Transcript Title Page

Support for this program was provided by a grant
from the Robert Wood Johnson Foundation
De-siloifying
MCH
Preparedness
HIV
EH
Chronic Disease
Brought to you from the vocabulary of Dr. Les Beitsch

June 2011-November 2011 ASTHO convened four
one-day planning meetings with RWJF, ASTHO,
invited PH practitioners, and ASTHO affiliates

Initial kick off meeting was held with all three
program areas together

Each meeting focused on one of the program areas:
EH, MCH, CD

Meeting purpose:
◦ Review current research and best practices on QI related to
the selected public health programs
◦ Develop a draft framework for a national demonstration
initiative on quality improvement practices in state public
health programs to support accreditation readiness efforts

Increase capacity for meaningful quality improvement
in state health agency CD, EH, MCH program areas

Increase ability to set aims and measure change in
target areas

Increase quality improvement skills and use the QI
model in planning and conducting future projects

Increase ability to meet measures in the PHAB
domains

Increase the sharing of information across states and
across programs

Contribute examples to the PHQIX database
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
Demonstrate the use of QI in MCH, EH and CD
programs to develop state health agency
documentation to meet PHAB measures.
Use efficiencies resulting from QI to inform agency,
program, resource, and accreditation decisions in
times of shrinking state and federal budgets.
Improve health impact, delivery of services, and
program operations among state public health
MCH, EH, and CD programs by applying quality
improvement methodology.
RWJF
 Dr. Pamela Russo-Senior Program Officer
 Katie E. Wehr-Program Associate
ASTHO Performance Team
 Jim Pearsol-Chief Program Officer
 Denise Pavletic-Director PH Systems
Improvement
ASTHO Environmental Health
 Ify Mordi-Senior Analyst Environmental
Health
ASTHO Chronic Disease
 Elizabeth Walker-Senior Director Chronic
Disease
QI Coaches
 Marni Mason-MarMason Consulting LLC
 Chris Bujak-Continual Impact LLC
National Affiliates
 Sharron Corle-Association of MCH
Programs (AMCHP)
 John Robitscher-National Association of
CD Directors (NACDD)

Each state team received the following:
◦ $100,000 in funding (contracts based on
deliverables)
◦ Assigned QI coach
◦ Access to subject matter experts in MCH, CD, EH

Training delivered through the following
venues:
◦
◦
◦
◦
In-person kick off training
Alternating monthly webinars/TA calls
Regular on-site training with QI coaches
Regular coaching through conference calls
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June 2011-November 2011: QI demonstration
initiative planning
December 2011: RFA released
January-February 2012: Peer review and
scoring of applications
February 2012: QI teams selected
March 2012: In-person kick off trainingincluding federal partners at CDC, HRSA, WIC
 April
2012-present
◦ QI Teams developed team charter,
refined aim statements, developed
measures, set targets, collected
baseline data
◦ Completed PLAN/DO phases
◦ In-process: CHECK/ACT-testing
theories of improvement, data
collection, re-testing

June-August 2013
◦ QI teams complete the ACT phase
◦ Implementation and sustainability

September 2013
◦ Determine QI examples that address PHAB
documentation requirements
◦ Submission of QI examples to PHQIX

October 2013
◦ Project close out
◦ In-person meeting to share results with each other, our
federal partners and affiliates

