The Quality Improvement Welcome Kit March 3, :00-3:30pm ET

Transcription

1 Public Health Improvement Webinar Series The Quality Improvement Welcome Kit March 3, :00-3:30pm ET Laurie Call Illinois Public Health Institute Lori Linstead Oklahoma State Department of Health Trouble signing on? Questions? Breonne at

2 Have you participated in a formal QI project? o Yes o No o Unsure Poll Question

3 What is Quality Improvement (QI)? Deliberate and defined improvement process Responsive to customer needs and improving population health Continuous and ongoing effort Measurable Improvements in Efficiency Effectiveness Performance Accountability Outcomes Riley, Moran, Corso, Beitsch, Bialek, and Cofsky. Defining Quality Improvement in Public Health. Journal of Public Health Management and Practice. January/February Increased Equity Improved Community Health 3

4 Systems are perfectly designed to get the results they achieve. Of all changes I ve observed, about 5% were improvements, the rest, at best, were illusions of progress. W. Edwards Deming 4

5 What percentage of the changes made at your agency are improvements that can be proven with data? o Less than 10% o Greater than 10% and less than 25% o Greater than 25% and less than 50% o Greater than 50% and less than 75% o Between 75% and 100% Poll Question

6 Why is QI important now? Reduced Budgets Increased Stakeholder Demand for Accountability Increased Community Needs Aging Government Workforce Accreditation Public Health needs increased efficiency, effectiveness, customer satisfaction and documented best practices. 6

7 The Quality Trilogy: Differentiating Between QI, QP and QA Quality Improvement Quality Planning Quality Assurance 7

8 Opeartions Begin The Quality Trilogy (adapted from Joseph Juran) Quality Planning Quality Control & Improvement (During Operations) Take Action Define Opportunity & Stakeholder Needs Design & Pilot Service or Process Sporadic Spike Original Zone of Quality Control Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? Act Plan Study Do Monitor Impact / Results of Service Process not Achieving Desired Results (An Opportunity for Improvement) Quality Improvement Time New Zone of Quality Control MCPP Healthcare Consulting

9 When to use Quality Planning Service/process has never existed before Customer requirements are not known Existing service/process performance is not capable of meeting customer requirements Service/process is ad hoc; extremely variable; never been well defined or worked on before as a whole Unstable environment major market, technology, organizational change No performance data exists or would take excessive time/expense to collect data MarMason Consulting 9

10 OKLAHOMA FLU PROCESS Quality Planning Defined the Need: Chose Complete Overhaul of Flu Process Timeline: Pre-Book through Post Season Why Quality Planning? Process had never existed before Process had never been well defined or focused on as a whole No performance data existed Assessed Need: Internal and External Stakeholders Program Staff Private and Public Providers Nursing Staff Immunization Field Consultants

11 Impact Has there been a cost savings? OKLAHOMA FLU PROCESS Quality Planning Was there a change in the doses of flu distributed? Monitoring Continue to monitor data to determine impact If there is a change, QI will be implemented for next flu season

12 They Are Not the Same Quality Assurance Reactive Works on problems after they occur Regulatory usually by State or Federal Law Led by management Periodic look-back Responds to a mandate or crisis or fixed schedule Meets a standard (Pass/Fail) Quality Improvement Proactively selects a process to improve Works on processes Seeks to improve (culture shift) Led by staff Continuous Exceeds expectations 12

13 Where does your agency or program area spend most of your time? o Quality Assurance o Quality Improvement o Quality Planning o About Equal Time Spent in All 3 Poll Question

14 Overview of The Model for Improvement: PDSA and Rapid Cycle Improvement 14

15 AIM Statement Institute for Healthcare Improvement Model for Improvement 1. What are we trying to accomplish? Data Root Cause Analysis 2. How will we know that a change is an improvement? 3. What changes can we make that will result in an improvement? Multiple Cycles A S P D Reference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide Designed to Accelerate Change.

16 The PDSA Cycle for Learning and Improvement Act What changes are to be made? Next cycle? Study Complete the analysis of the data Compare data to predictions Summarize what was learned Plan Define objective Identify questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Plan for data collection Do Carry out the plan Document problems and unexpected observations Begin analysis of the data 16

17 Plan Adapted from Gorenflo, G. & Moran, J.W. (2010). The ABCs of PDCA. Washington, DC: Public Health Foundation Identify and Prioritize Opportunities 7. Develop Improvement Theory Check/ Study 2. Develop AIM Statement 3. Describe the Current Process 8. Develop Action Plan Do 1. Reflect on the Analysis 2. Document Problems, Observation, and Lessons learned 4. Collect Data on Current Process 5. Identify All Possible Causes 6. Identify Potential Improvements 1. Implement the Improvement 2. Collect and Document The data 3. Document Problems, Observations, and Lessons Learned Act Adopt Adapt Abandon Standardize Do Plan

