Quality Improvement Plan

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1 OAK CREEK HEALTH DEPARTMENT Quality Improvement Plan 2013 Final Report 9/24/2013 The Oak Creek Health Department has developed a quality improvement plan to provide context and framework for quality improvement activities at the health department for the year of The quality improvement plan builds off of the completed Strategic Plan and the agency-wide self-assessment.

2 I. Purpose The purpose of the 2013 Oak Creek Health Department Quality Improvement (QI) Plan is to provide context and a framework for quality improvement activities at the Oak Creek Health Department. Policy Statement: The Oak Creek Health Department staff believes that improving performance leads to improved community health. The QI plan is a key component within a performance management system to guide performance improvement. The QI plan supports systematic evaluation and improvement in the quality of programs, processes and services to achieve a high level of efficiency, effectiveness and customer satisfaction. II. Definitions Accreditation Accreditation for public health departments is defined as: 1. The development and acceptance of a set of national public health department accreditation standards; 2. The development and acceptance of a standardized process to measure health department performance against those standards; 3. The periodic issuance of recognition for health departments that meet a specified set of national accreditation standards; and 4. The periodic review, refining, and updating of the national public health department accreditation standards and the process for measuring and awarding accreditation recognition. (Public Health Accreditation Board, 2011) Community Health Improvement Plan (CHIP) Is a long-term systematic effort to address health problems on the basis of the results of assessment activities and the community health improvement process. This plan is used by health and other governmental, education, and human services agencies, in collaboration with community partners to set priorities and coordinate and target resources. Evidence-Based Programs Evidence-based programs consist of collections of practices that are done within known parameters (philosophy, values, service delivery structure, and treatment components) and with accountability to the consumers and funders of those practices. Program Evaluation Program evaluation focuses on the implementation of a project (process). Process evaluation addresses questions which relate to whether the project was implemented as planned, whether there were changes to the project plan and if so, why those changes occurred. (Embracing Quality in Local Public Health: Michigan s Quality Improvement Guidebook, Pg.109) 1

3 Quality Improvement (QI) The use of a deliberate and defined improvement process, such as Plan-Do-Study-Act (PDSA), to focus efforts on activities that are responsive to community needs and improving population health. It 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. (Public Health Accreditation Board, 2011) Quality Improvement Methods/Models This is an approach or system of tools that is being used to guide problem solving. It can also be defined as a collection of process elements and practices that can be used as a pattern for process development and criteria against which a process can be assessed objectively. Some examples include the PDSA, total quality management (TQM), Network for the Improvement of Treatment Addiction (NIATx), LEAN, and etc. Quality Improvement Principles In pursuing continuous QI, four basic principles should be practiced: 1. Develop a strong customer focus including external and internal customers. 2. Continually improve all processes. Focus on processes. Identify them and work to improve them. 3. Involve employees through teams, training, support and celebration of accomplishments. 4. Use data and team knowledge to improve decision making. (The Public Health Memory Jogger II: A Pocket Guide of Tools for Continuous Improvement and Effective Planning, 2007, Pg. 1) Quality Improvement Team (Q-Team) The purpose of the Q-Team is to carry out our QI efforts at the Oak Creek Health Department including developing a comprehensive Quality Improvement Plan ; preparing to meet local health department accreditation standards related to QI; and develops and evaluates rapid cycle quality improvement tests. Q-team members will also be asked to plan and participate in a number of QI training activities. Quality Improvement Tools Quality improvement tools are designed to assist a team when solving a defined problem or project. These tools help the team get a better understanding of a problem or process they are investigating or analyzing. Examples of tools are: flow chart; five whys; cause and effect; and fishbone. (The Public Health Quality Improvement Handbook, 2009 Pg. 159) Plan-Do-Study-Act (PDSA) The plan-do-study-act cycle is a quality improvement method consisting of four steps: design or plan, test or implement, check or study the results, and act on the conclusions to identify an effective and efficient way to change a process (The Public Health Quality Improvement 2

Handbook, 2009, Pg. 133). See Figure 1 below for an overview of the PDSA Cycle (Gorenflo and Moran, 2009). Figure 1. Performance Management (PM) This is the practice of actively using performance data to make improvements.

