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Quality Improvement in Public Health

April 15, 2015

Management and Supervisor Training

Kathy Brooks, Susan Little,

Tara Lucas, Amanda Cornett

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Welcome and Introductions• Faculty Introductions

• Ground Rules• Participation is essential

• Learning and sharing from one another is important

• Don’t forget to silence cell phones

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Icebreaker

• Name

• Job Title and Organization

• Choose one adjective to describe yourself - Adjective should start with the same letter of

your first or last name

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Objectives

– Define QI and its importance in public health– Learn how to apply the Model for Improvement  

and Lean– Use QI tools to understand your current process 

and identify change ideas– Learn to use the Plan‐Do‐Study‐Act cycle to test 

changes– Identify ways to use QI & Practice Management 

(PM) tools in your agency– Discuss QI & PM resources available to public health 

agencies

Quality Improvement Definitions

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What is Quality Improvement?

“A continuous and ongoing effort and culture

to best achieve measurable improvements

in the efficiency, effectiveness, quality, performance, and outcomes of services and

systems

with the goal of improving the health

of North Carolinians and our communities.”

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NC DPH Management Team, 2009Adapted from Accreditation Coalition QI Subgroup Consensus Agreement

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Visual adapted from Marni Mason of MCPP Consulting; based on Joseph Juran’s Trilogy

QI Principles• Focus on systems, not individual

• Use data to clarify the problem and make decisions about what areas need improvement

• Identify the root cause of the problem (using data) and identify potential changes to improve the problem

• Customer focus: ideas/changes come from customers & front line staff

• Focus on testing changes using PDSA cycle

• Frequent, ongoing measurement and data-driven decision making

• QI is a never-ending process…it’s continuous

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What is Lean Thinking?

A systematic approach to

identifying and eliminating wasteful activity (non-value-added activities)

in the pursuit of perfection

through continuous improvement;

providing increased value to

our clients / community

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Lean Thinking

• Client / customer first

• Our People are the most valuable

resource

• Continuous improvement

• Focus on where the work is done

Evidence Based =

Research based outcomes-----------------------------------------

Evidence Strategies =

actual Evidence Based programs

Quality Improvement Approach

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“Every system is perfectly designed to achieve the

result it gets”

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“FINAL” PLAN

IMPLEMENT

PROBLEM

SOLUTION

Traditional model for introducing

change

FAIL

SYSTEM BARRIERS

Changing the System: Usual Model

Adapted from: Jean Vukoson’s Bright Futures Presentation and Concepts from Toyota Way

QI Approach

IMPROVED and SUSTAINED OUTCOMES

Define POSSIBLESolutions

Test solution

s & adapt

Assess current condition

Prioritize issues & set a target

Clarify problem

BIG, VAGUE PROBLEM

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Model for ImprovementWhat are we trying to accomplish?

(AIM)

How will we know that changes are an improvement?

(MEASURES)

What changes can wemake that will result in

an improvement?(IDEAS)

Act Plan

Study Do

Test Ideas & Changes with Cycles for Learning and Improvement

Evidence Based StrategiesPractice Management Examples:• EBS Screening: move to risk based screening vs

universal screening focuses on risk identification & reduction vs un-necessary screeningResources: Programmatic guidanceNOTE: STD requires universal screening

• EBS Health Communication : compliance with health recommendations is improved if there is a relationship with the provider reduce steps & messengers in the flow process and priority messages from the provider enhance communication & clients ability to apply the recommendationsResources: Programmatic Best Practice Clinic Flow Models; CDC Health Literacy strategies

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Improve the Health of Populations

Smoking Bans Linked To Lower Hospitalizations For Heart Attacks And

Lung Disease Among Medicare Beneficiaries

(Weg, Rosenthal and Sarrazin)

• MI fell 20 – 21%

• COPD fell 11% (workplace ban)

and 15% (bar smoking bans)

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Data Driven Decisions

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What is Gemba?• Gemba is the area in which the work is

being done

• To truly understand a situation, you must go to the Gemba and see for yourself! This is the Gemba Walk

• You are performing an observational walk-thru of the area you plan to improve

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• View of potential problems/waste: wastes or beaver dams in the system

• View from the client’s perspective:wait time, steps, messengers

• View from the worker’s perspective:handoffs; standard processes; motion

Gemba Walk

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Understand the Current Process

• Why is it important?– Helps you to see what is actually going on:

“can’t change what you don’t see”

– Reveals the true “root cause” of a problem

– Avoids putting a Band-Aid on the symptom

– Finds a real fix to prevent the problem from re-occurring

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8 Wastes ?• Defects• Overproduction• Waiting• Non Value-Added Processing• Transportation• Inventory• Motion• Employee (Underutilizing)

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Typically 40-60% of all lead time is non-value added.Typically 40-60% of all lead time is non-value added.

Actual VSM

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Value Stream MapWhat is it?