18 Plan 1. Identify and Prioritize Opportunities Examples Long customer wait times No shows for appts Inaccurate data Lengthy process time Budget over or underspent Low testing scores Failed inspections or Compliance tests Adapted from ABCs of the PDCA Cycle, G. Gorenflo and J. Moran, 1. Identify and Prioritize Opportunities Brainstorm possible QI project topics, there may be many options Select just one problem to address Develop a problem statement Potential Tools: Prioritization matrix

19 Plan Adapted from ABCs of the PDCA Cycle, G. Gorenflo and J. Moran, 1. Identify and Prioritize Opportunities 2. Develop AIM Statement SMART Specific Measurable Achievable Relevant Time-bound 2. Develop AIM Statement Express the one change you are you seeking to accomplish as a SMART Objective What improvement are you seeking? (Measure of change) + (in what?) + (by whom) + (by when)

20 Sample AIM Statements (SMART Format) By November 2014, CDPH will increase the % of youth ages 18 and younger who will receive preventive dental exams and referrals from 14% to 30%. To raise 1 or more doses of HPV vaccine coverage levels among year olds in Vaccines for Children clinics (26) from 38% to 50% by January, Chicago Department of Public Health (Measure of change) + (in what) + (by whom) + (by when) 20

21 Plan Adapted from ABCs of the PDCA Cycle, G. Gorenflo and J. Moran, 1. Identify and Prioritize Opportunities 2. Develop AIM Statement 3. Describe the Current Process 3. Describe the Current Process Understand the process and identify potential areas for improvement How does the process work now? Potential Tools: Workflow diagram (e.g., flow chart, value stream mapping)

22 Process Map: Swim Lanes Example

23 Plan Adapted from ABCs of the PDCA Cycle, G. Gorenflo and J. Moran, 1. Identify and Prioritize Opportunities 2. Develop AIM Statement 3. Describe the Current Process 4. Collect Data on Current Process 4. Collect Data on Current Process Collect/analyze data that aligns with the measure(s) in the AIM Statement What data do you already collect or can you collect to understand the problem or may serve as baseline data? Potential Tools: Pareto charts, histogram, run charts, scatter plots, control charts, etc.

24 # respondents Pareto Principle: 20% of sources cause 80% of any problem Pareto Chart: Why do fewer clients in clinic B receive HIV tests? Used to determine major contributors to a problem Not offered Client does not want Too much time Language barriers Unable to return Adapted from Beitsch L. Understanding and Utilizing Basic QI Tools. December 5, 2012.

25 Plan Adapted from ABCs of the PDCA Cycle, G. Gorenflo and J. Moran, 1. Identify and Prioritize Opportunities 2. Develop AIM Statement 3. Describe the Current Process 4. Collect Data on Current Process 5. Identify All Possible Causes 5. Identify All Possible Causes Identify all possible causes of the problem and determine the one root cause you will focus on. Potential Tools: Affinity diagram, cause and effect/fishbone diagram, the 5 whys, interrelationship diagraph, prioritization matrix, control and influence chart

26 Parents Policies Processes Parents do not appreciate costs/ benefits of vaccines Parents do not consider HPV vaccine a priority Parents do not know about HPV disease or vaccines HPV vaccine not required for school entry Providers with limited time CDPH staff with competing priorities Insurance coverage inconsistent Feedback messaging not HPV- focused Follow up limited to written communication All providers do not participate in feedback Inventory Management Provider biases Provider misconceptions Providers do not consider HPV vaccine a priority Providers uncomfortable answering HPV questions HPV vaccine coverage in VFC clinics has not increased as much as Tdap and MCV vaccine coverage. Resources Providers uncomfortable making HPV recommendations CDPH Immunization Program QI Project, 2013 Providers 26

27 Plan Adapted from ABCs of the PDCA Cycle, G. Gorenflo and J. Moran, 1. Identify and Prioritize Opportunities 2. Develop AIM Statement 3. Describe the Current Process 4. Collect Data on Current Process 5. Identify All Possible Causes 6. Identify Potential Improvements 6. Identify Potential Improvements Identify potential improvements to address the root cause Agree on one improvement (i.e., intervention) to test Revisit AIM Statement and revise measureable improvement objectives, as needed Potential Tools: Prioritization matrix, Influence and Control chart

28 Plan Adapted from ABCs of the PDCA Cycle, G. Gorenflo and J. Moran, 1. Identify and Prioritize Opportunities 7. Develop Improvement Theory 2. Develop AIM Statement 3. Describe the Current Process 4. Collect Data on Current Process 5. Identify All Possible Causes 6. Identify Potential Improvements 7. Develop Improvement Theory Articulate the effect you expect the improvement to have on the problem. Potential Tools: If. Then structure

