Transcript Slide 1

Creation of a Hybrid Quality Improvement Framework Tailored to the Needs of a
National Breast and Cervical Cancer Screening Program
Stephen D. James, Jr., MPH [1]; Melanie Livet, PhD [1]; Jessica M. Lazenby, JD [1]; Kris Khan, MS, RN [2]; Fred L. McClurg, Jr., MD, MS [3]
[1] SciMetrika, LLC, Research Triangle Park, NC
[2] Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Program Services Branch, Atlanta, GA
[3] The McClurg Group, Carmichael, CA
Background
The National Breast and Cervical Cancer Early Detection Program
(NBCCEDP) of the Centers for Disease Control and Prevention (CDC) is
a program that offers funding to US state, territory, and tribal-level
grantees to provide breast and cervical cancer screening and diagnostic
services to low-income, uninsured, and underserved women. Since its
inception in 1991, the program has served more than 3 million women,
providing more than 7.2 million screening examinations. See
http://www.cdc.gov/cancer/nbccedp/ for more information.
In collaboration with SciMetrika, the NBCCEDP recently undertook a
quality improvement (QI) initiative (The Wellspring Project) to assist
program grantees in identifying and correcting problem areas and
ensuring that current best practices were being utilized in the provision of
program services. As the first step in this larger project, SciMetrika and
CDC developed a new QI framework that can be tailored to the specific
needs of the NBCCEDP. This framework is intended to serve as a
standardized resource and guide for all program grantees in meeting
established CDC benchmarks for quality of service. While many QI efforts
in healthcare have focused on the hospital, inpatient care environment, a
unique aspect of the current effort is the public health, outpatient setting
for which the QI framework was developed, making it one of the first of its
kind.
Methods
Conference calls with QI coordinators: A brief qualitative analysis was
conducted on a document summarizing meeting minutes from regular
conference calls with grantee QI coordinators. These calls involved
discussions of the QI activities of individual grantees, challenges faced in
meeting CDC quality indicators, tools and strategies utilized to meet the
challenges, and grantee success stories.
Literature review: A total of 42 articles were identified and reviewed:
 18 Clinical Microsystems
 10 Lean/Six Sigma
 8 Malcolm Baldrige framework
 3 combination of the above
 3 other QI frameworks
Information was gathered to make a determination regarding the
applicability of each of the reviewed QI frameworks to the NBCCEDP and
its potential for adaptation. Out of the three preselected QI frameworks,
two were chosen to further inform the development of the Wellspring QI
framework (Clinical Microsystems and Malcolm Baldrige).
Figure 1. Flowchart overview of methods
Literature
review
Grantee site
visit
The
Wellspring QI
Framework
and Manual
Grantee site visit: Project team members visited a state-level grantee of
the NBCCEDP to gain a better understanding of the issues and
challenges faced by grantees, supplementing the information collected
during the literature review. Grantees were asked about daily operations,
current QI processes and their origins, problem identification and
subsequent challenges, QI facilitators or barriers, and what QI
tools/methods grantees might find useful.
Results
To inform the new QI framework’s development, the literature was
reviewed to identify QI conceptual models that were applicable to the
needs of the NBCCEDP. Drawing upon this literature review, information
collected during a grantee site visit, and conference calls with grantee QI
coordinators, a hybrid QI framework was created for use by the
NBCCEDP grantees. Grantee input on this framework was sought by
involving the grantees at various points during its development.
QI coordinator
conference
calls
Literature review inclusion criteria: Inclusion criteria included: 1) written
in English; 2) published between January 1997 and November 2007; 3)
research conducted in the US, Great Britain, Australia, New Zealand, or
Canada; 4) peer-reviewed and indexed in the PubMed database; 5)
application of a preselected QI framework (Clinical Microsystems,
Malcolm Baldrige National Quality Program, Lean/Six Sigma) in an
appropriate setting (public health, outpatient, preventive); 6) demonstrated
use or in-depth description of the QI model.
Additional
grantee input
Grantee site visit: Key issues facing the grantee that impact service
quality include: use of non-reimbursable diagnostic procedures, staff
turnover, meeting cervical timeliness benchmarks, static funding despite
increasing costs, and a lack of resources for case management and
provider education. Data reporting, provider monitoring, fiscal tracking,
and use of corrective action plans and performance assessment reports
are common current QA/QI activities. The grantee requested more
communication facilitation between grantees and provision of example QI
models and processes that have worked well for others.
