Introduction to Local Health Department Accreditation and Quality Improvement

1. Introduction to Local Health Department Accreditation and Quality Improvement Erin Mowlds, Program Manager for Local Accreditation Local Accreditation Webinar Series Coalition of Local Health Officials

2. Purpose & Objectives • Overview of basic accreditation concepts • Discuss the value of accreditation • Process for LHDs to become accredited • Why now? • Training and Funding Resources • Overview of basic Quality Improvement (QI) concepts • Discuss the benefits of QI • Helpful QI Resources • Answer Questions • Discuss Next Steps

3. What is accreditation? Public health department accreditation is defined as the development of a set of standards, a process to measure health department performance against those standards, and reward or recognition for those health departments who meet the standards. • A set of standards that assure high quality services, accountability and efficiency. • Consistent standards combined with strong accreditation process helps the entire public health system do better. • Most other government entities already go through accreditation

4. Public Health Accreditation Board (PHAB) • Non-profit entity formed to implement and oversee national public health department accreditation • Beta Test: Deschutes County • PHAB works to promote and protect the health of the public by advancing the quality and performance of public health departments in the United States through national public health department accreditation.

5. Why Accreditation? • Identify performance improvement opportunities • Improve management • Develop leadership • Improve relationships with the community. • Encourage and stimulate quality and performance improvement in the health department • Stimulate greater accountability and transparency.

6. October 12, 2011 - Public health can play a large role in reforming Oregon’s healthcare system, Mike Bonetto, health policy advisor to Governor Kitzhaber, told officials at Oregon’s Public Health Association’s annual conference. “….You have the expertise where no one else does,” especially in terms of equity, “ he said.” “….However, there’s a lack of communication and integration between public health and the rest of the healthcare system that results in public health playing a much smaller role than it could …”

7. Benefits of Accreditation • Credibility, transparency, and accountability • Recognition of high performing health departments • Framework for effective planning • Culture of quality and performance improvement • Access to resources for improvement • Public health services aimed at improving health outcomes

8. Accreditation & the Work You Are Already Doing • 10 Essential Services of Public Health • Important messaging frame • Recognition for the work you are already doing • Shows what public health does • Minimum Standards

9. 10 Essential Services & 12 Domains

10. DOMAIN Domain Structure • Standard: required achievement • Measure: level required to meet standard • Documentation: shows the achievement www.phaboard.org

11. PHAB Standard Example

12. Preparing for Accreditation • Engage leadership and staff • Conduct a self-assessment • LHD positioned to focus on the Standards and Measures • Develop a plan to address weaknesses • Develop QI plan • Consider costs and payment plan • Assign Accreditation Coordinator • Create accreditation team • Complete the PHAB Readiness Checklist • Complete online orientation • Start prerequisites • Start collecting documentation

13. Accreditation Prerequisites • Community Health Assessment (CHA) • Community Health Improvement Plan (CHIP) • Agency Strategic Plan (SP)

14. Community Health Assessment (CHA) • Health status of the population, identify areas for health improvement, determine factors that contribute to health issues, and identify assets and resources that can be mobilized to address population health improvement. • Collaborative process of collecting and analyzing data and information for use in educating and mobilizing communities, developing priorities, garnering resources, and planning actions to improve the population’s health.

15. Community Health Improvement Plan (CHIP) • Long-term, systematic plan to address issues identified in the CHA. • Describe how the health department and the community it serves will work together to improve the health of the population of the jurisdiction that the health department serves (more comprehensive than the roles and responsibilities of the health department alone). • Community-driven, participatory planning process, stakeholder involvement.

16. Strategic Plan (SP) • Process for defining and determining an organization’s roles, priorities, and direction over three to five years. • Sets forth what an organization plans to achieve, how it will achieve it, and how it will know if it has achieved it. • Provides a guide for making decisions on allocating resources and on taking action to pursue strategies and priorities. • Focuses on the entire health department. Health department programs may have program-specific strategic plans that complement and support the health department’s organizational strategic plan.

