Quality Improvement in the Local Health Department “Get Better at Getting Better”

1. Quality Improvement in the Local Health Department“Get Better at Getting Better” Kristen Wenrich, MPH, CPH Bethlehem Health Bureau

2. Snapshot of Bethlehem • Bethlehem is a city in Eastern Pennsylvania (60 miles north of Philadelphia) and is part of the larger Lehigh Valley • Population of 73,000 • Hispanic Population: 18.2% • The Health Department employs 30 staff • The Health Department is one of 10 county/municipal health departments in Pennsylvania

3. What is Continuous Quality Improvement? Continuous Improvement is about: • Changing and improving existing work processes and services to make them better • Engaging people who are doing the job in improving the job • Creating focus by finding and targeting key work processes and areas for improvement • Helping us learn from solving problems • Doing these at a rate greater than ever before

4. It Is Not Just Today… Creating an environment where each individual is an agent of change… focused, engaged, able to see the waste in any work processes and armed with techniques to eliminate it

5. History of QI in the City of Bethlehem • Partnership between the City of Bethlehem and Air Products • Upper Management-First Round of Trainings • Mayor created a Continuous Quality Improvement Team • Action Plans created for each department • The Team began running QI “events” in the fall of 2007. • Health Bureau received NACCHO grant in 2008 which served as an impetus to focus on QI and dedicate a staff person to the initiative.

6. “CI In the City” • City-Wide Engagement • All Bureaus and Departments • Activity and Results • Permitting process cycle time • Purchasing transaction and cost reduction • Citizen Feedback System improvements • Vehicle maintenance turnaround cycle time • Office Layout improvements for efficiency and citizen satisfaction • Graffiti removal System • Fire hydrant management • Police shift changeover communication improvement • Water and Sewer process improvements • Oil and grease reduction program

7. Why Quality Improvement? • Stronger programs and services will ultimately enable health departments to better protect, promote, and preserve health in the communities they serve. • Improve employee morale • Provide better, more efficient services to residents and taxpayers. • QI can improve performance to meet accreditation standards.

8. QI: Ingredients for Success • Strong partnership between local Fortune 500 company and the City-two organizations working together to improve their community • Support from leadership to drive the initiative and accountability • Dedicated staff person representing the Health Department who is trained in a variety of tools to facilitate QI events • Employees who are involved, engaged, teamed, and capable. • List of key target areas for improvement

9. Key QI Positions • Organizational Champion (Mayor) - Provides focus and leadership for quality improvement effort. • QI Manager (Health Director) - “Senior Organization” champion in an organization; drives improvement plans with Leadership team members by providing leadership and focus in quality improvement. • QI Leadership Team (Program Managers) - Lead improvement efforts within the scope of the Health Department • QI Tool Facilitator - Prepares for and leads the application of tools to accomplish a specific improvement within the organization.

10. “Seeing” and eliminating non value added…in any process, anywhere Forms of Waste • Motion • Waiting • Interruptions • Searching • Inspection • Defects and variation • Setup • Inventory • Unnecessary processing • Methods that do not meet the community’s needs Waste Anything that adds cost without adding value Value Activities the community is willing to pay for Changes the product, service, and information Done right the first time ..\CI\forms of waste.doc

11. Quality Improvement Tools Reliable methods used to identify and eliminate “waste” in any work process and create results. • Root Cause Analysis-Problem solving technique to frame a problem, identify issues, determine root causes, identify solutions, and track progress. • Mapping-Graphically displaying the steps in a process and identifying value-added and non-value-added work. • Process Kaizen- A focused, high-energy, team-based approach for eliminating waste in a discrete work process. Embodies several other tools. • Mistake Proofing-Controlling a process in order to minimize the occurrence and effects of human error. • 5 S- Making a safe, clean, neat, and efficient arrangement of the workplace which most effectively enables the work performed there.

