECUTIVE SUMMARY...3 II. MISSION AND VISION...5 III. QUALITY IMPROVEMENT AT HEALTH...5 Current state of QI...5 Future desired state of QI...6 a) QI Team:...6 b) QI Team Leadership...6 c) QI Forum:...6 d) QI Team Cycle...6 e) QI Team 1 Responsibilities...8 f) QI Teams 2 and 3 Responsibilities...9 g) QI project identification...9 h) Budget and resource allocation...10 IV. QI PLAN...11 a. Goals and Objectives...11 b. Plan monitoring...13 c. Plan Evaluation...13 V. QI ACTIVITIES AND RESOURCES...15 a. Internal Communications...15 b. Resources...15 c. QI-related Definitions...16 VI. APPENDICES...18 Appendix 1: Accreditation Logic Model...18 Appendix 2: HEALTH Workforce and Professional Development Logic Model...19 Appendix 3: Organizational Chart...20 Appendix 4: Rhode Island-designed PDSA logo...21 Appendix 5: Quality Improvement 8-hour Training Agenda...22 Appendix 6: RI QI poster template for project submission...24 Appendix 7: QI Project Worksheet...25 Appendix 8: Quality Times Newsletter (in effect December 2011-May 2012)...31 Appendix 9: Quality Improvement Intranet Homepage...32 List of Figures Figure 1. Four-year cycle of Quality Improvement Teams... 7 Figure 2. Roles QI Team members are expected to play while in the QI Team....8 Rhode Island Quality Improvement Plan - June

5 I. EXECUTIVE SUMMARY The Rhode Island Department of Health ( HEALTH ) is the statewide health agency responsible for protecting and promoting the health of Rhode Islanders, serving a population of 1,050,292. In 2011, and with the receipt of the National Performance Improvement Initiative (NPHII) grant from the Centers for Disease Control and Prevention (CDC), HEALTH initiated efforts to prepare to apply for accreditation through the Public Health Accreditation Board (PHAB). PHAB s Domain 9, which supports the 9 th essential service of public health, documents how a health department works to evaluate and continuously improve health department processes programs and interventions. This domain also requires the implementation of an agency-wide quality improvement (QI) program, including the development of a QI Plan. After assembling the first Quality Improvement (QI) Team in late 2011, with representation from all seven organizational units, HEALTH has successfully begun an effective QI movement throughout the department. The 16 members of the first QI Team received four days of Train-The-Trainer sessions over the summer of 2012, resulting in several QI projects completed by early 2013 and more underway. To promote the QI value and engage staff, HEALTH organized a QI Fair in early April to coincide with National Public Health Week. Nearly half of HEALTH s approximately 450 employees attended. The event met a primary goal of exhibiting QI activities and accomplishments, while also sparking interest in QI and deepening support throughout the department. Building off this early momentum and success, HEALTH soon thereafter selected members for QI Team 2. Thirty staff were trained in June of They are expected to begin a QI project during the latter part of To further strengthen the foundation of QI at HEALTH, this Quality Improvement Plan is designed to advance three primary goals: 1. Develop a strategy to maintain QI capacity 2. Inform and communicate staff about QI activities 3. Foster and support a culture of QI HEALTH will annually review the QI activities included in this plan with input gathered at an annual meeting with all members of the QI Team, along with feedback from all members of the Department s Executive Committee (EC) formed by the agency leadership. HEALTH will release a revised QI Plan and an Annual Report of the QI activities presented in the QI Plan. In particular, four key measures will be reported to Executive Committee as indicators of progress in QI efforts: Rhode Island Quality Improvement Plan - June

6 a. Percent of staff who received the basic QI training during the year. b. Percent of QI projects completed by QI Team during the year and ready for accreditation. c. Percent of attendees at the annual QI Fair. d. Percent of staff expressing support of the QI activities, as reported through the annual survey HEALTH plans to offer multiple opportunities to inform staff and encourage participation in QI activities, utilizing a variety of mediums. An annual QI Fair shall remain a key component for engagement, serving as an occasion to exhibit all completed and in-progress QI projects. To better understand and measure the culture of QI, an annual survey sent to all staff will also be conducted. The goal of the survey will be to annually measure current knowledge and support for QI activities, and to gather information to better meet the needs of staff. As described in this document, HEALTH proposes a four-year cycle of QI. Each four-year cycle includes an initial phase where one team is trained, completes a QI activity, later serves as QI Faculty, and then mentors new QI team members who engage in new QI projects. After completing the mentoring phase, Faculty members may become part of the QI Board, while others may transition into department-wide roles as QI Ambassadors. This phase is repeated three times before a new four-year cycle starts. HEALTH is pleased to see this level of buy-in and support of the QI goals in the few months since its inception. Such progress has only been possible with the dedication and commitment from a small group of individuals participating in the QI Team, and the support of those around them. We do expect further progress in the coming year, and we are eager to consider new ways to measure the culture of QI throughout HEALTH in coming years. HEALTH sincerely thanks everyone who made this early progress possible, and invites others to continue to support QI to enhance the work we do and the programs we manage. Ultimately, this work benefits Rhode Islanders who receive the results of our efforts. Rhode Island Quality Improvement Plan - June