17. 7 Steps to Accreditation

18. Why Now? • Training & TA resources available to counties • Grant opportunities • Potential to become more competitive applicant for other funding opportunities • Potential for a stronger voice at the table in CCO conversations • Important to show what PH does as all these transitions occur. • Important to focus on efficiency and quality improvement in current economic environment.

19. Other issues to consider • CCOs and CHAs • Hospital IRS Benefit CHA requirement • Minimum Standards Revision • Commissioner Support • Grant opportunities • Health equity and health disparities

20. Oregon Trainings & Resources • State-Wide Accreditation Work Group • Accreditation List-Serve • CLHO Five Part Webinar Series • Regional and one-on-one trainings • Quality Improvement Technical Assistance (Matt Gilman) • Quality Connection Newsletter • Grantee Trainings • PHAB Timeline • Documentation Tool • Customizable One Pager information sheet

21. National Resources • PHAB Resources • http://www.phaboard.org/accreditation-process/guide-to-national-public-health-accreditation/ • http://www.phaboard.org/accreditation-process/public-health-department-standards-and-measures/ • NACCHO Resources • http://www.naccho.org/topics/infrastructure/accreditation/preparing.cfm • http://www.naccho.org/topics/infrastructure/accreditation/exampledocumentation.cfm • RWJ Resources • http://www.rwjf.org/publichealth/accreditation.jsp

22. Quality Improvement and Accreditation • Basic understanding of QI concepts • QI and accreditation • How QI fits into public health • Applying QI • Looking at our work as a process • What does improvement look like?

23. What is Quality Improvement? • QI is the use of a deliberate and defined process, such as Plan-Do-Check-Act, which is focused on activities that are responsive to community needs and improving population health. • It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes and other indicators of quality services or processes which achieve equity and improve the health of the community. Developed by the Accreditation Coalition Workgroup and approved by the Accreditation Coalition in June 2009

24. Why Quality Improvement? • Foundation of Accreditation • Focuses on efficiency and effectiveness • Demonstrates commitment to high quality services • Shows that we are good at what we do and always improving

25. QI in the context of accreditation QI is an important component of accreditation and of an effective, efficient HD Domain 9, interwoven throughout Increased leadership buy-in Re-accreditation improve improve Accreditation improve Improving the public’s health through continuous Quality Improvement

26. Domain 9: Quality Improvement Domain 9 Evaluate and continuously improve processes, programs, and interventions Standard 9.1: Use a Performance Management System to Monitor Achievement of Organizational Objectives Standard 9.2: Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions

27. Applying QI:Plan Do Check Act • 4 phase cycle • Plan: Understand Problem • Do: Develop Potential Solutions • Check: Testing Solutions • Act: Analyzing Results

28. PLAN • Most critical step • Investigate and fully understand the situation • Identify all opportunities for QI and prioritize them • Ideas for QI come from all levels– staff have opportunity for getting ideas heard and acted upon. • Problem Statement • Aim Statement • Where are we now? • Develop an action Plan

29. Root Cause Analysis Tools • Five Why Processes: Assists teams in driving to the root cause of a problem by thoroughly understanding the problem where it occurs. • Fishbone Diagram Equipment People What’s the Problem Methods Materials

30. DO • Implement the improvement • Document Everything • Problems • Unexpected observations • Lessons learned • Knowledge gained

31. CHECK • Analyze effect of improvement plan • Was improvement achieved? • Document everything • Lessons learned • Knowledge gained • Any surprising results that emerged

32. ACT • Act upon what was learned: • ADOPT: Celebrate and standardize • ADAPT: Adjust and repeat • ABANDON: Start Over • Once you have adopted, monitor and hold the gains

33. Accreditation and process improvement • 9.1.5 Evaluate the effectiveness of processes, programs, and interventions and identify needs for improvement. • Intent of this measure: key processes and all programs and interventions of the agency are evaluated and monitoring data is used to identify areas and methods for improvement.