4 Handbook, 2009, Pg. 133). See Figure 1 below for an overview of the PDSA Cycle (Gorenflo and Moran, 2009). Figure 1. Performance Management (PM) This is the practice of actively using performance data to make improvements. The practice involves strategic use of performance measures and standards to establish targets and goals. PM can also be used to prioritize and allocate resources, to inform managers about needed adjustments or changes in policy and program directions to meet goals and to improve the quality of public health practice. (The Public Health Quality Improvement Handbook, 2009 Pg.18) Performance Management System A fully functioning performance management system that is completely integrated into health department daily practice at all levels includes: 1. Setting organizational objectives across all levels of the department, 3

5 2. Identifying indicators to measure progress toward achieving objectives on a regular basis, 3. Identifying responsibility for monitoring progress and reporting, and 4. Identifying areas where achieving objectives requires focused quality improvement processes. (Public Health Accreditation Board, 2011) Public Health Accreditation Board (PHAB) PHAB is the national accrediting organization for public health departments. A nonprofit organization, PHAB is dedicated to advancing the continuous quality improvement of Tribal, state, local and territorial public health departments. (Public Health Accreditation Board, 2011) Rapid Cycle Improvement (RCI) This is a quality improvement model based on the plan-do-study-act (PDSA) model. The RCI model entails four steps: set the aim (goal), define the measures (expected outcome), make changes (action plan), and test changes (solution). The concept behind RCI is to first make a change on a small scale to see how it works; then modify it and try it again until it works well for staff and customers and becomes a permanent improvement. After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team may implement the change on a broader scale. (Embracing Quality in Local Public Health: Michigan s Quality Improvement Guidebook, Pg. 33, 109) SMART Criteria Specific Measureable Actionable Relevant Time bound Story Board This is the graphic representation of an organization s quality improvement journey. A QI story board is a visual depiction of the team s story, beginning at the plan phase and ending at the act phase. It can be updated continually throughout the PDSA cycle. Graphics are key when creating a story board with minimal complementary text. The QI story board should include key elements of all stages of the PDSA process. (Embracing Quality in Local Public Health: Michigan s Quality Improvement Guidebook, Pg. 110) Strategic Planning A deliberate decision making process to define where an organization is going that results in a plan that sets the direction for the organization. The plan provides a template for all employees and stakeholders to make decisions that move the organization forward. (Public Health Accreditation Board, 2011) 4

6 III. Overview of Quality Improvement in the Health Department The Oak Creek Health Department received the CDC Public Health Infrastructure Grant for Preparation for Voluntary Accreditation. Through this funding, resources have been allocated for quality improvement training, an agency Public Health Accreditation Board (PHAB) selfassessment, the development of a quality improvement plan, and the completion of one quality improvement project. Currently, Health Department staff participate in QI trainings and accreditation preparation presentations that are provided by DPH, IWHI and other local health departments. Through such trainings, staff participates in activities organized to share knowledge and experiences between local health departments, and identify and work on common areas of need related to quality improvement, accreditation and performance management. Internally, the Plan-Do-Study-Act (PDSA) model is being used by staff to complete projects. Additionally, a variety of tools selected from The Public Health Memory Jogger II: A Pocket Guide for Continuous Improvement and Effective Planning are used to assist staff in problem solving. However, no formally documented QI projects have been completed since The PHAB self-assessment completed in April 2013, indicated a number of areas requiring attention, most importantly community engagement (Domain 4) and the evaluation and continual improvement of processes, programs and interventions (Domain 9). Continuing work on QI will help to focus process improvement efforts to address these areas. The department is now ready to develop and implement a QI plan. This will provide a framework to better align QI efforts with the department strategic plan and priorities. Implementation of the QI plan will be the first step in adopting a culture of continuous QI and the development of a larger performance management system. IV. Governance Structure The Health Officer will provide leadership for the direction of the QI efforts within the department, and will oversee that QI projects are in line with the department vision, mission, and strategic plan. The Health Officer will also allocate resources for QI, promote a QI culture, and review and provide final approval for the QI Plan. The Health Officer will review the QI plan biennially, and will provide a report of the QI program at least annually to the Board of Health (BOH) Each QI project will be led by a QI Project Lead as outlined in the Project Proposal worksheet. The QI Project Leads will meet with the Health Officer on the first Wednesday of every month at 2 p.m. to report progress of approved QI projects. QI Project Teams are convened by the QI Project Lead as required for specific initiatives. These Project Teams are accountable to the QI Project Lead and report activities and results on an ongoing basis. All employees will be encouraged to: participate on at least one QI Project Team 5