7 II. Mission and Vision The primary mission of the Rhode Island Department of Health (HEALTH) is to prevent disease and to protect and promote the health and safety of the people of Rhode Island. Our vision is that every Rhode Islander should have access to high quality, affordable healthcare, delivered at the most appropriate time and place. Furthering its overall mission, HEALTH has added to its vision the commitment to apply for the new public health accreditation program. With funding from the National Public Health Improvement Initiative (NPHII) grant received in 2010, HEALTH began aligning its plans to meet the accreditation requirements. Specifically, the agency has drawn goals and long-term outcomes framed within logic models that are supported by its Executive Committee. The Accreditation Logic Model, approved in 2011 (see Appendix 1) depicts HEALTH s ultimate outcome: to build and maintain a culture of Quality Improvement (QI). Likewise, basic QI training will be offered to all staff according to the 2013 Workforce and Professional Development Logic Model (see Appendix 2). Other pragmatic examples of the agency s commitment to accreditation and quality improvement include engaging the leadership in meaningful roles to promote a culture of QI. Each Executive Committee member has viewed the twohour online Accreditation orientation offered by the Public Health Accreditation Board (PHAB) in The Committee dedicates part of its weekly regular agenda to performance improvement and accreditation updates. Collectively, HEALTH is investing significant efforts in its commitment to QI and is supporting agency-wide activities to apply for accreditation in III. Quality Improvement at HEALTH Current state of QI HEALTH has been involved in quality improvement efforts in several parts of the Department for many years in targeted activities, especially in the Chronic Disease and Home Visiting programs. The first agency-wide quality improvement group, however, was convened in late 2011 and received the Train-The-Trainers comprehensive four-day session in July and August The group completed and exhibited members first QI projects at HEALTH s inaugural QI Fair that was held on April 1 to coincide with National Public Health Week (NPHW). Organizationally, the Director s Office has direct oversight over QI efforts (see Department s organizational chart in Appendix 3), with the Performance Improvement and Accreditation Manager serving as Lead. While the QI Team is primarily an internal effort, QI activities are also extending into other HEALTH Rhode Island Quality Improvement Plan - June

8 initiatives with external partners, and the agency recently received a small grant and technical assistance to conduct a QI project with funding from the Association of State and Territorial Health Officials (ASTHO). At HEALTH, quality improvement is conducted using the Plan, Do, Study, Act (PDSA) method. Hence all the training, materials and templates mentioned in this plan refer to the use of the PDSA method (see RI-developed logo in Appendix 4). Future desired state of QI HEALTH s vision is to foster and maintain a culture of quality improvement. This vision is described as having every activity, effort, program, initiative, and event that HEALTH supports, sponsors, maintains and is otherwise engaged in, following the QI principles. This involves having all staff trained in the basic principles of QI, continuously maintaining a QI team and favoring an organizational structure where QI is encouraged, supported, maintained, and recognized as part of HEALTH itself. Following the structure described in this document, the mission, vision, and futuristic view of quality improvement, HEALTH is well positioned to implement the QI plan, by supporting a team structure, with a reasonable cycle and expectations as described next. a) QI Team: The QI team will be represented by at least one member from each of HEALTH s organizational units (divisions and centers). Team members are recruited with the approval and support of the division/center director. Identification of the team members is done jointly and in coordination among and between the Division/Center lead, the Deputy Director, and Director. b) QI Team Leadership: The QI team is currently led by the Performance Improvement and Accreditation Manager, who receives guidance and support from the Director and Deputy Director, and is responsible for aligning the team s goals with the overarching vision of the Department and commitment to Accreditation. c) QI Forum: The Quality Improvement Team will maintain a forum for faculty/mentors and mentees (i.e. new QI team members) to provide ongoing support and technical assistance. The Public Health Improvement Exchange (PHIX) meets twice a month, for 90 minutes each time. The agenda for each meeting is decided as a group at the previous meeting, and notes of the major decisions and group s activity is documented via to the group. d) QI Team Cycle: The QI team s participation is set up in a four-year cycle: Rhode Island Quality Improvement Plan - June