12. Health Department QI Events • Restaurant Permitting Process • Data Collection Procedures • Public Health Emergency Call Center • Grant Rejections • Citation Process for garbage, weeds, complaints • Paper Reduction • Rapid HIV Testing in Prison

14. Data Collection Event • Conducted self-assessment to determine areas of weakness • Identified data collection as a target for improvement • Interviewed staff to determine areas of weakness in regard to data collection (19 issues identified) • Conducted a root cause analysis on identified issues • Data collected manually • Entering same data into multiple databases • Not sharing data with other program areas • Data is not analyzed on a regular basis • Roles and responsibilities regarding data collection unclear • Staff training on Excel, Access, SPSS • Developed a process for data collection during a 3-day mapping event.

15. Data Collection Event • Piloted process in 4 program areas • Modified process based on pilot • Rolled out the process Department-wide • Constantly refining the process

16. Data Collection Results • A reliable process for data collection has been created and documented and is in active use in all program areas • Survey/assessment tools are piloted prior to distribution • Training plan created for staff-SPSS, Excel • Central point person identified for data collection • All data is entered into a database • Collect data directly from computer when possible • Data sharing between program areas • Standard demographic data collected for all program areas

17. Data Collection Event Results

18. Lessons Learned • Expect resistance • Begin by tackling issues/problems that frustrate staff the most to obtain buy-in • Involve the entire staff • Always keep QI on the forefront, i.e. staff and manager meetings • Communicate results-reinforce that the change has made a difference

19. Sustainability • Dedicated resource to facilitate and implement QI initiative • Buy-in and support from administration • Build quality improvement into the organization’s culture • QI is an agenda item at every manager/staff meeting • Every staff member engaged in the process • QI is included in the Health Department’s yearly program plans • Each program area must identify at least 1 QI goal annually

20. Path Forward:Developing the 2010 QI Plan • Continuing to improve our ability to target the most important areas impacting local health • “Voice of the Citizen” needs assessment and Quality Function Deployment evaluation • Use health data and sigma evaluation to identify top programs that impact macro health outcomes • Continuing to improve our efficiency of execution • Kaizen our processes for faster program impact, less waste • Enhance our ability to measure progress and drive learning • Continuing to improve our capacity • Abilities to solve problems, deploy solutions, serve the Community

21. The Future of QI in the Health Department • Continue to train Health Department staff • Continue to identify areas to target for QI • Collaborate with community partners to institute QI • Prepare for Accreditation

22. Quality Improvement:Can We Build It? Yes, We Can!

23. Agenda We have lots to talk about, team! • Describe QI Initiative at Tacoma-Pierce County Health Dept • How it got started • QI infrastructure • QI projects • Performance measures • QI training • Share Lessons Learned by the Builders • How to start • Building & sustaining culture change • Turning the spotlight on yourself

24. QI Initiative at the Tacoma-Pierce County Health Dept OK, team. Let’s see what we can build!

25. Lesson Find out what motivates your boss/you and play up that aspect of QI Competition Data Budget Efficiency

26. Quality Improvement Council Horizontal representation Senior management Led by Director Assessment staff = coordinator Mission To improve the health of Pierce County by ensuring efficient and effective processes and programs through on-going review of performance measurements.

27. Lesson Maximize your efforts by starting “big” QI and “little” QI at the same time Take the time to build the infrastructure; it will save you time later Start small with individual QI projects Build success and change your culture one QI project at a time

28. QI Plan and Evaluation Annual QI plan Lists major activities Includes calendar Identifies persons responsible & time lines Annual evaluation of QI plan Evaluates QI Council meetings Analyzes performance measure data Examines completion rate of QI plan activities These are the building blocks of a good QI program.

