Doug Taylor and Joe Kyle Office of Performance Management

Implementing an IHI Model Collaborative on Tobacco Use Screening in a state and local health department setting in South Carolina What we did and what we learned Doug Taylor and Joe Kyle Office of Performance Management South Carolina Department of Health and Environmental Control Pam Gillam Center for Healthcare Policy and Research University of South Carolina

Presentation Overview Overview SC DHEC and Health Services Agency Strategic Plan and Priorities Development of Tobacco Cessation Policy IHI Collaborative Model Implementing statewide tobacco cessation policy

SC DHEC Structure 7- Member Board appointed by Governor w/consent of Senate Commissioner selected by the Board Agency is not part of the Governor’s Cabinet Four Deputy Areas Centralized system/Vertically Integrated State HD/Central Office 8 Regions No local BOHs

SC DHEC’s 8 Public Health Regions

Health Services Largest Deputy Area in DHEC 2.662 FTE’s statewide in 8 Public Health Regions with local health departments in all 46 counties and over 90 service delivery sites Major areas of responsibilities include CDC/HRSA programs Diverse team of health and environmental professionals to include: Nurses, administrators, physicians, epidemiologists, nutritionists, pharmacists, administrative support, laboratory specialists, health educators, and social workers

General Role of Central Office and Role of Regions Central Office (State) Level State level Health Improvement Obtaining Resources Development of Policies, Regulations, etc Program Guidance & Oversight Subject Matter Expertise – Consultations (public & private sector) State, Federal and National relationships, partnerships Region (Local) Level Community level Health Improvement Direct Service Delivery Implementation of Policies Region and local relationships, partnerships

Agency Priorities SC DHEC’s Strategic Plan 2005-2010 5 Broad Goals 24 Strategic Goals 88 Objectives Each Deputy Area monitors their Objectives through performance measures Since 2007 all Deputy Areas began presenting performance related data to DHEC’s Executive Management Team

DHEC Strategic Plan Goal 2:Improve the quality and years of healthy life for all Strategic Goal 2-A:Promote healthy behaviors Tobacco Related Objectives 2-A-1:Develop effective state and local partnerships to promote healthy behaviors including good nutrition, physical activity and tobacco use cessation. 2-A-3:Implement interventions to prevent tobacco use, promote cessation and reduce exposure to secondhand smoke. 2-A-4:Collaborate with public and private partners to develop and implement statewide prevention plans targeting diabetes, cardiovascular health, cancer, injury, tobacco, obesity or associated risk factors.

Priority Performance Measure DHEC Health Services will adopt policy to implement the Public Health Service Guideline (2As+R) for tobacco use and dependence with all of its clinical clients.

Tobacco Cessation Policy Development Timeline HS Management Retreat prioritized Tobacco (and Tobacco Use Screening) as a public health issue (Jan 07) Original draft policy developed in 2007 The updated Clinical Practice Guidelines were released from the Federal Government in May 2008 Tobacco Prevention and Control staff updated draft policy and submitted to DHEC’s Manual Oversight Committee for review and approval (summer 2008) Policy deployment then delayed until Tobacco Collaborative results were in, since results would affect policy content and deployment strategies After Collaborative, policy approved in November 2009 with an official implementation date of July 1, 2010 (1st time this way) State level team organized to support implementation of policy

SCDHEC’s Use ofthe IHI’s Breakthrough Collaborative for Tobacco Cessation Pamela S. Gillam, MPA Center for Health Services & Policy Research Arnold School of Public Health University of South Carolina

Presentation Objectives • To recognize the key components/phases of the IHI Breakthrough Series as a quality improvement methodology • Understand how SCDHEC adapted the IHI Breakthrough Series model to work in its environment

What is the IHI Breakthrough Series? IHI’s Breakthrough Series (BTS) is an improvement method that relies on spread and adaptation of existing knowledge to multiple settings to accomplish a common aim.

IHI Breakthrough Series(6 to 18 months time frame) Select Topic (develop mission) Participants (10-100 teams) Prework Dissemination Publications, Congress. etc. P Develop Framework & Changes P P A D A D A D Expert Meeting S S S LS 1 LS 2 LS 3 Holding the Gains Planning Group AP1 AP2 AP3* Supports Email (listserv) Phone Conferences Visits Assessments Monthly Team Reports *AP3 –continue reporting data as needed to document success LS – Learning Session AP – Action Period

IHI Goals for a BTS • Achieve results • Accelerate improvement– get results faster! • Define, document, and disseminate good ideas • Build clinical and public health leaders of change

The IHI Breakthrough Series is NOT: • Research for new clinical knowledge • Single-setting (single team) focus • Small changes to existing systems • A benchmarking project • A consulting engagement

IHI BTS- 5 Phases • Phase 1- Topic Section- General • Phase 2- Topic Selection- Development and Expert Meeting • Phase 3- Prework • Phase 4- Learning Sessions and Action Periods • Phase 5- Holding the Gains and Spread

IHI Breakthrough Series Phase 1: Topic Selection

DHEC Tobacco CollaborativeNovember 2008 - June 2009 Select Topic (develop mission) Participants (7 teams) Prework Dissemination Publications, Congress. etc. P Develop Framework & Changes P P A D A D A D Expert Meeting S S S LS 1 LS 2 LS 3 Holding the Gains/ Spread Planning Group AP1 AP2 Supports Email (listserv) Monthly Phone Calls TA Visits Monthly Team Reports LS – Learning Session AP – Action Period

Topic Selection for TCC • There is a gap between science (evidence) and practice; 2A+R identified as EBP;DHEC not doing it. • Examples of better performance exists; Other states using it. • A good “Business Case” exists for the topic; Seen as priority in 2 Regions participating in MLC3.

