Transcript Slide 1

Applying Quality Improvement Techniques
to Analyze Problems and Find Solutions
(Session B-2, April 12, 2006)
National Public Health Performance Standards
Program Annual Training
Facilitators:
Stacy Baker & Tiko Lieou
Steps in Performance
Improvement
1. Organize participation for performance
improvement.
2. Prioritize areas for action.
3. Explore “root causes” of performance.
4. Develop and implement improvement plans.
5. Regularly monitor and report progress.
Source: NPHPSP Users’ Guide, 2006
To Carry Out a Quality Improvement
Process, “Plan-Do-Check-Act”
Source: Turning Point Performance Management Collaborative,
From Silos to Systems: Using Performance Management to Improve
the Public’s Health , March 2003.
Act
Plan
Check
Do
To Carry Out a Quality Improvement
Process, “Plan-Do-Check-Act”
Plan
Do
Plan changes aimed at
improvement, matched to
root causes
Carry out changes; try
first on small scale
Check
See if you get the desired
results
Act
Make changes based on
what you learned; spread
success
Act
Plan
Check
Do
See Problem Solving, p. 12
Two Jurisdictions: Same Score, Different Reasons
Low Score on Essential Service 10
(Research for New Insights and Solutions to Health Problems)
Jurisdiction A
Jurisdiction B
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No university or
research institution
nearby
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No leadership support for
research with local
universities
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Don’t know how to
link with research
institutions, despite
leadership interest
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No incentives for
organizations or staff to
identify innovations