29. Outline of QI Plan Scope and structure Mission and scope Organizational structure Dedicated resources Roles and responsibilities Approval of QI plan and evaluation QI activities RCI projects TPCHD performance measures Projects at the request of the director Program evaluation reports Review of health indicators Review of after action reports Public health standards review Training and recognition • QI Council calendar • Staff responsible • Completion date • QI Council review date • Additional review dates

30. Lesson Borrow, copy and plaguerize Public health exemplary practices Other health care sectors Wildly different industries

31. QI Calendar

32. Evaluation of QI Plan Seven components Results of performance measures Impact of improvement actions from QI projects Results of program evaluation reports Results from health indicator process Completion rate of activities in QI Council calendar Evaluation of QI Council meetings by its members Qualitative evaluation of function of and resources allocated to the QI initiative. Quantitative and qualitative components We need to examine our progress!

33. Lesson Culture change is difficult, REALLY difficult Leaders’ words and actions will be scrutinized Very important to create “safe” environment to learn from mistakes Active listening is key (may seem silly, but . . . )

34. QI Projects: RCI Rapid cycle improvement projects Missing race/ethnicity data on STD case reports On-site septic system inspections Internal process for purchasing of goods Internal process for requesting maintenance services Solid waste complaint response process

35. Lesson Hire a great consultant/trainer Quality organizations’ consultant lists RWJF evaluator list for QI grant Recommendations from folks here

36. QI Projects: Health Indicators Indicators, indicators EVERYWHERE! Focused on indicators that were: Significantly worse than state average Trend getting significantly worse Chlamydia Low birth weight Adult Obesity

37. QI Projects: Public Health Standards Based on 2008 Washington State Standards for Public Health site review results Human Resources policies and procedures “Closing the loop” Sharing data with communities Two QI teams Will re-measure in 2011

38. Performance Measures Twelve department-level measures Modeled after Healthy People 2010 Leading Health Indicators . . . plus two more. Approx. 10-20 performance measures per business unit Percent of solid waste complaints responded to within 20 days. Reduce the rate of positivity at Infertility Prevention Project (IPP) sites.

39. Departmental Performance Measures

40. Lesson Don’t try to take on the world during your first year (or two) Take baby steps and be okay with it Recognize that QI takes resources—acknowledge it vs. hide it Identify what is crucial to measure and only measure that Be redundant with other project/grant outcomes

41. Lesson Moving to a QI culture takes top-down and bottom-up efforts (but top-down is more important) When division director hadn’t bought in, worked with lead staff and Director/Deputy Director Find high level champions and praise their efforts Make QI easier for directors and staff to do

42. Program Evaluation Menu labeling Maternal/child home visiting Tobacco control Cross cultural collaborative I love program evaluation almost as much as making pizzas!

43. QI Training & Tools I have what I need for the work I need to do. • Just-in-time training for QI project teams • Performance measures training • QI Council training on QI concepts • QI concepts staff can use in daily work

44. TPCHD’s QI Resources Staff .5 FTE (two main staff) in assessment Additional time from program staff Budget Consultant/trainer fees Books and materials ASQ membership With this crew, it’s “no prob, Bob!”

45. Lesson Take the time to read The Quality Toolbox (Tague. ASQ) The Improvement Guide (Langley, Nolan, Nolan, Norman & Provost. Jossey-Bass) The Public Health QI Handbook (Bialek, Duffy & Moran. ASQ) Journal of Public Health Management and Practice, Jan/Feb 2010

46. Lessons Learned by the Builders QI

47. How to Start Must have director and other senior management leading the initiative. Use your assessment staff. Start small; get people excited about a single project. Remember more is not better. That’s brilliant!

48. Building/Sustaining Culture Change Critical to make data/reporting meaningful to staff Resource levels decline for some projects after first attempt (health indicators & performance measures) Staff need lots of practice/training Celebration of successes is important Quality planning is more appropriate than QI for some projects with long-term outcomes.

49. Turning the Spotlight on Yourself Don’t be afraid to evaluate your own QI program. Take credit when good things happen. Don’t get defensive if things don’t go as planned.

50. Results of QI Initiative Most performance measures at department- and business unit-level achieved their stated target. Improvements sustained for RCI/QI projects. Health indicator projects met 100% of annual performance measures. Funding & staffing for QI has increased. Well done, team!