MEASURES:
◦ 100% of projects will have achieved measureable
improvement against their intended target(s)/refined aims.
◦ 100% of states will submit one QI example to the PHQIX.
◦ 50% increase in the number of QI examples that address
PHAB documentation requirements.
◦ 50% increase in the types (i.e., CD, EH, MCH) of QI
examples that address PHAB documentation requirements.
 Arizona
 Connecticut
 Maryland**
 Minnesota**
 Oregon**
 Lydia
Emer-Oregon
 Karen Silver-Maryland
 Stephanie Lenartz-Minnesota
Breaking Down Silos: Demonstrating QI
Among the Maternal and Child Health,
Environmental Health and Chronic Disease
Programs in State Public Health Agencies
Community of Practice for Public
Health Improvement, Open Forum
June 12, 2013
OREGON HEALTH AUTHORITY
WELCOME TO OREGON!
OREGON HEALTH AUTHORITY
Performance Management Program
Public Health System Characteristics
•
•
•
•
Decentralized
36 counties
34 health departments
Oregon Health Authority:
State super-agency comprising
public health, mental health and
Medicaid
• Portland and Salem, Oregon
• Population served: 3.8 million
OREGON HEALTH AUTHORITY
Performance Management Program
ASTHO Grant Overview
• Improve health impact, delivery of services, and
program operations
• Develop state health agency documentation to
meet PHAB measures.
• Use efficiencies to inform agency, program,
resource, and accreditation decisions in times of
shrinking state and federal budgets.
OREGON HEALTH AUTHORITY
Performance Management Program
OREGON’S PROJECTS
OREGON HEALTH AUTHORITY
Performance Management Program
Oregon MothersCare (OMC)
Goal: Improve data transfer and tracking
• Reduce time from OMC appointment to
Oregon Health Plan approval by improving
processes
• Reduce time between OMC first contact and
prenatal appointment
OREGON HEALTH AUTHORITY
Performance Management Program
Improvement - Before
One-page paper tracking
form faxed to State office
• Manual process to
enter, track, organize
forms.
• Manage data for 26
sites.
• Lots of follow up with
sites.
OREGON HEALTH AUTHORITY
Performance Management Program
Improvement - After
Web-based system
• Reduced State staff
time to manage data
process.
• Staff time re-direct to
supporting OMC sites.
• Local sites have
greater ownership of
their data.
OREGON HEALTH AUTHORITY
Performance Management Program
Results
Clients served in 2011
Fax sheets
Reams of paper at 500 sheets per ream
Number of reams per tree
Trees saved per year
OREGON HEALTH AUTHORITY
Performance Management Program
4,279
8,558
17
16.67
1.03
OMC Future Work
• Quality Planning
– Internal and external work groups collaborating and
using quality planning tools to re-define the work
OMC will do in the transformed healthcare world.
– Affinity diagramming exercises to help define new
business needs.
OREGON HEALTH AUTHORITY
Performance Management Program
Oregon State Cancer Registry (OSCaR)
Goal: Improve data system quality. By the end of
the project, 90% of providers will be reporting
electronically.
• Ensure timely and accurate data submission
from all providers (CDC requirement: within 6
months of diagnosis)
• Improve program efficiency and data quality
OREGON HEALTH AUTHORITY
Performance Management Program
Project Development
• Initial strategy – Improve number of physicians
submitting data to the registry.
• Re-scope – With meaningful use requirements,
physicians must submit data electronically.
Project shifted from improving paper-submitters
to planning for electronic data submission.
OREGON HEALTH AUTHORITY
Performance Management Program
Project Status
• Outreach to
participating and
non-participating
providers is
currently underway.
• Barriers to reporting
data are being
assessed
OREGON HEALTH AUTHORITY
Performance Management Program
Drinking Water
Goal: Ensure that Drinking Water testers receive
efficient and timely reimbursement for tests.
• Move stand alone contracts into State omnibus
contract.
OREGON HEALTH AUTHORITY
Performance Management Program
Project Status
• New contract language developed that focuses
on reimbursement for tests.
• New contract mechanism will launch on July 1,
2013.
OREGON HEALTH AUTHORITY
Performance Management Program
Project Plan After July 1, 2013
• Identify future scope of work county contracts
that addresses a greater percent of identified
local program needs.
• Identify opportunities to continuously improve
Drinking Water program element and scope,
looking for opportunities to leverage learning
across other program areas.
OREGON HEALTH AUTHORITY
Performance Management Program
PROJECT LEARNING
OREGON HEALTH AUTHORITY
Performance Management Program
Sometimes it IS about the people, not
just the process
• Committed program team with strong, involved
leadership.
• Active involvement of local sites and
stakeholders.
• Staff QI champions empowered to learn and
apply.
OREGON HEALTH AUTHORITY
Performance Management Program
Sometimes it IS about the process
•
•
•
•
Process was owned by the program.
Scope was clearly defined.
Data was accessible.
Learned the difference between Quality
Improvement and Quality Planning, and when
to use each framework.
OREGON HEALTH AUTHORITY
Performance Management Program
Challenges
• Staff and leadership turnover and impact on
priority setting.
• Legislative session and other political issues.
• Time to make QI the urgent project among
competing priorities.
• Integrating QI into program culture.
• Engaging diverse partners across the state in
an ongoing and meaningful way.
OREGON HEALTH AUTHORITY
Performance Management Program
Find Us Online
• Performance Management Program
http://1.usa.gov/PerformanceManagement
Program
• PH Accreditation and Quality
Improvement
www.healthoregon.org/accreditation
OREGON HEALTH AUTHORITY
Performance Management Program
Contact Information
Lydia Emer
Performance Manager
[email protected]
971-673-1223
OREGON HEALTH AUTHORITY
Performance Management Program
COPPHI Open Forum: Maryland
RWJF National Quality Improvement
Demonstration Initiative
Strengthening Public Health
Connections for WIC Families
Karen M Silver, MPP, PIM
Deputy Director, Office of Population Health Improvement
DHMH
Overview
• AIM and Measures
▫ 4 project areas
• Tools
▫ “Bugle of scope”
▫ Process mapping
• Case Study: Fax to Assist
• Extracting Lessons Learned
• Next Steps
Problem
• 10,000 Maryland WIC clients receive a
“Referral” to PH services each month
▫ No data to show - are referrals to public health
services effective?




