Rapid Cycle Quality Improvement: Lessons from a Lead Poisoning Prevention Program Deanna Durica, MPH ddurica@cookcounty

1. Rapid Cycle Quality Improvement: Lessons from a Lead Poisoning Prevention Program Deanna Durica, MPH ddurica@cookcountyhhs.org

2. Quality Improvement (QI) • Deliberate and defined improvement process • Focused on activities that are responsive to community needs and improving population health • Continuous and ongoing effort • Measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes • Achieve equity and improve the health of the community • Plan-Do-Study-Act (Riley, Moran, Corso, Beitsch, Bialek, and Cofsky. Defining Quality Improvement in Public Health. Journal of Public Health Management and Practice. January/February 2010).

3. Why QI? • Augment teamwork • Boost morale • Cut costs • Enhance customer satisfaction • Get better results • Improve work flow • Increase accountability • Meet accreditation standards • Promote healthier people and communities

4. Turning Point performance management model 2 1 Source: Silos to Systems: Using Performance Management to Improve the Public’s Health. Turning Point Performance Management National Excellence Collaborative: Seattle WA; Turning Point National Program, 2003. 4 3

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

6. Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook Plan Do Study

7. CCDPH: Context • Cook County Department of Public Health Jurisdiction • 125 municipalities • 30 townships • unincorporated areas • 4 CCDPH Districts • 700 sq miles • 4 other state certified LHDs • SCC Childhood Lead Poisoning • ~200 reported Elevated Blood Lead (EBLs) per year • 15 IDPH/CC designated ‘high risk” communities

8. CCDPH Lead Poisoning Prevention Program: Three Units – One Goal • Prevention Services Unit • Lead Poisoning Prevention and Healthy Homes Unit • Referrals for services, policy and outreach, coordination of QI, data, some client follow-up, remediation funding and client applications • Integrated Health Support Services • Public health nurses visit families – health and nutrition information, case management, developmental screening • Environmental Health Services • Lead Inspectors visit families to inspect home and identify housing-based lead hazards, remediation coordination with renovators and families

9. Step 1: Getting Started • Identify a problem or opportunity • Hx of issues w/ coordination/cohesion • Lack of data on program activities • Little cross-unit knowledge of actions • Secure sponsorship • Support of key leadership essential • Prevention Services (Lead Poisoning) • Nursing Director/Assistant Director • Chief Medical Director/ Environmental Health • Plan

10. Step 2: Assemble the Team • Initial Process - Began in Feb 2011 • Initial meetings – key agency leaders/ managers/selected staff involved in LPP • Expanded meetings to involve all LPP staff ~20 staff • Purpose: • Instruct on QI /Rapid Cycle methodology • Examine current processes • Identify areas for change • Develop an AIM statement • Plan

11. Lead QI AIM • We will work together to improve the quality of the lead case management process in order to: • More effectively act to intervene on exposures (process) • Identify and prevent sources of lead exposure. (population)

12. Step 3: Examine the Current Approach • Create a process map  • Collect information to understand the current approach • Identify the root cause • Useful Conceptual Tools • Affinity Diagram • Cause and Effect Diagram • 5 Whys • Brainstorming • Plan

14. Important - Check for Completeness • Are ALL the process steps identified clearly? • Make sure each detailed step is included • Validate the flowchart with those who carry out steps in process • Are the symbols used correctly? • Check to see if there is only one output arrow from an activity box. If there is more than one arrow, you may need a decision diamond.

15. Process Map Use – Questions ??? • Who is involved in the process and when? • What activities are being performed • When and where is the activity performed? • How many steps: • Directly produce the service? • Are absolutely necessary/are redundant? • How many decision points are there? • Are they ways to increase the efficiency of the process? • What are opportunities for improvement?

16. Process Mapping: Value • All team members were clear about the current process (at the same time) • Steps were reflected actual practice vs. written procedures • Key steps/trigger points/vulnerabilities were identified • Potential areas for improvement/ measurement • Builds enthusiasm/shared commitment

17. Process Mapping Result: Key “Problems” Identified Lack of population/prevention focus Issue 1 : Lack of overall (team) case management • ID’ed through analyzing the steps – what was there Issue 2: Lack of population/prevention focus • ID’ed through analyzing the steps – what was missing Solution: Applied tools to “delve” into the problem(s) – Root Cause /Cause Effect analysis • Fishbone Diagram • 5 Whys

18. Fishbone Diagram • Why Use It? • To allow a team to identify, explore and graphically display underlying causes related to a problem • What Does it Do? • Enable a team to focus on the content of the problem - not history or personal issues with problem • Creates a snapshot of the collective knowledge and consensus of a team around a problem. • Looks at causes, NOT symptoms - results of the problem

19. Organize on Fishbone • Main problem is the head of your fish • Major causes go on the fish spines • Examples of headers: • People, Plant, Procedures, Policies • Manpower, Machinery, Materials, Methods • Admin, HR, Finance, Operations, Procurement • Lifestyle, Environment, Forms