Conference calls with QI coordinators: The QI coordinator meeting
minutes analysis suggested that grantees were employing various QA/QI
measures, including provider audits to monitor clinical and financial
performance, and random chart reviews. Meeting cervical timeliness
benchmarks was a major challenge for a number of grantees. Some
grantees had made efforts to address this issue while others still had not
determined the underlying cause(s).
The Wellspring Quality Framework
Taking these findings into account and drawing upon the Clinical
Microsystems and Malcolm Baldrige National Quality Program models,
the Wellspring project team developed an integrated framework to guide
QI efforts within the public health environment of breast and cervical
cancer screening.
Figure 2. Wellspring Quality Framework Core Areas of Focus:
The Wellspring Quality Framework
Patient
Centered:
Actions take into account
the patient, her
capabilities, perceptions,
and values
Resource
Sensitive:
Actions utilize
program
resources
judiciously to
maximize impact
Evidence-based,
Data Driven:
Actions guided by
continuous
monitoring and
utilization of
performance data
Systems
Oriented:
NBCCEDP
QA/QI
Activities
Actions
impact people,
processes,
and systems
of the
program
Public Health
Mission Focused:
Actions guided by
mission and goals
of the NBCCEDP
The five framework domains as depicted in Figure 2 provide a “blueprint”
for the construction of a locally-developed and user-specific QI strategy. It
is crucially important to consider and address these core areas of focus in
order to enhance the quality of services provided through the NBCCEDP.
Improvements in quality can be realized by identifying and attending to the
QI needs within each domain.
The resulting model is one that is non-prescriptive in terms of process or
tools and it is adaptable to all NBCCEDP grantee programs and the
multiplicity of QI problems that they face. Thus, the QI strategy can be
tailored to the specific environment, needs, and expertise of the user. The
framework has a strong focus on identifying and improving processes and
systems flaws as a means to improve quality in a holistic manner. Within
each of the framework domains, a variety of QI tools can be implemented
to remedy identified problem areas. Essential QI tools such as the PlanDo-Study-Act (PDSA) cycle, flow charting, process mapping, and data
analysis and display apply to each of the framework domains. Additionally,
several QI tools drawn from Clinical Microsystems (e.g., Microsystem
Assessment Tool or Patient Value Compass) and Malcolm Baldrige (e.g.,
Baldrige-based self-assessment), or a number of other, more general QI
tools can also be adapted for use.
As a result of the Wellspring Project, NBCCEDP QI coordinators will be
provided with a QI manual that details the framework and suggests
practical tools and strategies for identifying and solving QI problems. The
use of this hybrid QI framework and its associated tools, which are also
adaptable to other public health settings, will ensure that grantees meet
established quality benchmarks in the provision of program services.
Disclaimer
The findings and conclusions in this report are those of the authors and do
not necessarily represent the official position of the Centers for Disease
Control and Prevention.
Acknowledgements
Discussion
Information gleaned from the literature review and grantee interactions, in
conjunction with the expertise of a QI content expert, informed the
development of a new hybrid QI framework designed specifically to
address the needs of the NBCCEDP, its grantees, and the issues they
face. Two of the three primary QI models included in the literature review
were selected to serve as source frameworks for the new Wellspring QI
framework: Clinical Microsystems and the Malcolm Baldrige National
Quality Program.
Clinical Microsystems focuses on the front line delivery units that provide
services to eligible women, utilizing the QI tools of measurement, and
monitoring and feedback while remaining grounded in systems thinking.
This approach meshes well with the Baldrige organizational performance
criteria which emphasizes the program’s leadership, its strategic
objectives, and the impact these have on patients, providers and
employees. A feature common to both models and also reflected in the
Wellspring QI framework is a strong systems focus.
This project was made possible through CDC contract number 200-2007M-21884 and through the support and input of various individuals. The
authors would especially like to thank Jean Orelien, DrPH and Deborah
McGill, DrPH for their valuable support and input on this project.
Contact information
Stephen James, MPH
SciMetrika, LLC
100 Capitola Drive, Suite 104
Research Triangle Park, NC 27713
919-544-8988
[email protected]
www.scimetrika.com
SciMetrika: “Solutions for the
Advancement of Human
Health”