9 Figure 1. Four-year cycle of Quality Improvement Teams Note that this four-year cycle assumes that the first team (Team 1) will receive the Quality Improvement training in the four-day (28 hours) Train-the-Trainers modality. When Team 1 completes their first QI project, which includes submission of the poster for accreditation documentation, team members become Faculty/Mentors. Next, Team 1 provides an eight-hour training to Team 2, following a curriculum prepared by HEALTH for that purpose (see Appendix 5), or an improved version of it. After the training, Team 2 members begin attending the ongoing Public Health Improvement Exchange (PHIX) meetings that take place twice a month for technical assistance and support. Each Team 1 member mentors one or two Team 2 members until completion of their QI project, which includes exhibition of their poster that will be used as documentation for accreditation purposes. Upon completion of a Team 2 project, these members also become QI Faculty, to conduct the training for Team 3 and then mentor new members until completion of their new projects. At the same time, Team 1 members transition onto the QI Board to oversee planning and other decision-making. Rhode Island Quality Improvement Plan - June

10 Team 2 members, now joining Team 1 as Faculty/Mentors, will provide the same or revised eight-hour QI training to new Team 3 members. Note that Team 2 will become the mentors for Team 3 until completion of their QI project, which shall include exhibition of their poster at the annual QI Fair and on the Intranet and shall be used for documentation for accreditation purposes. Once Team 3 projects are also completed, members will become QI Faculty and will mentor the brand NEW Team 1, which will receive the Train-The-Trainers four full-days modality. At the same time, Team 1 and Team 2 members will either join the QI Board or become QI Ambassadors. With the selection of the new Team 1, the cycle will start over, as indicated in Figure 1. In summary, Team members responsibilities evolve over to fulfill three roles and conduct a minimum of 2 complete QI projects over a period of 2-3 years: a) QI Trainee --> b) QI Faculty/Mentor --> c) QI Board member/qi Ambassador Figure 2. Roles QI Team members are expected to play while on the QI Team. e) QI Team 1 Responsibilities Based on the above description, members of the Team 1 commit to the following: 1. Attend the full Train-the-Trainers training (4 days, or approx. 28 hours) 2. Complete one QI project from beginning to end and submit it in the template provided for that purpose (included in Appendix 6) 3. Serve as QI Faculty/Mentors to prepare and deliver training to Team 2 4. Mentor and provide technical assistance to QI Team 2 AT LEAST until they complete and submit their QI project in the template provided for that purpose (Appendix 6) 5. Participate/present at the PHIX meetings for technical assistance and support to all other QI members, as well as at the annual QI fair and other QI-related events to exhibit the completed work. 6. Provide input, support, and feedback in the preparation/review of HEALTH s QI plan, goals, activities, communication efforts, PHIX support, etc. 7. Participate in the QI team for a minimum of two (2) years from the time the training is received, and for a maximum of four years, provided that at least one QI project is complete and at least one new member of the upcoming class is trained, mentored, and completed one QI project. 8. Promote and maintain advocacy for HEALTH s QI efforts as QI Ambassadors when their direct involvement/function in the QI team ends. 9. Support the QI Teams transitions from Trainees to Faculty to Ambassadors. Rhode Island Quality Improvement Plan - June