No feedback from
management to recognize
staff research
Reasons for
Low Score

Little or no funding
in budgets for
research
Source: NPHPSP Users’ Guide, 2006
Two Jurisdictions: Same Score, Different Reasons
Low Score on Essential Service 10
(Research for New Insights and Solutions to Health Problems)
Potential
Improvement
Actions
Jurisdiction A
Jurisdiction B
 Identify out-of-state
research partners
 Meet with leaders to show
benefits to local priorities
 Access sample
academic-practice
linkage agreements
 Recognition and grant
incentives for innovative
solutions
 Try building 5%
research time into
two large programs,
plus seek in-kind
student/ faculty
assistance
 Prompt manager feedback
on contributions via
employee reviews
Source: NPHPSP Users’ Guide, 2006
Common root causes
of performance problems
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Methods & Procedures
Motivation
Materials & Equipment
People
Information & Feedback
Environment
Policy
Some QI Tools to Help Teams
Analyze Performance
Brainstorming
 Technique to generate many
ideas in a short period of time
 Ideas solicited without
judgment from team members
 Set a high minimum number
(e.g., 15-20) to push beyond
the obvious
IDENTIFY POTENTIAL CAUSES • SORT INTO CATEGORIES
Brainstorming Example
Why doesn’t the state public health system effectively assist
local jurisdictions with epidemiologic investigations?
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State personnel shortages
Limited state staff expertise
Too many hurdles to request help
Slow response to local requests
No process to detect when help may be
needed
 Local staff forget whom to contact
 People don’t know what technical
assistance is available
IDENTIFY POTENTIAL CAUSES • SORT INTO CATEGORIES
Affinity Diagram
Reasons for Reporting Lag
Providers see no
benefit to timeliness
No penalties
Too many steps to identify and
correct missing data
No clear time
standards
No one assigned at
doctor’s offices
Faxes checked
weekly
No follow-up from
health department if
late
Reports sent to wrong
health department
Online form
hard to use
Affinity Diagram
Reasons for Reporting Lag
Incentives/Consequences
Providers see no
benefit to timeliness
No follow-up from
health department if
late
No penalties
People
No one assigned at
doctor’s offices
Information
Methods
Faxes checked
weekly
Too many steps
to identify and
correct missing
data
Reports sent to
wrong health
department
No clear time
standards
Materials
Online form
hard to use
Fishbone Technique
(Cause & Effect Diagram)
Why doesn’t the jurisdiction produce a regular
community health profile?
Motivation/Incentives
No feedback
on reporting
Lack of
participation
from partner
organizations in
data collection
and use of CHP
Staff not
evaluated on
CHP
Poor presentation and
interpretation of data
for community
stakeholders and
partners
Data requests get lost
or slow in reaching
necessary people
Lack of standardized
procedures for reporting
and collecting data
Provider reporting
methods inconsistent for
diseases and events
No QA process for
data reports
Methods/Procedures
No system to
check quality of
data received
No experts or outside
consultants to advise
Lack of expertise
on how to use and
develop CHP
Lack of outreach
and education by
public health
agency
Never see how data
are used in reports
No standardized format for
data presentation
Lack of clear direction
Partners do not
understand
importance of CHP
Low priority in
organizing CHP
Takes time
away from
billable care
Providers do not
care if they report
data in a timely
fashion
Necessary leadership
not involved
No reward for CHP at
state and federal levels
No money
budgeted for
CHP
Complicated
or no IT
system for
reporting
People
Community
partners do not
see themselves
as part of public
health system
Frequent
system errors
Lack of training for
Staff not hiredthe staff about CHP
with expertise
Too many types
of reporting
systems (fax,
email, paper)
Difficult to
generate
information for
health
assessment
Paper forms for
data request too
long
No Regular
Community Health
Profile (CHP)
No Regular
Community
Health Profile
(CHP)
System outdated still uses DOS
platform
Few people
trained to use
the system
Materials/Equipment
Difficult to use
computer system
to enter data for
health
assessment.
Still working with an
incomplete document
template for organizing
into CHP
Health Problem Analysis Worksheet
Direct Contributing
Factors
Risk Factors
Health Priority
aka - NCAA Chart
Indirect Contributing
Factors
Practice Exercise:
Affinity Diagram or
Fishbone Diagram
Check assumptions
about what causes the most,
or the most serious, problems
 Ask those who know best to rank
 Use available data to test hypotheses
 Invest in a short test if needed (check sheet)
Nominal Group Technique
 Helps to prioritize and create
consensus from a list of
potential causes or solutions
 Allows every team member to
rank choices
IDENTIFY WHICH CAUSES TO ADDRESS • GO FOR HIGHEST IMPACT
Nominal Group Technique
Why doesn’t the state public health system effectively
assist local jurisdictions with epidemiologic investigations?
Sonya
Patty
Rashid
Total
Few state
personnel available
3
4
4
11
No process to
detect local needs
2
1
2
5
Slow response
4
3
3
10
Locals don’t know
what assistance is
available
1
2
1
4
4= most
important
cause
1= least
important
cause
IDENTIFY WHICH CAUSES TO ADDRESS • GO FOR HIGHEST IMPACT
Pareto Principle:
20% of sources cause
80% of any problem
80
Reasons for delayed epi.
assistance (2+ days)
Approval
wait
70
Incorrect
contact
60
Reasons
No one assigned
Local refuses help
Wait for approval
Incorrect local contact
Incomplete data
#
3
1
39
5
2
50
Not
assigned
40
30
20
Incomplet
e data
10
Refusal
0
Reason
IDENTIFY WHICH CAUSES TO ADDRESS • GO FOR HIGHEST IMPACT
Flowchart
• Use to check and clarify how
processes work
Start
Process
Step
• Helps to identify breakdowns
and bottlenecks
• Examines relationships
among process steps in
systems
No
Decision
Yes
End
Help Teams Look for Root
Causes and Solutions in…
NPHPSP
Assessment Notes
MAPP or Similar
Community
Initiatives or
Assessments
Reports
Research Findings
NPHPSP Users’ Guide (CDC)
www.cdc.gov/od/ocphp/nphpsp/ToolKit.htm
Memory Jogger II &
Problem Solving Memory Jogger (Goal QPC)
www.goalqpc.com
Public Health Infrastructure
Resource Center (PHF)
www.phf.org/infrastructure/performance
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Searchable QI tools
NPHPSP-related tools
Sample action plans
Publications
Case studies