29 Plan Adapted from ABCs of the PDCA Cycle, G. Gorenflo and J. Moran, 1. Identify and Prioritize Opportunities 7. Develop Improvement Theory 2. Develop AIM Statement 8. Develop Action Plan 3. Describe the Current Process 4. Collect Data on Current Process 5. Identify All Possible Causes 6. Identify Potential Improvements 8. Develop Action Plan Indicate what needs to be done, who is responsible, and when it should be completed Potential Tools: PDCA Action Plan

30 QUALITY IMPROVEMENT CHILD CARE PROJECT

31 National Immunization Survey (NIS) Oklahoma Children Months of Age 2012 Coverage Levels - 61%

32 PLANNING Define Objective How to Raise Coverage Levels? Opportunity Child Care Record Audits AIM STATEMENT By December 31, 2014, improve overall compliance of child care facilities by 10% from 77% to 87%. Specific; Measurable; Achievable; Relevant; Timebound = SMART

33 CHILD CARE RECORD AUDITS Improvement Theory If children aged months enrolled in licensed child care facilities are up-to-date on the 4:3:1:3:3:1:4 childhood series then... Overall childhood immunization coverage rates in Oklahoma will improve Action Plan Field Consultants to perform child care record audits in assigned counties. Why This Action Plan/Intervention Strategy? Plan/Intervention within Program s control to improve overall compliance.

34 FLOW CHART

35 FORCE FIELD ANALYSIS

36 FISHBONE DIAGRAM

37 PRIORITIZATION MATRIX

38 Plan Adapted from ABCs of the PDCA Cycle, G. Gorenflo and J. Moran, 1. Identify and Prioritize Opportunities 7. Develop Improvement Theory 2. Develop AIM Statement 3. Describe the Current Process 4. Collect Data on Current Process 5. Identify All Possible Causes 6. Identify Potential Improvements 8. Develop Action Plan Do 1. Implement the Improvement 2. Collect and Document The data 3. Document Problems, Observations, and Lessons Learned Implement the Action Plan & collect data Potential Tools: Action Plan, spreadsheets

39 Do or Implement Implement the Improvement Field Consultants complete child care record audits for facilities Discussions with OK Department of Human Services (enforcement component for non-compliance) Review current immunization protocols and procedures Analyze the current process for record audits Data Collect and Document Upon completion of audit, send information monthly to Immunization Service Immunization Service will track record audit information Analyze record audit results by individual child care facility Aggregate results for all audited facilities to determine overall compliance

40 Plan Adapted from ABCs of the PDCA Cycle, G. Gorenflo and J. Moran, 1. Identify and Prioritize Opportunities 7. Develop Improvement Theory Check/ Study 2. Develop AIM Statement 3. Describe the Current Process 8. Develop Action Plan Do 1. Reflect on the Analysis 2. Document Problems, Observation, and Lessons learned 4. Collect Data on Current Process 5. Identify All Possible Causes 6. Identify Potential Improvements 1. Implement the Improvement 2. Collect and Document The data 3. Document Problems, Observations, and Lessons Learned Compare new data to baseline data Was AIM Statement measure met? Potential Tools: Same as Plan stage

41 CHECK REFLECT ON ANALYSIS: Overall compliance increased to 86.3% We discovered fewer record audits were performed in 2014 as compared to LESSONS LEARNED: Immunization Service Staff new to QI process Determining root cause is vital Inconsistency in data Essential to develop partnership with state licensing/enforcement agency (Oklahoma Department of Human Services) Child Care Staff unable to interpret immunization records Lacked standardized process to know which facilities were being audited Competing priorities for Field Consultants Need for uniformity in reporting among Field Consultants Child Care QI Project: Baseline Data Compared with Project Timeline Data 77% 86.3% Baseline (Deccember 2013) Project Timeline (December 2014)

42 Plan Adapted from Gorenflo, G. & Moran, J.W. (2010). The ABCs of PDCA. Washington, DC: Public Health Foundation Identify and Prioritize Opportunities 7. Develop Improvement Theory Check/ Study 2. Develop AIM Statement 3. Describe the Current Process 8. Develop Action Plan Do 1. Reflect on the Analysis 2. Document Problems, Observation, and Lessons learned 4. Collect Data on Current Process 5. Identify All Possible Causes 6. Identify Potential Improvements 1. Implement the Improvement 2. Collect and Document The data 3. Document Problems, Observations, and Lessons Learned Act Adopt Adapt Abandon Standardize Do Plan

43 ACT ADAPT FUTURE PLANS What changes need to be made? New Process for Record Audits Inclusion of Educational Component for Child Care Facilities Revised Employee Performance Review for Field Consultants Continued Training and Assistance to Field Consultants Joint Follow-Up Plan for Non-Compliant Child Care Facilities Oklahoma State Department of Health Oklahoma Department of Human Services