7 each year; develop an understanding of basic QI principles, models and tools through QI training; and apply QI principles and tools to daily work. Roles and Responsibilities Health Officer Provides vision and direction for the QI plan Convenes the QI Lead Team Reports on QI activities to the BOH Serves as a voting member of the QI Lead Team Review and provide final approval on the documents such as the QI plan QI Project Lead Provide QI expertise and guidance for QI project teams Provide QI training to new and existing staff Advocate for QI and encourage a culture of learning and QI among staff QI Project Team Responsible for the implementation of QI projects and for the reporting of activities and results to the QI Project Lead; identify appropriate staff to participate in QI projects as needed. Report to the QI Project Lead on program evaluation activities All Staff Review annual QI plan prior to approval Assist in development of department QI activities Apply QI principles and tools to daily work Administrative Support Maintain minutes of QI meetings Provide administrative support for other QI activities as needed V. Training and Recognition New Employee Training New employees will receive QI training as part of orientation to the department, which will include one of the following online courses: Public Health Foundation QI Tutorial NIATx Process Improvement New employees will be encouraged to complete additional self-study using on-line resources including the Institute for Wisconsin s Health website and the State Division of Public Health 6

8 media site archived trainings. All new employees will participate in at least one project within the first 12 months of employment. Current Employee Training Current employees will participate in at least one QI training each year; provide monthly updates on projects at staff meetings; participate on at least one QI project each year; and receive project specific training as available. Training for will include to following topics: QI and Accreditation Overview PDCA and project selection SMART criteria Flowcharts Root Cause Analysis (5 Why s, Cause and Effect Diagrams, Force Field Analysis) Development of storyboards Data collection, analysis and display (including run charts, Pareto charts, check sheets) Brainstorming and Affinity Diagrams WI Division of Public Health Performance Management 101 Webinar True QI Project Lead Training The QI Project Lead will follow the same requirements as current employees but may also get additional training or practice by partnering with other public health system partners in order to further develop QI knowledge and skills. Employee Recognition Employees submitting QI project proposals, participating on QI projects or participating on a QI Team will be recognized annually. Recognition may include thank you letters signed by the Health Officer or Mayor, articles in Oak Creek publications, or certificates of appreciation. In addition, QI project team members will be provided with opportunities to present their work at Board of Health meetings or other appropriate events. High performing employees will be recognized at a Board of Health meeting. VI. QI Project Selection & Completion QI projects may be longer term, larger scale strategic efforts, or they may be shorter term, smaller scale efforts such as process improvements. Regardless of the scale, these projects should be approached with some similarity. There should be planning, data collection and analysis, testing and measuring of performance to ensure that changes will in fact be improvements, then continuous review and improvement over time. 7

9 Project Proposal Employees are encouraged to recommend their own QI projects as the QI Project Lead. These projects should apply common quality improvement tools and techniques to help teams achieve their desired results. The QI Project Proposal worksheet will be used to submit recommendations for potential projects. Large scale projects involve multiple programs and address high priority initiatives or key services. These projects may be identified through agency-wide self-assessments and strategic planning that identifies a need for improvements or new initiatives. Project Selection QI Project Proposals are reviewed on a quarterly basis by the Health Officer. Proposal will be approved, returned for additional work, or declined. Proposals will be assessed based on the following criteria: The project aligns with the department Strategic Plan and the Community Health Improvement Plan. The project supports the department s mission, vision and values. The problem that is targeted for improvement is clearly defined. The project uses SMART criteria The project is significant and/or important. The project has been chosen based on review of data and/or a performance measure(s). Appropriate stakeholders have been identified to be involved in the project. The project has the potential to impact multiple programs/activities. In order to be ready for accreditation, at least one project will be in the administrative area and one in the program area every year. QI Project Team Reporting Approved projects are required to submit follow-up progress and completion reports to the QI Project Lead using the QI Project Worksheet that follows the PDSA model. If the project is estimated to take longer than 3 months, quarterly reports are required. 8