Adaptation of Phase 1: Topic Selection

IHI Breakthrough Series Phase 2: Topic Development And Expert Meeting

In this step, Experts are Identified • Experts are knowledgeable in the subject matter/QI • Some experts are chosen to be Collaborative Faculty For TCC, faculty were staff from Division of Tobacco Control and Prevention/Office of Performance Mgmt/USC/Regional Leadership

Experts Develop the Following: • Collaborative Charter, that includes— • Change Package- 12 Changes in TCC Change Package • Measurement Strategy- Primary Measures used- # of smokers, # who accept referral, amount of time to implement intervention

Adaptation of Phase 2: Topic Development and Expert Meeting

IHI Breakthrough Series Phase 3: Prework

Prework For Planning Group For Collaborative Teams Develop TCC teams Discuss aims and focus work Engage the senior leader Initiate measurement and other information gathering Begin development of storyboard • Develop materials- TCC change package, Prework materials • Present to Region leadership on TCC • Assist regions in developing teams • Plan LS1

TCC Teams Region 4 Region 8 Beaufort Family Planning Hampton Family Planning Jasper WIC Colleton WIC • Lake City Family Planning • Darlington WIC • Sumter WIC

Adaptation of Phase 3: Prework

IHI Breakthrough Series Phase 4: Learning Sessions and Action Periods

Learning Session Objectives Learning Session 1 Get Ideas Get Methods Get Started Learning Session 2 Get More Ideas Get Better at Methods Get a “Stride” Learning Session 3 Celebrate Successes Get ready to Sustain and Spread Test all changes on small scale Test & implement all changes Action Period 1 Action Period 2

Learning Session Objectives • Learn and “get” the Change Package • Learn method for accelerating improvement (PDSA) • Get connected to colleagues • Make solid plans for taking action quickly

TCC LS1 Agenda DAY 1 DAY 2 Orientation to The Model for Improvement/PDSA Measurement and Reporting Team Meeting time Next Steps (Action Period 1) • Introduction to IHI BTS process • Review of Collaborative’s mission and goals • Intro of 2As + R • Intro of Change Package • Training in 2As + R • Intro to QI • Team Meeting time

Model forImprovement What are we trying to accomplish? AIM How will we know that a change is an improvement? MEASURE What change can we make that will result in improvement? CHANGES Plan Act Study Do From: Associates in Process Improvement

Sumter County HD AIM 1: By the end of the collaborative, 100% of Prenatal/Post-Partum WIC clients and Sumter Co. HD will receive the 2As + R. AIM 2: 25% of Tobacco Users will accept referral to Quitline.

Sumter County HD MEASURES: • Length of Client Visit– 1:1 time with NES • Average length of time to implement 2As + R with clients • Client Tobacco Use Rate • % of WIC PN, PP, BF clients who receive 2As + R with fidelity • % of tobacco users accepting referral to the Quitline

Sumter County HD CHANGES: (taken from change package) • IB. Include tobacco use as a vital sign. • IC. Ask patients if they use tobacco and document tobacco-use status on a regular basis. • ID./IVB. Designate staff/clinicians to implement the 2 A’s and R.

Sumter County HD CHANGES: (taken from change package) • IIA. Implement a tobacco-user identification system. • IIC./IIIB. Track the degree to which clinicians are identifying, documenting and treating patients who use tobacco and provide feedback to staff/clinicians about their performance. • IVA. Have tobacco cessation materials and other information in every exam room or room in which clients are seen.

Hampton County HD PDSA Cycle PLAN PHASE (of PDSA) WHO: Support Staff will be provided the necessary posters and cards for the Quitline WHAT: Material placement and distribution of a set number of materials which will be counted at the beginning and the difference tabulated at the end of the PDSA cycle for the number of cards and the tear off on the posters WHEN: Starting on December 15, 2008 and continuing through December 19, 2008 WHERE: In Health Departments clinic waiting room(s) and exam rooms

Action Period Objectives • Support teams in their improvement work • Build collaboration and shared learning • Assess collaboration and progress This is the time of maximal learning AND WHERE THE REAL ACTION IS!

Adaptation of Phase 4: Learning Sessions and Action Periods

IHI Breakthrough Series 5th Phase: Holding the Gains and SPREAD

Holding the Gains and Spread Holding the Gains-- Continued tracking of improvements Spread-- Adapting change to areas or populations other than your pilot populations Part of the BTS Design!

For TCC, Thinking about Spread Important • 2 As + R was going to become a DHEC policy • Promising practices for implementing 2As + R in WIC and Family Planning • Talked about Spread in LS1 and LS2

Beaufort County HD2A+R SpreadTraining Plan • WFD Coordinator presents @ site meetings • Ice Breaker • Policy • Power Point Presentation • Current Tobacco Cessation Programs • Smoking Prevalence & Disease Connection • Impact of Quitting & Success of Cessation Programs • 2A’s+R Protocol • Role Plays

Beaufort County HD Spread

Doug Taylor and Joe Kyle Office of Performance Management