Smoking cessation
Immunizations
Lead testing
Family Planning/
comprehensive women’s health
WIC Referral Process
WIC Intake
• Client interviewed
by WIC Staff
• Self report data:
Lead, Smoking,
etc.
• Staff measure:
wt/ht/ hgb
• Staff doc
immunization
status (only official
documentation
accepted)
• Manual data entry
into WOW system
Referral
Action
Referral
Given
• Client given
referrals – no
consistent method
of referring (some
via database, some
via paper)
• Client must initiate
contact with
referral (i.e call
Quitline, visit family
planning, get a
lead test)
• Monthly
spreadsheet of
children without
documented
immunizations sent
to Immunization
Registry
• Immunizations may
contact family
DISCONNECT
Is the WIC referral system effective?
Feedback
• None provided
back to WIC
Maryland Project Aim
To:
Enable increased follow up of referred WIC
services by Public Health Services
For: WIC clients referred to or educated about lead
testing, immunizations, smoking cessation, and
women’s health and family planning services
By:
Integrating the WIC and public health services’
processes, knowledge, information, and data
So that:
There is an increase in WIC clients that
receive the services to which they were
referred
Project Measures – version 4.0
Goal
Measure
Target
Increase the # WIC children
not up to date on
immunizations that are
contacted by a LHD IZ
coordinator
Decrease the # children lost to Decrease by 25%
follow up on LHD IZ Report
Increase the number of
individuals referred to smoking
cessation services
Increase the # referrals made
to Quitline through the Fax to
Assist service
Increase to 10 referrals within
project period
Increase comfort and
knowledge of comprehensive
women’s health issues – i.e
domestic violence, PPD,
contraception education
Increase the # WIC providers
(in pilot clinics) educated and
trained in comprehensive
women’s health topics
Increase to 100%
- sub measure: positive
change between pre and post
test comfort and knowledge
questions
Increase # lead test referrals
for those identified as not
having a lead test
Increase the # WIC children
- Increase % MA covered
covered by Medicaid that are
children who are lead tested to
identified as not having a lead 80% (MD data – not only
test that are contacted by their WIC))
health care provider
Identifying the point of intervention
EXPLORE/
ASSESS
•Accurate
referrals
given
•Impact
client
motivation
to seek
services
•Quality of
referral
services
IMPROVE
WIC Centers: Montgomery and Prince George’s Counties, MD
Improved Outcomes
% WIC participants
with a referral/
recommendation
that receive the
service
Improved Referrals
IMPROVE
% WIC participants that receive a
complete and quality referral/
recommendation
% WIC Eligibles that Come Into WIC
Center
% MD Population that is WIC
Eligible
EXPLORE/
ASSESS
Process Mapping
• Visual exercise
▫ Increases discussing
• Team involvement
▫ Moving pieces
• Compare current and future states**
▫ Key to improvement hypothesis
▫ Literally highlight problem areas
• Increases engagement
Improvement Hypothesis
Issue/Waste
Improvements/ Test
Proposed
Results Expected
Immunizations
Delayed Children are not being reached by
LHD IZ coordinator
Provide a more comprehensive
report to IZ coord. to ensure
follow-up and contact
Decrease # children that are
lost to follow up AND carried
over to next month’s report
(Immunet Delayed Children
Immunizations report)
Tobacco
Needs improved process that includes
provider initiated follow up on smoking WIC
participants
Directly link each WIC clinic to FTA
database – become provider
Refer to Quitline through Fax to
Assist
Increase # WIC participants
referred to FTA = more tobacco
cessation services accepted.
Family Planning/ Comprehensive Women’s
Health
Low referral rate to FP services