11 f) QI Teams 2 and 3 Responsibilities: Members of the Teams 2 and 3 of the QI cycle at the Department of Health commit to the following: 1. Attend the eight-hour training prepared by HEALTH s QI Faculty. 2. Complete at least one QI project from beginning to end and submit their QI project in the template provided for that purpose (see Appendix 6). 3. Serve as QI Faculty as needed to prepare/deliver training to new QI team members. 4. Mentor and provide technical assistance to QI Team members of the upcoming class [Team 2 to Team 3, and Team 3 to the new Team 1] AT LEAST until they complete and submit their QI project in the template provided for that purpose (see Appendix 6). 5. Participate/present at the PHIX meetings for technical assistance and support to all other QI members, as well as at the annual QI Fair to exhibit the completed work and other QI related events. 6. Provide input, support, and feedback in the preparation/review of the Department s QI plan, goals, activities, communication efforts, PHIX support, etc. 7. Participate in the QI team for a minimum of two (2) years from the time the training is received, and the maximum of four years, provided that at least one QI project is complete and at least one new member of the upcoming class is trained, mentored and completed one QI project. 8. Promote and maintain advocacy for HEALTH s QI efforts as QI Ambassadors when their direct involvement/function in the QI team ends. 9. Support the Teams transition from Trainees to Faculty to Ambassadors. g) QI project identification: The Division/Center leads work with their QI team representatives to identify new QI team members and select potential projects. When selecting each project, the Division/Center lead and QI team will ensure that it meets the following criteria: - Strategic: The extent to which the QI project would advance and promote overall strategic goals and Strategic Plan(s) for HEALTH and programs. - Supported: The extent to which available resources, including staff and budget can support the project. - Feasible: The extent to which the project is within the control of the program and team. - Measurable: The project must have an initial measure and an end measure (i.e., hours before and after, number of errors before and after, cases before and after, days before and after, etc.). - Complete: The time the project would take to be complete. The project will be complete when the PDSA is complete, and the poster for the project is submitted, approved and ready for Accreditation purposes To formally review and present the QI project, staff is asked to use the QI Project Worksheet (see Appendix 7). Rhode Island Quality Improvement Plan - June

12 h) Budget and resource allocation: Resources currently allocated for the QI team, including the support from the Performance Improvement and Accreditation Manager, the Communications Unit, and the materials production, newsletters, etc., come from the National Public Health Improvement Initiative grant. Note that this budget supports the overall umbrella investments, and excludes other staff time and programmatic expenses for the completion of the individual QI projects. Rhode Island Quality Improvement Plan - June

13 IV. QI Plan a. Goals and Objectives In the long term, HEALTH aims to maintain and support a culture of quality improvement in the agency, as shown in the Accreditation Logic Model in Appendix 1. With this in mind, the Quality Improvement Plan is formulated to achieve three main goals: Goal Objective Timeframe Responsible Person(s) 1a. Maintain a QI team Ongoing, Magaly working and promoting QI with annual Angeloni activities at all times review 1. Develop a strategy to maintain QI capacity at HEALTH 2. Inform and communic ate QI progress and activities to all leadership and staff 1b. Provide QI training for the QI team and staff 1c. Complete and exhibit QI efforts 1d. Offer basic QI training to all staff 2a. Publish articles via a department-wide employee newsletter sharing most recent QI news and updates (e.g. related performance measures, QI projects, and accreditation updates) 2b. Maintain and update the Intranet sections for QI, Accreditation and Performance Improvement 2c. Exhibit posters at lobby to promote QI and Accreditation efforts, and public health 2d. Conduct a QI fair to exhibit all projects at least once a year 2e. Engage the Executive Committee in QI strategic Summer and fall, as needed QI team Measure - Number of QI team members transitioning into the faculty role - Percentage of staff who received the basic QI training - Total number of QI team members Ongoing QI team - Number of QI projects completed and ready for accreditation documentation Ongoing, measured annually Monthly Workforce development Angela Lemire, CPHC, working with CPHC Lead Andrea Bagnall Degos (newsletter editor) of staff who received the QI basic training each year -Percentage of monthly editions issued during a calendar year that include QI and/or accreditation topics (100% = 12) Ongoing Angela Lemire - Number of hits on the QI section of the Intranet pages, measured monthly Quarterly Angela Lemire - Number of posters prepared and displayed at the central lobby and laboratories building At least annually Ongoing Angela Lemire Magaly Angeloni QI Team Magaly Angeloni - Percentage of COMPLETE QI projects exhibited during the QI fair - Percentage of staff attending the QI fair -Percentage of quarterly QI Rhode Island Quality Improvement Plan - June