20. Identify “sub-causes” • Technique: Use the 5 whys • Ask “Why?” up to “5 times” (or until unable to go lower) related to the problem • Drill down to root causes • Identify related causes and roots of those causes

21. Selecting an Area for Improvement • Examine root cause analysis • Choose the items you want to focus on • Looks for causes that repeat within the major categories • Choose causes that the team can control or influence • Best if selected through consensus • May/should have evidence to support choice

22. Step Four: Identify Potential Solutions • Key questions: • What will the future look like if your problem is addressed? • What will your problem look like if your ‘cause’ is addressed • How will you make this change? • For selected solutions Ask “How” (not Why?) • How will you get there? • How will you measure progress? that you’ve ‘arrived’? • What data will you need to collect and how? • Develop SMART objectives • Plan

23. What did we figure out? Process map and Fishbone helped us to Identify opportunities for change: • Problem – There are significant gaps in communication • Consensus – We need tools to improve communication. Even if that means more work on the front end, it will help in the long run. • Problem – Different staff make separate visits to the same clients about the same issue • Consensus - We need to figure out a way to visit the client together. • Problem – We know what we should be doing it, but we don’t know if we’re actually doing it. • Consensus – We need to measure how well we’re doing our jobs to build value for our program. How will we know we’ve improved the process? Need measures… presumes that we have data and communication (fundamental)

24. What will we change first? • Consensus decision 1: Improve communication through making client data available to all • How? All case data to be entered into a Unified Lead Case Summary sheet (ULCS) by each unit. • PDSA approach – Monthly analysis of the ULCS data in a Case Conference Meeting.

25. What else can we change? • Consensus decision 2: Joint visits for clients will enhance service provision and increase client satisfaction. • How? Established communication protocol for public health nurses and inspectors so that both staff can schedule and attend the client visit together. • PDSA approach? Monthly checks – # of successful joint visits vs. # of possible joint visits

26. And a little more change (but that’s enough for now) • Consensus decision 3– we need to measure how well we’re doing our jobs to build value for our program. • How? Establish benchmarks based on present program protocols. • PDSA approach? Monthly analysis of benchmarks at our Case Conference meetings. Are we doing what our protocols say we do? • But if we need to change anything else, um, maybe, let’s think about that a little bit…

27. Benchmarks

28. Step 5: Development of an Improvement Theory • Predict the relationship between the problem and the solution • Use an “If…then…” statement • If we implement this solution…. • Then this will happen to the problem… • If we establish a communication protocol, we’ll be able to provide joint visits to all of our clients. • Plan

29. Step 6: Test the Theory • What: Ensure that nursing staff is informed of scheduled visit date and make a joint visit • How: Emails • To whom: nurses and nursing supervisors • Carry out the plan • Document problems and unexpected observations • Does our communication protocol mean that we actually make the joint visits? Document on the UCLS spreadsheet

30. Step 7: Study the Results Primary purpose is to determine if the test – from Step 6 - was successful • Compare results with the AIM statement/ consensus decisions • Do the results match? Lead Program tools for reflecting on the analysis: • Monthly Lead Management team and Case Conference meetings (rapid! – not waiting for a lot of data) • Evaluate the benchmarks and the actions taken • Share the data • Facilitate the discussion • Study

31. Indicator close-up: Joint Visits • 100% of EBL children with levels 20 or greater will receive a joint home visit • Data helped us to improve services to clients • Data helped us to EXPAND services

32. Step 8: Standardize the Improvement or Develop a New Theory Was there an Improvement? YES NO Implement changes on a larger scale • Act Develop a new theory and test it

33. Step 9: Establish Future Plans • Act to sustain your accomplishments • Change processes • Change policies • Communicate the results with customers, stakeholders • Continue PDSA cycles and regularly review performance data • Plan more improvement projects • Act

34. Adapt and even… Evolve • Could see the #s of kids served • Could see the work load • Could see our way to new services The data changed “We already have too much to do!” to “We can do that!”

35. QI resulted in EXPANDED services Original indicator: 100% of EBL children with levels 20 or greater will receive a joint home visit REVISED indicator: 100% of children meeting the following criteria will receive a joint visit: • Children 0-36 months at any EBL • Children 37 months and older at EBLs of 20 and greater

36. Process and People “I don’t want to get dinged.” • Trust building • Facilitation skills • Meeting planning • Shared purpose and explicit roles and expectations “Communication is so much better!”

37. Questions and Discussion

38. References Hatry HP. Public and private agencies need to manage for results, not just measure them. Retrieved from http:www.urban.org/url.cfm?ID=900731&renderforprint=1 on October 26, 2012. Mason M. Quality Improvement Principles Methods and Tools. Riley WJ, Moran JW, Corso LC et al. Defining quality improvement in public health. J Public Health Management Practice, 2010, 16(1), 5-7. Tews DS, Heany J, Jones J et al. Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook. 2nd Edition. US Department of Health and Human Services. Consensus statement on quality in the public health system. Available at http://www.hhs.gov/ash/initiatives/quality/quality/phqf-consensus-statement.pdf