Support for this program was provided by a grant from the Robert Wood Johnson Foundation

1. Association of State and Territorial Health Officials (ASTHO)National Quality Improvement Initiative for State Public Health AgenciesBreaking Down Silos: Demonstrating QI among the Maternal & Child Health, Environmental Health, and Chronic Disease Programs in State Public Health Agencies Support for this program was provided by a grant from the Robert Wood Johnson Foundation

2. De-siloifying HIV MCH Preparedness EH Chronic Disease Brought to you from the vocabulary of Dr. Les Beitsch

3. QI Demonstration Initiative Planning Grant • June 2011-November 2011 ASTHO convened four one-day planning meetings with RWJF, ASTHO, invited PH practitioners, and ASTHO affiliates • Initial kick off meeting was held with all three program areas together • Each meeting focused on one of the program areas: EH, MCH, CD • Meeting purpose: • Review current research and best practices on QI related to the selected public health programs • Develop a draft framework for a national demonstration initiative on quality improvement practices in state public health programs to support accreditation readiness efforts

4. QI Demonstration Initiative Vision • Increase capacity for meaningful quality improvement in state health agency CD, EH, MCH program areas • Increase ability to set aims and measure change in target areas • Increase quality improvement skills and use the QI model in planning and conducting future projects • Increase ability to meet measures in the PHAB domains • Increase the sharing of information across states and across programs • Contribute examples to the PHQIX database

5. QI Demonstration Goals • Demonstrate the use of QI in MCH, EH and CD programs to develop state health agency documentation to meet PHAB measures. • Use efficiencies resulting from QI to inform agency, program, resource, and accreditation decisions in times of shrinking state and federal budgets. • Improve health impact, delivery of services, and program operations among state public health MCH, EH, and CD programs by applying quality improvement methodology.

6. National Project Team Members RWJF • Dr. Pamela Russo-Senior Program Officer • Katie E. Wehr-Program Associate ASTHO Performance Team • Jim Pearsol-Chief Program Officer • Denise Pavletic-Director PH Systems Improvement

7. National Project Team Members ASTHO Environmental Health • Ify Mordi-Senior Analyst Environmental Health ASTHO Chronic Disease • Elizabeth Walker-Senior Director Chronic Disease

8. National Project Team Members QI Coaches • Marni Mason-MarMason Consulting LLC • Chris Bujak-Continual Impact LLC National Affiliates • Sharron Corle-Association of MCH Programs (AMCHP) • John Robitscher-National Association of CD Directors (NACDD)

9. QI Initiative Structure • Each state team received the following: • $100,000 in funding (contracts based on deliverables) • Assigned QI coach • Access to subject matter experts in MCH, CD, EH • Training delivered through the following venues: • In-person kick off training • Alternating monthly webinars/TA calls • Regular on-site training with QI coaches • Regular coaching through conference calls

10. Timeline • June 2011-November 2011: QI demonstration initiative planning • December 2011: RFA released • January-February 2012: Peer review and scoring of applications • February 2012: QI teams selected • March 2012: In-person kick off training-including federal partners at CDC, HRSA, WIC

11. Timeline • April 2012-present • QI Teams developed team charter, refined aim statements, developed measures, set targets, collected baseline data • Completed PLAN/DO phases • In-process: CHECK/ACT-testing theories of improvement, data collection, re-testing

12. NEXT STEPS: • June-August 2013 • QI teams complete the ACT phase • Implementation and sustainability • September 2013 • Determine QI examples that address PHAB documentation requirements • Submission of QI examples to PHQIX • October 2013 • Project close out • In-person meeting to share results with each other, our federal partners and affiliates

13. How will we know if the teams are successful? • MEASURES: • 100% of projects will have achieved measureable improvement against their intended target(s)/refined aims. • 100% of states will submit one QI example to the PHQIX. • 50% increase in the number of QI examples that address PHAB documentation requirements. • 50% increase in the types (i.e., CD, EH, MCH) of QI examples that address PHAB documentation requirements.

14. And the winners are…. • Arizona • Connecticut • Maryland** • Minnesota** • Oregon**

15. Presenter introductions: • Lydia Emer-Oregon • Karen Silver-Maryland • Stephanie Lenartz-Minnesota

16. Breaking Down Silos: Demonstrating QI Among the Maternal and Child Health, Environmental Health and Chronic Disease Programs in State Public Health Agencies Community of Practice for Public Health Improvement, Open Forum June 12, 2013 OREGON HEALTH AUTHORITY

17. WELCOME TO OREGON!

18. Public Health System Characteristics • Decentralized • 36 counties • 34 health departments • Oregon Health Authority: State super-agency comprising public health, mental health and Medicaid • Portland and Salem, Oregon • Population served: 3.8 million

19. ASTHO Grant Overview • Improve health impact, delivery of services, and program operations • Develop state health agency documentation to meet PHAB measures. • Use efficiencies to inform agency, program, resource, and accreditation decisions in times of shrinking state and federal budgets.

20. OREGON’S PROJECTS

21. Oregon MothersCare (OMC) Goal: Improve data transfer and tracking • Reduce time from OMC appointment to Oregon Health Plan approval by improving processes • Reduce time between OMC first contact and prenatal appointment

22. Improvement - Before One-page paper tracking form faxed to State office • Manual process to enter, track, organize forms. • Manage data for 26 sites. • Lots of follow up with sites.

23. Improvement - After Web-based system • Reduced State staff time to manage data process. • Staff time re-direct to supporting OMC sites. • Local sites have greater ownership of their data.