14 Goal Objective Timeframe Responsible Person(s) conversations and feedback 3. Foster and support a culture of QI at HEALTH 3a. Disseminate the lessons learned from the QI projects in a format that can be shared widely 3b. Evaluate the QI efforts, level of exposure, and support to QI activities 3c. Offer basic QI training to all staff 3d. Create opportunities to gather input in the design of the QI plan 3e. Link the QI plan with HEALTH s Strategic Plan, Health Assessment and Improvement Plan, Workforce Development Plan 3f. Evaluate and increase overall levels of customer satisfaction Annually Annually Ongoing, measured annually Annually Ongoing Annually Magaly Angeloni Magaly Angeloni CHDA support Workforce development Magaly Angeloni Magaly Angeloni QI Team HEALTH Leadership Magaly Angeloni HEALTH leadership Measure discussions with Executive Committee (100%=4); one of which will be the QI Annual Report Preparation of a success story from the field and submitted to the NPHII grant; also published in the internal e-newsletter -Percentage of staff responding to annual satisfaction survey - Number of suggestions received through the survey that were implemented for the next period -Percentage of staff who received the QI basic training each year - Number of attendees to the QI Annual Meeting to review the annual QI report - Number of staff attending the annual meeting to comment on the QI plan -Percentage of programs that are routinely and systematically using QI tools ( Programs =47 according to State Budget document) - Number of Dashboard performance measures reporting Customer Satisfaction -Percentage customer satisfaction reported by individual units (laboratories, CHDA, Info Line, QI) Rhode Island Quality Improvement Plan - June

15 b. Plan monitoring Monitoring of the QI plan will be the responsibility of the Performance Improvement and Accreditation Manager, who reports to HEALTH s Deputy Director and Director. Monitoring takes place utilizing: - Regular reporting to Executive Committee: This includes providing regular updates on progress, improvements, or challenges faced by the QI team, and ongoing reporting to the Department s Deputy Director and Director. This will also include quarterly presentations of QI efforts. - Department-wide newsletter articles: This includes articles about completed and current (pending) QI projects, new project AIM Statements, interviews of QI team members, QI hot topics or findings, best practices, activities such as the QI Fair, etc. (See Appendix 8) - Tracking completed QI projects: This tracking involves the collection of QI poster templates, for submission for Public Health Accreditation, either annually or for Accreditation application. - Annual Report: Discussed with Executive Committee and shared with all staff via the Intranet, newsletter, all employees staff meeting or other department-wide mechanism. This annual report will include, at minimum: o Number of QI projects completed o Number of staff participating in the QI team(s) o Number of staff trained on the basics of QI o Lessons learned, devised from the QI complete projects o Priorities for the next year - Dashboard Report: Monthly reporting of the number of current QI projects in HEALTH s Dashboard report. This is posted an archived on the Intranet. c. Plan Evaluation To assess the effectiveness of this QI Plan, the QI Annual Report will include results on all goals and objectives listed in this plan. The plan will also include four measures: 1. Activity measure: This will involve the annual QI Fair to exhibit the completed projects and invite all staff to view and discuss results. This is expected to be a highly visible event to also include workshops and other informative kiosks to inform and engage staff in QI dialogue. Measure: Percentage of HEALTH employee attendees at the annual QI Fair. 2. Capacity Measure: This will measure the capacity that HEALTH, as a whole, has created for QI. A target will be proposed and/or revised to achieve for this measure in the next year. Rhode Island Quality Improvement Plan - June

16 Measure: Percentage of staff who received the basic QI training during the year. 3. Process measure: This will measure those QI projects that were completed during a calendar year, from among all QI projects conducted during that period. Measure: Percentage of QI projects completed by QI Team during the year, with completed storyboard posters ready for accreditation documentation. 4. Outcome measure: This will measure the overall knowledge, satisfaction, and/or support of QI activities and will be gathered through an annual survey of HEALTH employees. Measure: Percent of staff expressing support of the QI activities, as reported through the annual survey Upon completion of the QI Annual Meeting and with the results of the analysis, and discussion, the new QI Plan will be drafted and shared with the QI team for comments. Once those comments are gathered, and revisions incorporated as needed, the plan will be made available to all staff for comments via the Intranet for no more than three weeks. Comments will be analyzed by the QI team and the final plan will be then posted on the intranet for future reference. Rhode Island Quality Improvement Plan - June