34. LEAN • LEAN is an improvement process that focuses on what the client wants/ needs and develops a process that delivers that as efficiently as possible • Aimed at maximizing value, reducing waste and incidental work • In LEAN: • Assess your current state • Remove waste • Smooth out the process • Test it out

35. Gathering data • Family Planning client process • Total cycle time (client check-in to client check-out) = 120 minutes • Check-in process = 10 minutes • Provider visit = 60 minutes • Check-out process = 10 minutes • Where do the extra 40 minutes go?

36. A process is… • …a series of sequentially-oriented, repeatable operations and steps having a beginning and an end. • A process usually results in a product (tangible) or a service (intangible).

37. Why focus on process? • Nearly every tangible output, service, or product is the result of a series of system processes. • Over 80% of process improvement opportunities are within the process itself. • Processes can be mapped, measured, and managed to ensure consistent, positive results.

38. Levels Of A Process BusinessDevelopment Core Functional Departments Business Process (“Strategic”) Sales Underwriting Contracting Customer Service BusinessProcesses Sub-process Supplier Customer High Level Process Map Terms Terms Docs Negotiate Close Underwriters (ext.) Customers (int.) Cust. Service Dept. Detailed Sub-Process Map Tasks Procedures

39. Levels Of A Process BusinessDevelopment Core Functional Departments Business Process (“Strategic”) Sales Underwriting Contracting Customer Service BusinessProcesses Sub-process Supplier Customer High Level Process Map Terms Terms Docs Negotiate Close Underwriters (ext.) Customers (int.) Cust. Service Dept. Detailed Sub-Process Map Tasks Procedures

40. Creating a process map • Collect current state information by walking the same path as an input (client or document) • Follow the person around, interview and ask questions at each point in the process • Find out what is happening at each step and/or what decision is being made • Use the following 3 symbols: Decision Yes Beginning or End Step in the process No

41. The steps of improvement…the Lean way 1) Identify value add and necessary steps Process step Process step Process step Process step Process step Process step Process step Process step Waste Value Add Necessary Waste Necessary Value Add Waste Necessary 2) Move Value Added and necessary steps to Future state Value Add Process step Necessary Process step Necessary Process step Value Add Process step Necessary Process step 3) Make it flow Move to External Necessary Process step Necessary Process step Value Add Process step Value Add Process step Necessary Process step

42. Composition of a process

43. 5% 90-95% non value-added Why Focus on Waste? • Many processes are 90–95% non-value-added work. • Focusing on eliminating waste is the best leverage for an improvement effort. • Quality and service level are enhanced. Value Added Cycle Time Lead Time

44. Waste in the Public Sector Preparing unnecessary reports Too many meetings/work groups and needing to obtain authorization Firefighting Working from unreliable information Doing things others have already done Rework and checking other people’s work Working with badly designed IT systems Dealing with failure demand

45. Questions to answer…

46. Supporting Team Level QI • Many different methodologies, across all: • Team Dashboard (Physical central location) • Focus on progress and performance • Mechanism for staff to submit ideas • New and ongoing issues/ activities • Brief, frequent check-in meetings • Timely communication • Forum to discuss issues • Review QI ideas • Reduce need for longer meetings • Celebrate successes

47. QI Myths and Truths • Myth: QI is about weeding out the poor employees • Truth: QI is about improving the process, not blaming the people • Improving the process will allow the people to succeed. • Myth: If I don’t achieve my goal, I’ve failed • Truth: When doing QI, there is no such thing as failure

48. Questions? Next webinar– March 6th Accreditation Work Group– February 13th

49. Next Steps for QI • Start talking about QI at your HD • Encourage staff to learn about QI • Additional training available– • Contact Matt Gilman • matt.s.gilman@state.or.us • 503-757-1612 • Contact me for additional resources

50. Thank you! Erin Mowlds erin@oregonclho.org 541-280-6400