Low WIC staff knowledge of resources and
women’s health issues
Implement evidence based
comprehensive women’s health
training
Increase knowledge of
women’s health services
available as well as how to
identify certain conditions
Lead
High number of MA covered WIC children NOT
lead tested (required in MD)
Gain a better understanding of
county capacity and changes from
new 5-9 guidelines (i.e data
match)
Future state: more developed
lead infrastructure, ready to
take in non-lead tested WIC
children
Test: Fax to Assist
• Baseline:
▫ 0 referrals made to Quitline from Fax to Assist
▫ New resource for WIC clinics
• Evidence based smoking cessation program
• Tests:
▫ Sign up all pilot WIC sites to become providers
 Training included
▫ Make WIC a “How Heard About” field on Quitline
database
• Result: Increase in # WIC participants referred
to smoking cessation services who receive
follow-up
Status of Test Proposed
Test Proposed
Successful If…
Status
Sign all pilot clinics up as Fax
to Assist Providers
WIC pilot clinics become FTA
providers
100% of pilot clinics signed up
to become FTA providers
Add WIC to “How heard about”
field in Quitline database
WIC coordinators send fax
applications to MD Quitline,
increase referrals from baseline
(0)
7 referrals were made from
both CCI and Prince George’s
WIC clinics (As of January 2013
- inception of test 12/1/12)*
(Maryland Tobacco Quitline Monthly
2 client accepted services
4 clients pending
1 client not reached
Services Report, December 2012)
o Identified provider sign up inconsistency
o Identified a data collection/ measurement issue
Extracting Lessons Learned:
Status, Reason, Learning, Direction ™
• Reasons for positive results
▫ No need to buy equipment
▫ FTA is an easy process that works within the WIC
clinic flow
▫ Buy in at the clinic level
▫ Fax to Assist involvement on
Expanded Team
Extracting Lessons Learned:
Status, Reason, Learning, Direction ™
• Reasons for progress prevention:
▫ No standardized process for provider sign up
▫ Measurement inconsistency (i.e. Pending status)
▫ Quitline trainings not monitored by QI team
QI Project: Lessons Learned
• Where we are:
▫ Study/ Act phase
• So far we have learned…
▫
▫
▫
▫
Grant writing process improvement
Scope and size of project
Who is at the table?
Communication, communication,
communication…
Next Steps
• Complete Study:
▫ Comprehensive women’s health training
evaluation
• PHQIX submission
• Develop Act plans for each
▫ Adopt, Adapt, Abandon?
• Close out meeting with Core, Expanded and
WIC clinic teams
COORDINATING AGENCY-WIDE
TOBACCO OUTREACH EFFORTS
Minnesota Department of Health (MDH)
June 2013
Overview
 Problem
 Team
 Plan phase
 Do Phase
 Current project status
 Next steps
 Challenges to date
 Successes to date
Problem
MDH has many divisions housing various
programs and activities to address the
issue of tobacco use and exposure to
second hand smoke.
However, there is not a coordinated
approach among these divisions to work on
tobacco-related issues.
QI Project
Team
 John Olson, Team Leader, Environmental Health
 Dianne Ploetz, Office of Statewide Health Improvement Initiatives
 Scott Smith, Communications Office
 Justine Greene, Environmental Health
 Jen Harvey, Community and Family Health
 Kathy Norlien, Health Promotion and Chronic Disease
 Chelsie Huntley, Facilitator, Office of Performance Improvement
 Stephanie Lenartz, Facilitator, Office of Performance Improvement
 Marni Mason, ASTHO QI Consultant
PDSA Flowchart
Source: Adapted from The ABC’s of the PDSA, Public Health Foundation.
57
Aim Statement
Improve cross-divisional coordination
of tobacco outreach activities by 50%
by September, 2013.
Project Outcome Measures:
 Percent of staff who believe they have the authority to coordinate with others outside of their division or