17 V. QI Activities and Resources a. Internal Communications QI activities are currently communicated to staff utilizing several channels, including: - Updates to Executive Committee: Updates from the Performance Improvement Program are a standing agenda item in the weekly meetings with Executive Committee. Hence, the group receives a key update in the form of a short presentation, discussion, or report at each Executive Committee meeting. - Department-wide e-newsletter: A monthly internal electronic e-newsletter (i.e. Now@HEALTH) is available to all staff through via and on the Intranet. Articles contained therein related to Quality Improvement and accreditation may also be used in staff trainings and/or for documentation required for accreditation. - Dashboard Report: The Performance Improvement Program provides a monthly report of ongoing QI projects. This measure is reported along with all other programs measures to the Director in the monthly Dashboard report. - QI Fair: Held at least once a year, this event exhibits the QI projects completed by the QI Team. The event will also serve to introduce the next QI Team and recognize the work of the latest QI team. - Posters: QI project storyboards and lobby displays posted in the Cannon Building and the State Health Laboratories facility help provide higher levels of visibility in promoting the QI culture and providing updates to staff. Besides being displayed at QI Fairs, these materials may also be re-used for training purposes. - Presentations: Additional efforts and presentations are made to staff and small groups to promote or support current QI efforts. Some may be made upon request. - Intranet: A section of the intranet contains all information about QI, accreditation and performance measures and is updated on an ongoing basis (see Appendix 9). b. Resources The collaborators and supporters of the National Public Health Improvement Initiative and other agencies are making available a number of resources to support Quality Improvement. Some of these resources are listed below. - The Public Health Memory Jogger II - Public Health Quality Improvement Encyclopedia - ement_encyclopedia.aspx Rhode Island Quality Improvement Plan - June

18 - The Public Health Quality Improvement Handbook The Public Health Foundation - Robert Wood Johnson Foundation, Public Health Quality Exchange - American Public Health Association National Association of City and County Health Officials US Department of Health and Human Services c. QI-related Definitions QI or Quality Improvement: Quality Improvement in public health is the use of a deliberate and defined improvement process, such as the Plan-Do-Study-Act method, which focuses on activities that are responsive to community needs and improving population health. QI refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community. As opposed to Quality Assurance (QA), QI proactively selects a process to improve. PDSA or Plan-Do-Study-Act: According to Wikipedia, PDSA is an iterative four-step management method used in business for the control and continuous improvement of processes and products. It is also known as the Deming circle/cycle/wheel, Shewhart cycle, control circle/cycle, or plan do study act (PDSA). The PDSA model is also often referred to as Plan-Do-Check-Act (PDCA) and these terms are relatively interchangeable. (HEALTH chooses to use study due to the deeper level of data analysis this term conveys, compared to check. ) QI Team members: Upon completion of QI training, members complete at least two QI projects from beginning to end, and participate in PHIX meetings as the forum to give and receive QI support and technical assistance. QI Faculty/Mentors: QI team members who have received QI training, have completed at least one QI project, and have participated in the PHIX meetings, are thereby prepared to serve as faculty to train and mentor new QI team members in the use and practice of the PDSA tools. QI Ambassador: QI Team members who complete at least one QI project and mentor at least one other QI team member until the completion of the project commit to utilize QI tools in their regular work at HEALTH, and support other ongoing QI efforts at HEALTH. QI culture: Having a QI culture is described in this document as a state in which every activity, effort, program, initiative, and event that HEALTH supports, Rhode Island Quality Improvement Plan - June

19 sponsors, maintains, and is engaged will follow the QI principles. This involves having all staff trained in the basic principles of QI, continuously maintaining an active QI team, and favoring an organizational structure where QI is encouraged, supported, maintained, and recognized as part of HEALTH itself. Rhode Island Quality Improvement Plan - June

20 VI. Appendices Appendix 1: Accreditation Logic Model Rhode Island Quality Improvement Plan - June

21 Appendix 2: HEALTH Workforce and Professional Development Logic Model Rhode Island Quality Improvement Plan - June

22 Appendix 3: Organizational Chart Rhode Island Quality Improvement Plan - June

23 Appendix 4: Rhode Island-designed PDSA logo Rhode Island Quality Improvement Plan - June

24 Appendix 5: Quality Improvement 8-hour Training Agenda 2013 QI Training Day 1 8:30 am 12:30 pm Prerequisites: One or more ideas identified with your team/supervisor for your QI project Module Details Trainer Welcome and Introductions Plan and charge for the day M. Angeloni (30) 1.2 Plan, do, study, Act (PDSA) model K. Calcagni (30) 1.3 Creating your AIM statement M. Angeloni (30) BREAK 30 minutes 1.4 Data and measurement T. Cooper T. Marak (30) 1.5 QI Tools: Flowchart, Fishbone, Force field Analysis, Logic Model T. Marak S. Poucher M. Simoli (60) 1.6 AIM statements Workshop M. Angeloni (30) 1.7 Wrap Up and Announcements for Day 2 M. Angeloni (5) Before Day 2 of the Training: 1. View part 1 of the Online Accreditation Orientation video from the Public Health Accreditation Board (PHAB) 2. Meet with your mentor to discuss your questions, ideas, feedback, and anything other impressions about Day 1 and to prepare for Day 2 Rhode Island Quality Improvement Plan - June