10 VII. QI Plan Management National Benchmark/Objective: PHAB Standard 9.2: Develop and implement quality improvement processes integrated into organizational practice, programs, processes and interventions. Goal #1: Establish a written QI Plan based on OCHD policies and strategic plan. Objective: By September 30, 2013, develop a QI Plan that seeks to: increase staff knowledge of quality improvement; supports development and implementation of QI processes and projects; improve services, health outcomes, and address the requirements of PHAB accreditation. Responsible Individual or Team: Health Department Staff Performance Measure: OCHD QI Plan 2013 Target: Completed and signed OCHD QI Plan Key Activities: Draft of QI Plan completed by Health Department Staff Draft of QI Plan vetted by Health Department Staff Revised QI Plan presented to the Board of Health QI plan approved and signed by Health Officer Goal #2: Implement QI efforts at the OCHD. Objective: By December 31, 2013, effectively implement each element of the annual QI plan within the defined timeline for each. Responsible Individual or Team: Health Officer Performance Measure: Comply with the requirement for at least two QI projects per year with at least one from an administrative area and at least one from a program area Target: Documentation of two completed QI project Key Activities: Health Officer will orient OCHD staff to the QI Project Selection & Completion process Health Officer will review QI project proposals quarterly Quarterly, each Project Lead will submit the QI Project Worksheet with updates for review by the Health Officer Health Officer will meet as needed with QI Project Teams to plan, implement or evaluate QI-related activities QI Project Teams will document outcomes of QI projects Goal #3: Demonstrate employee participation in training on QI methods and tools. Objective: By December 31, 2013, provide QI training and application opportunities for all employees. Responsible Individual or Team: Health Officer Performance Measure: Percentage of staff trained on QI Plan, methods and tools 2013 Target: Train 100% of staff Key Activities: QI training records maintained for all employees QI training and project participation included as a requirement and recorded in employee annual performance evaluations Document training on QI plan at orientation and staff meetings Document continuing QI training for all staff Document training on PM system for all staff 9

11 X. Communication Strategies Communication of QI activities conducted by the Oak Creek Health Department will be accomplished through: Quarterly updates at regularly scheduled staff meetings; A copy of the biennial QI plan provided electronically to all employees; Display of QI storyboards; Presentations at meetings that may include Board of Health meetings, council meetings, or other identified events; Reports on QI efforts at least one time a year on the department webpage; and Recognition of high performing employees at the annual department meeting. XI. Sustainability QI and Employee Performance Evaluation: QI activities will be included as a required activity for all positions. Employee involvement in QI activities will be evaluated through the annual performance evaluation process. Agency QI Plan and Policy: The agency QI plan and policy statement developed in Oak Creek was designed to create an environment for sustainability and growth of the QI culture. The QI plan will be reviewed biennially to ensure its effectiveness in aligning with agency performance priorities and strategies, and guiding agency-wide QI efforts. A QI policy will be developed and included in the agency s policies and procedures in

12 Name Title Date Reviewed Signature Judith Price RN, BSN, MSHCA Community Public Health Officer (CPHO) 9/27/2013 On File 11

13 References Bialek, R., Duffy, G. L., & Moran, J. W. (2009). The Public Health Quality Improvement Handbook. Milwaukee, WI: Quality Press. Fillmore-Houston Community Health Service. (2012). Fillmore-Houston community health service quality improvement plan Retrieved from ouston/qiplan.pdf Gorenflo G, Moran JW (2009). The ABC s of PDCA. Retrieved from Kane County Health Department. (2011). Kane County health department 2011 quality improvement plan. Retrieved from Plan-Final.pdf Kane, T., Moran, Jack & Armbruster, Sonja. Developing a health department quality improvement plan. Retrieved from _Improvement_Plan.aspx, accessed July 2012 Public Health Accreditation Board Standards & Measures. (2011). Standard 9.2: develop and implement quality improvement processes integrated into organizational practice, programs, processes, and interventions. (Version 1.0). Retrieved from Version-1.0.pdf Roudabush, K.D. (2012). Using models to drive process improvement. Retrieved from Scamarcia Tews, D., Sherry, M. K., Butler, J. A., & Martin, A. (2008). Embracing Quality In Local Public Health: Michigan's Quality Improvement Guidebook. Princeton, NJ: National Network of Public Health Institutes and the Public Health Leadership Society. Sedgwick County Health Department. (2011). Sedgwick county health department 2011 quality improvement plan last updated 02/16/2011. Retrieved from 12

14 Plan.pdf Tacoma/Pierce County Health Department. (2009) Quality improvement plan. Retrieved from The Public Health Memory Jogger II: A Pocket Guide of Tools for Continuous Improvement and Effective Planning. (2007). Salem, NH: GOAL/QPC. Washington County Department of Public Health and Environment (PHE). (2012) Quality improvement plan. Retrieved from on/qiplan.pdf Washington State Department of Health. (2011). Quality improvement implementation plan Retrieved from West Allis Health Department, (2011). Performance management system quality improvement plan. Accessed July 8,

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