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45 Rapid Cycle PDSA A P A P S D A S P D S D Project Difficulty Knowledge and Experience Duffy, G., Moran, J., and Riley, W. Rapid Cycle PDCA. Published in Quality Texas Foundation Update (August 2009). Available at: 45

46 Rapid Cycle PDSA Short cycles Iterative process Hold the gains from one cycle to the next Recurring cycles allows testing of multiple interventions A S P D Duffy, G., Moran, J., and Riley, W. Rapid Cycle PDCA. Published in Quality Texas Foundation Update (August 2009). Available at: 46

47 Principles of Quality Improvement 1 Know your stakeholders and what they need 2 Focus on processes 3 Use data for making decisions 4 Use teamwork to improve work 5 Make quality improvement continuous 6 Demonstrate leadership commitment MARMASON Consulting: Quality Improvement in Public Health: It s Not Another Program 47

48 Voice of the Customer VOC Identify stakeholders and their needs Set goals based on stakeholder needs MARMASON Consulting: Quality Improvement in Public Health: It s Not Another Program 48

49 Improve overall process, not just one part 85% of poor quality is a result of poor work processes, not of staff doing a bad job 1 Processes often go wrong at the point of the handoff Some of the most complex processes are the result of creating a work around 1. Walton, Mary. (1986) The Deming Management Method. New York: Berkeley Publishing Group. See page 242 regarding W. Edward Deming's 85/15 rule. MARMASON Consulting: Quality Improvement in Public Health: It s Not Another Program 49

50 It s Process, Not People Public Health Emergency Response Program Problem: Decline in employee call-down response in Oct Theory: People are not responding 50

51 Mar-08 Mar-09 Feb-10 Dec-10 Apr-11 Jul-11 Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 It s Process, Not People Public Health Emergency Response Program Reality: System not accurately recording responses, lack of understanding Result: Change in system = improved (and SUSTAINED) improvement 100% 80% 60% 40% 20% 0% KCHD Staff Acknowledgement of Employee Call-Down Drills 51

52 Use performance assessment data to target improvement Use data analysis tools to develop information Analyze data to identify root cause Use data to monitor performance outcomes MARMASON Consulting: Quality Improvement in Public Health: It s Not Another Program 52

53 Using Data Throughout the QI Process AIM: The CDPH HIV Prevention Program will decrease missing data variables from 39% in 2012 to 10% by September 2013 and 5% by January Data was used to: Target improvement - % of missing variables Identify root causes - customer survey; % clinics using excel reporting form and other reporting tools; Monitor performance outcomes rate of uptake of new reporting form; % missing data associated with new reporting forms 53

54 QI efforts need buy-in from all stakeholders Creative ideas are needed Division of labor is needed Process often crosses functions Solution generally affects many MARMASON Consulting: Quality Improvement in Public Health: It s Not Another Program 54

55 Team Charter Team Behavior Charter Ground Rules Decision-Making Communication Roles and Participation Agreements Values Team Purpose Charter Why Team Exists Adequate Knowledge and Representation on Team Understanding of Stakeholders Documentation and Measures of Team Progress Indicators of Team Progress Movement in right direction. Types of Measures and Outcomes Short, Intermediate and Long-term Projected Dates 55

56 Use conclusions from data analysis to identify areas for improvement Charge, train and support QI teams Plan-Do-Study-Act cycle Develop AIM statement Use tools to understand root causes Use data for baseline and analysis Design process improvement to address root causes Act Study Plan Do MARMASON Consulting: Quality Improvement in Public Health: It s Not Another Program 56

57 Reward improvements Connect strategic plan to performance improvement Know and use quality principles Initiate and support QI teams Encourage staff to use QI in daily work Assure adequate QI infrastructure for quality assessment and improvement activities MARMASON Consulting: Quality Improvement in Public Health: It s Not Another Program 57

58 Are you interested in learning more about QI? o Yes o No o Unsure Poll Question

59 As a result of this session, are you interested in participating in a QI project? o Yes o No o Unsure Poll Question

60 QI Resources Institute for Healthcare Improvement - Public Health Quality Improvement Exchange (PHQIX) NNPHI Public Health Performance Improvement Toolkit - 2?view=file&topic=59 NACCHO QI in Public Health - Michigan Public Health Institute QI Guidebook - Public Health Foundation (PHF) Performance Improvement Learning Series Catalog - ng_series_catalog.aspx

61 Presenter Contact Information Laurie Call Director, Center for Community Capacity Development Illinois Public Health Institute (IPHI) (312) Lori Linstead Director, Immunization Services Oklahoma State Department of Health (405)

62 Public Health Improvement Webinar Series Questions? Comments? Ideas? Tips? Interested in more training and funding opportunities from NNPHI? Sign up for announcements at