25 2013 QI Training Day 2 8:30 am 12:30 pm Reminder: Have your aim statement ready for discussion Module Details Trainer 2.0 Welcome and Agenda M. Angeloni (15) 2.1 Team building C. Fontana (30) 2.2 Trust the Process The PDSA Model Putting it all together Course Corrections Lessons learned BREAK 30 minutes M. Angeloni + TBD (45) 2.3 Breakout Workshops (will be assigned) Group 1: DOC M. Angeloni (60) Group 2: Beck C. Fontana (60) Group 3: Rm. 306 T. Marak (60) 2.4 Questions and Answers M. Angeloni (30) 2.5 QI resources and support A. Lemire (15) 2.6 Announcements and Next Steps M. Angeloni (15) Welcome to PHIX Scheduled included Rhode Island Quality Improvement Plan - June

26 Appendix 6: RI QI poster template for project submission Rhode Island Quality Improvement Plan - June

27 Appendix 7: QI Project Worksheet Quality Improvement Project Worksheet: Your Tool to Develop the Aim Statement As part of Public Health Accreditation, the Rhode Island Department of Health is required to conduct quality improvement (QI) projects on an ongoing basis, to achieve measurable improvements in the efficiency, effectiveness, performance, and accountability in services or processes to achieve equity and improve the health of the community. This worksheet will guide you to gather key information and data that you ll need to begin your quality improvement planning process. Objectives To work with your team to formulate your Quality Improvement (QI) project and complete the first two steps in the Plan-Do-Check-Act project, which are to: 1. Identify and prioritize opportunities within your division or program to resolve a problem or improve a process. 2. Develop your QI project aim statement (see section 6). This 1-2 sentence statement will describe your project with a clearly defined, measurable goal, and deadline. Directions Tips 1. Complete sections Submit the whole completed worksheet to the Performance Improvement and Accreditation Program Manager for review and approval. Your division or program should also keep a copy for accreditation and QI records. Answer the following questions to the best of your abilities, using the best information you and your team have at this time. It s okay at this stage for you or another expert to make a best estimate to answer some of these questions, because your QI project and aim statement will evolve as you go through the complete QI process. Later on, you will likely get better information to help resolve a problem or improve a process. Involve others from your division, program, and/or stakeholders as you ask questions, brainstorm, and gather data and other information. This exercise might result in your team deciding that your initial idea for a QI project is not as high of a priority as you first thought, or your questions might reveal another project is a greater priority at this time. That s okay that s part of the overall quality improvement process and planning priorities! Rhode Island Quality Improvement Plan - June

28 Similarly, you might find that your problem is bigger than initially thought, with more than one contributing factor or multiple root causes. That s okay too, because this exercise will also help focus your quality improvement project to tackle one root case at a time. Repeat this process later on to address another issue or idea, then another, until you ve met your original larger goal. Get This Original File Online at Section 1: Project Description 1.1 Describe the problem or opportunity to be addressed: 1.2 Why is this issue important to work on now? What s the foreseen impact on the Department, your division or program, employees, the public, or a particular community? 1. 3 Where is the STARTING point for this project? In other words, when you look at the process you re trying to improve, at what step within that process flow will your project BEGIN to study and make changes? TIP: A FLOW CHART tool might be helpful here to clearly identify this stage in the process. Example: when the patient registers at the clinic for the appointment. 1.4 Where is the ENDING point for this project? When you look at the process you re trying to improve, what s the last step within that same process flow to study and improve? Again, a FLOW CHART tool might be helpful here to clearly identify this stage in the process. Example: when the patient checks out at the front desk after the appointment. 1.5 Team Sponsor: Who has endorsed this project from your division or program, or from another division or program? This person will also be considered part of your QI Project Team. 1.6 Team Leader: Usually, this is the QI Team representative coordinating the QI project and documentation. 1.7 Team Members: List anyone who will agree to help you steer this project, take on project components, advise you, provide data or insight, identify problems, brainstorm Rhode Island Quality Improvement Plan - June