office.
Percent of staff who have coordinated with another division(s) around tobacco efforts in the past year.
Percent of staff who are satisfied with the level of cross-divisional coordination of tobacco outreach
activities.
Percent of staff who can identify individuals at MDH with tobacco-related expertise outside of their division.
Percent of external partners who know who to contact at MDH for tobacco-related expertise.
Describe Current Process
Collect Data on the Current Process
Used three methods of collecting data and information to
assess coordination:
1. Analyzed the Activities and Materials inventory. Counted
activities and materials. Assessed materials for
duplication.
2. Surveyed 106 MDH staff who were identified by team
members as having tobacco-related responsibilities.
3. Surveyed LPH contacts and tobacco advocacy group
partners.
Services Counts by Division
Source: Activities and Materials Inventory
Activity
EH
CFH
OSHII
HPCD
COM
Total
Provide Technical Assistance
2
9
12
4
1
28
Provide Information
1
2
13
2
1
19
1
5
1
4
11
4
1
Set Strategies Identify Gaps
Distribute Manage Money
2
Provide Training
1
5
Collect Analyze Data
2
2
Promote Events
2
Assure Compliance
7
1
2
6
2
2
2
Develop Materials
2
Provide Referrals
1
Total
7
7
17
41
11
2
1
9
85
Materials Inventory Observations
Of the 40 tobacco-related materials collected:
 Only a few items were duplicates.
 MDH Website Search ‘Tobacco’ = 2810 hits.
 The Tobacco documents/resources are not named in an
easily searchable manner on the website.
 Tobacco Outreach efforts are compartmentalized and
specific for distinct groups of people.
Surveys: Resulting Baseline Measures
 Percent of staff who believe they have the authority to coordinate with
others outside of their division or office (34%)
 Percent of staff who have coordinated with another division(s) around
tobacco efforts in the past year (36%)
 Percent of staff who are satisfied with the level of cross-divisional
coordination of tobacco outreach activities (18%)
 Percent of staff who can identify individuals at MDH with tobacco-
related expertise outside of their division (39%)
 Percent of respondents who know who to contact at MDH for
tobacco-related expertise (53%)
Data Collection Report
MDH Survey: I can identify individuals at MDH with tobacco expertise outside of my division/office.
Response
Chart
Frequency
Count
Strongly agree
8.9%
5
Agree
30.4%
17
Neutral
16.1%
9
Disagree
35.7%
20
Strongly disagree
8.9%
5
Total Responses 56
Conclusion(s):
 The percent of respondents who disagree with knowing who to contact at MDH outside of their division office for
tobacco expertise was 45% which is not acceptable. Only 39% of respondents agree with this statement which is not
acceptable and is an opportunity for improvement.
Identify Opportunities for Improvement
Due to the nature of this broad topic and all the “causes” that surfaced from the
surveys and the activities and material inventory, we first identified
opportunities for improvement – then conducted a root cause analysis of the
opportunity chosen.
Opportunities for Improvement
Lack of demonstrated coordination across MDH and less
than acceptable satisfaction with coordination.
Difficulty in finding resources and materials
Lack of internal and external knowledge of who to contact
for what
Lack of promotion of and support for building internal
staff relationships across divisions
Lack of understanding among partners as to what
technical assistance is
Unacceptable level of overall satisfaction with MDH
tobacco outreach from our partners
Data
Supports
Ability to
Make and
Sustain
Improvements
Degree of
Impact/
Spread
Level of
Control/
Influence
Value/
Meaning
Doable in
Given
Timeframe
Total
Opportunity:
Lack of internal and external knowledge of who to contact for what
Improvement Theories
IF we develop a mechanism for people to collaborate/meet
to foster relationships, we will have better knowledge of the
expertise and resources available for tobacco-related
subject matter.
IF we develop a better staff directory, then it will be easier
to find/identify the right people to collaborate with.
Action Plans
Do Phase – Implement the Improvement
Subgroup A
Test: Mechanism to collaborate
Tobacco Outreach Events: Feb. 7 and May 16
What We Heard
 Staff want a better understanding of what others do.
 There are many potential areas for collaboration: grants,
data sharing, alignment of “plans”, research.
 The majority of attendees would be willing to post their
photos on the Intranet in a directory.
Staff Directory
106 “tobacco outreach” staff
CFH “tobacco” Staff
A
S
TPC Unit
P
D
A P
S D
QI Team
A
S
A P
S D
P
D
Subgroup B
Current Project Status
 Follow-up survey to event attendees to determine
sustainability issues
 Completion of a baseline tobacco staff directory
Next Steps
 Move into the STUDY phase. Analyze data related to
sustaining tobacco outreach events.
 Analyze use of tobacco staff directory.
 Repeat the MDH staff survey to determine improvement
on project metrics.
 Move into the ACT phase.
Challenges to Date
 Managing the project scope
 Engaging all at MDH with tobacco-related responsibilities
 Time commitment for a lengthy project
Successes to Date
 Data, Data, Data
 Dedicated team
 Involvement of stakeholders
 Use of QI tools and consultation
Thank you!
Stephanie Lenartz, MBA, CQIA, SSGB
Quality Improvement Consultant
Minnesota Department of Health
[email protected]
Tel: 651-201-4141