24. Results • Clients served in 2011 4,279 • Fax sheets 8,558 • Reams of paper at 500 sheets per ream 17 • Number of reams per tree 16.67 • Trees saved per year 1.03

25. OMC Future Work • Quality Planning • Internal and external work groups collaborating and using quality planning tools to re-define the work OMC will do in the transformed healthcare world. • Affinity diagramming exercises to help define new business needs. OREGON HEALTH AUTHORITYPerformance Management Program

26. Oregon State Cancer Registry (OSCaR) Goal: Improve data system quality. By the end of the project, 90% of providers will be reporting electronically. • Ensure timely and accurate data submission from all providers (CDC requirement: within 6 months of diagnosis) • Improve program efficiency and data quality

27. Project Development • Initial strategy – Improve number of physicians submitting data to the registry. • Re-scope – With meaningful use requirements, physicians must submit data electronically. Project shifted from improving paper-submitters to planning for electronic data submission.

28. Project Status • Outreach to participating and non-participating providers is currently underway. • Barriers to reporting data are being assessed

29. Drinking Water Goal: Ensure that Drinking Water testers receive efficient and timely reimbursement for tests. • Move stand alone contracts into State omnibus contract.

30. Project Status • New contract language developed that focuses on reimbursement for tests. • New contract mechanism will launch on July 1, 2013.

31. Project Plan After July 1, 2013 • Identify future scope of work county contracts that addresses a greater percent of identified local program needs. • Identify opportunities to continuously improve Drinking Water program element and scope, looking for opportunities to leverage learning across other program areas.

32. PROJECT LEARNING

33. Sometimes it IS about the people, not just the process • Committed program team with strong, involved leadership. • Active involvement of local sites and stakeholders. • Staff QI champions empowered to learn and apply.

34. Sometimes it IS about the process • Process was owned by the program. • Scope was clearly defined. • Data was accessible. • Learned the difference between Quality Improvement and Quality Planning, and when to use each framework.

35. Challenges • Staff and leadership turnover and impact on priority setting. • Legislative session and other political issues. • Time to make QI the urgent project among competing priorities. • Integrating QI into program culture. • Engaging diverse partners across the state in an ongoing and meaningful way.

36. Find Us Online • Performance Management Program http://1.usa.gov/PerformanceManagementProgram • PH Accreditation and Quality Improvement www.healthoregon.org/accreditation

37. Contact Information Lydia Emer Performance Manager Lydia.S.Emer@state.or.us 971-673-1223

38. COPPHI Open Forum: MarylandRWJF National Quality Improvement Demonstration Initiative Strengthening Public Health Connections for WIC Families Karen M Silver, MPP, PIM Deputy Director, Office of Population Health Improvement DHMH

39. Overview • AIM and Measures • 4 project areas • Tools • “Bugle of scope” • Process mapping • Case Study: Fax to Assist • Extracting Lessons Learned • Next Steps

40. Problem • 10,000 Maryland WIC clients receive a “Referral” to PH services each month • No data to show - are referrals to public health services effective? • Smoking cessation • Immunizations • Lead testing • Family Planning/ comprehensive women’s health

41. Feedback Referral Action Referral Given WIC Intake WIC Referral Process • None provided back to WIC • Client given referrals – no consistent method of referring (some via database, some via paper) • Monthly spreadsheet of children without documented immunizations sent to Immunization Registry • Client interviewed by WIC Staff • Self report data: Lead, Smoking, etc. • Staff measure: wt/ht/ hgb • Staff doc immunization status (only official documentation accepted) • Manual data entry into WOW system • Client must initiate contact with referral (i.e call Quitline, visit family planning, get a lead test) • Immunizations may contact family DISCONNECT Is the WIC referral system effective?

42. Maryland Project Aim To: Enable increased follow up of referred WIC services by Public Health Services For: WIC clients referred to or educated about lead testing, immunizations, smoking cessation, and women’s health and family planning services By: Integrating the WIC and public health services’ processes, knowledge, information, and data So that: There is an increase in WIC clients that receive the services to which they were referred

43. Project Measures – version 4.0

44. EXPLORE/ ASSESS Identifying the point of intervention IMPROVE • Accurate referrals given • Impact client motivation to seek services • Quality of referral services % WIC participants with a referral/ recommendation that receive the service Improved Outcomes Improved Referrals % WIC participants that receive a complete and quality referral/ recommendation % WIC Eligibles that Come Into WIC Center % MD Population that is WIC Eligible IMPROVE EXPLORE/ ASSESS WIC Centers: Montgomery and Prince George’s Counties, MD

45. Process Mapping • Visual exercise • Increases discussing • Team involvement • Moving pieces • Compare current and future states** • Key to improvement hypothesis • Literally highlight problem areas • Increases engagement

46. Improvement Hypothesis

47. Test: Fax to Assist • Baseline: • 0 referrals made to Quitline from Fax to Assist • New resource for WIC clinics • Evidence based smoking cessation program • Tests: • Sign up all pilot WIC sites to become providers • Training included • Make WIC a “How Heard About” field on Quitline database • Result: Increase in # WIC participants referred to smoking cessation services who receive follow-up

48. Status of Test Proposed • Identified provider sign up inconsistency • Identified a data collection/ measurement issue

49. Extracting Lessons Learned:Status, Reason, Learning, Direction ™ • Reasons for positive results • No need to buy equipment • FTA is an easy process that works within the WIC clinic flow • Buy in at the clinic level • Fax to Assist involvement on Expanded Team

50. Extracting Lessons Learned:Status, Reason, Learning, Direction ™ • Reasons for progress prevention: • No standardized process for provider sign up • Measurement inconsistency (i.e. Pending status) • Quitline trainings not monitored by QI team