29 solutions, or otherwise offer you feedback to help accomplish your project goal. You may add more people over time. Team member Area of expertise Role 1.8 Glossary of Terms (if applicable): Section 2: Benefits and Costs Brainstorm: How will this opportunity to solve a problem or improve a process benefit the Department of Health, your program or division, or the external community? Some benefits may be measured by costs, while others may not. List as many benefits that come to mind, by priority. Examples of a non-financial benefit might be improved employee morale, better teamwork, less time fixing problems, or fewer calls or ed complaints from. A financial benefit might look at costs in terms of labor hours, supplies or resources, or averted penalties for non-compliance. Reducing overtime pay, elimination of third party service fees, or cutting rental storage costs are some examples. If no benefits come to mind, or if the benefits seem minimal and insignificant when weighed against the amount of time you re about to spend on this project, you might need to identify a new project. 2.1 Internal Benefits (HEALTH): Non-Financial: Financial: 2.2 External Benefits (Public/Community): Non-Financial: Financial: 2.3 Anticipated Project Costs Estimate costs to implement your project based on staff time, supplies needed to purchase, mileage, usability testing, etc. Staff (describe role, title or name, whichever is easy) Estimated # of hours Example: epidemiologist 25 Data entry 12 Total Rhode Island Quality Improvement Plan - June

30 Other costs: Mileage Materials Supplies Total Section 3: Current State and Desired Future State 3.1 Describe the current state of the problem or opportunity and its current performance (baseline data): Example: Reported calls received from the public in the Office of are tracked manually by staff at the front desk. No office-wide tracking tool or protocol exists at the moment. The office receives numerous complaints from callers who were transferred multiple times and received poor service as a result of that. This creates a problem for projecting staffing needs and identifying types of calls received, for management purposes. 3.2 Describe the ideal future state basically how you and your team would like things to be once your goal is achieved: Example: The office of has a system in place to receive and track the calls received from the public, staff is trained to handle the calls appropriately, and complaints from the public about continuous transfers are minimized. 3.3 What are the key driving and restraining forces impacting the current state and the ideal future state? Use the OPTIONAL tool below to guide brainstorming to frame this big picture concept for your team. Driving forces are positive factors that HELP your issue, while Restraining forces are considered working AGAINST your ideal future state. + DRIVING FORCES - RESTRAINING FORCES Example: Need to quantify the # of complaints to justify need to management Example: Lack of data entry staff Desired Future State of the issue Current state of the issue Rhode Island Quality Improvement Plan - June

31 Section 4: Improvement Description 4.1 Describe the improvement goals to be achieved: State this as a simple and clear measurable goal, noting how it s measured if applicable. Examples: Fewer staff hours involved, fewer complaint calls, fewer errors in data entry, fewer questions from staff about the process, etc. 4.2 The timing of these improvements: What s the exact date of your project completion deadline goal? If it s a complex project, please list any benchmark or interim measures that will help you know whether you re on track. 4.3 We will measure improvements by: Your primary measure should be listed below as #1. (Refer back to your improvement goals or measures as described above in 4.1). However, your program might have other measures to also test your project s effectiveness during the final evaluation stage as you examine all the benefits or liabilities and consider whether to adapt, adopt, or abandon your solution for future implementation Section 5: Know Your Internal and External Customers 5.1 Your measures in 4.3 should help you take a closer look at the project impacts that will benefit or impact various stakeholders or audiences. This might include staff, healthcare providers (which ones?), other licensees, community partners, and/or other specific customers served in the public sector by the Department of Health (if applicable). List as many customers or end users as you can. Remember your list may grow or change over time as you gather more data and other information Section 6: Write your Aim Statement here! Based on what you ve learned about your project, sum it up in your Aim Statement using this format: By (date), the (Division, Center or Program) will (briefly describe your project in measurable terms) (quantify your outcome/ desired data end goal). Examples: Rhode Island Quality Improvement Plan - June

32 - By Dec. 24, 2012, Santa s workshop elves will reduce the number of reported workers compensation accidental injury claims by at least 10%, from 10 in 2011 to 9 or less in By Oct. 31, 2012, the Great Pumpkin will increase the number of appearances to pumpkin patch believers from 0 (zero) to 1 or more. Your aim statement: Additional Notes: Acknowledgement of funding source: This training document was supported by funds made available from the Centers for Disease Control and Prevention, Office for State, Tribal, Local and Territorial Support, under Grant #5U58CD Disclaimer: The content, proposals, and opinions within this document are those of the authors and do not necessarily represent the official position of or endorsement by the Centers for Disease Control and Prevention. Rhode Island Quality Improvement Plan - June

33 Appendix 8: Quality Times Newsletter (in effect December 2011-May 2012) Rhode Island Quality Improvement Plan - June

34 Appendix 9: Quality Improvement Intranet Homepage Rhode Island Quality Improvement Plan - June