• Used to visually represent the steps in a process

• Shows complexity, handoffs, unnecessary loops in the process

• Identifies data points

• Provides context for consensus building regarding what we do and what we think we do

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Value Stream MapHow do you create one?1. Define process to examine and set limits2. Observe the work processes first hand and

document observations3. Document each of the process steps4. Arrange steps in order of sequence, including

when things go wrong, corrections, decisions5. Get input from outside group

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Results: Decrease Lead Time

VSM identified “beaver dams” & extra steps

Wilson VSM

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Try It!

• Identify the wastes of this meeting process• Identify gaps & areas for improvement in the

process• Think about how you could use a Value Stream

Map for your meeting process

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Fishbone Diagram• What it is?

– A visual display that allows teams to organize information and identify multiple causes of a problem

• Why use it?– Provides structure during brainstorming– Enables team to think through all potential causes– Creates a snapshot of the team’s collective knowledge– Breaks problem into smaller pieces– Focuses on causes rather than symptoms– Helps prioritize and focus on specific areas

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Fishbone Diagram

Policies

PeoplePlace/Technology

Procedures

Cause

Cause

Cause

Cause

Cause

Cause

Cause

Cause

Cause

Problem

Methods

Machine

Materials

Manpower

Root Cause

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Fishbone Example

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5 Whys

What it is?

• A question asking method

• Used to quickly determine the root cause of a problem

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Fishbone and 5 Whys Example

1. ~100 apps/consultant at one time

2. Most agencies send apps at the last minute

3.  Apps are mistakenly thrown away

4.  Agencies don’t realize that the app is an important document

5.  No indication of “important” document on mailing envelope

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Try It!

• Review the identified problem• Use the Fishbone and identify potential causes of

the problem• Use the 5 Whys to drill down to the root cause

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Aim Statement

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What is an aim statement?

– An explicit statement of the desired outcome that is time specific and measurable

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Key components of an aim statement

–What are we trying to accomplish?

–Why is it important?

–Who is the specific target population?

–When will this be completed?

–How will this be carried out?

–What is our measurable goal(s)?

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What Changes Can We Make?

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Brainwriting

• What it is?– Alternative form of brainstorming

• Why use it?– Everyone contributes ideas

– Reduces threat of ideas being blocked by others

– Quick way to generate many innovative ideas

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BrainwritingIdea

1Idea

2Idea

31 AAA BBB CCC

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3

4

5

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Idea 1

Idea 2

Idea 3

1 AAA BBB CCC

2 DDD EEE FFF

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4

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Idea 1

Idea 2

Idea 3

1 AAA BBB CCC

2 DDD EEE FFF

3 GGG HHH III

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6 3 5 Method (6 people, 3 ideas, 5 minutes)

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Brainwriting Example

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Alternative Brainwriting Methods• Gallery Brainwriting

– Write problem statements on flip charts

– Each person selects a flip chart, reviews problem statement & writes 3 ideas on post-it notes (1 idea/post-it)

– Rotate to the flip chart on the right, review problem statement, read the ideas, add 3 new ideas and/or enhance the other ideas

– Continue until everyone has visited each flip chart

– Review ideas and group them into themes

• Index card– Display the problem statement at the front of the room

– Each person writes 3 ideas on an index card & passes it to person on their right

– Each person reviews ideas on card, adds 3 new ones or enhances the other ideas

– Continue process for 20-30 minutes

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Gallery Brainwriting Example

1. Problem Statement

2. Each person has a different colored adhesive note

3. Ideas reviewed and grouped into themes

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Try It!

• Review the identified problem• Use the Brainwriting template • Write 3 ideas in Row A • When we call “Time” pass your paper to the right• Review the 3 ideas and add your own

ideas on Row B

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Evidence Based Strategies

Practice Management Examples:•EBS : compliance with health recommendations improved if relationship with provider reduce steps & messengers in process

•Examples: best practices tested by other agencies:

– Streamlined clinic flow processes

– Organization of clinics (integrated vs. stand alone)

• Team approach and huddles

– Practice management dashboards 46

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Measurement• Brings rationality to the process

• Replaces subjectivity with objectivity

• Focuses on process, not individuals

How Will We Know? (MEASURES)

“ The nurse practitioners never•complete the encounter forms!”

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How Will We Know? (MEASURES)

• Measurement is the voice of the process

• Accurately tells you how well the process is working

• Any process that can be mapped can be measured

• Measures are linked to the goals in your project aim statement

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Types of Project Measures

• Outcome – Ultimate results we are trying to

achieve

• Process– What we do to achieve the outcome

• Balancing– What we could “mess up” while trying

to improve process & outcome

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Examples of Project Measures • Outcome

– Increase provider productivity to 100% benchmark

• Process– Decrease lead time for preventative service by 25%

in next quarter

• Balancing– 80% of clients will rate wait time in clinic as “very

good”– 80% of clients will rate their understanding of health

information shared by the provider as “clear understanding”

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Practice Management Measures

• Budgeted vs. actual revenue

• Payer source by program

• Productivity benchmarks: capacity vs. actual seen

• No show rate

• Demand for services by program

• Revenue compared to costs

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PM Data DashboardService County by Practitioner Summary

Practice Management Data Dashboard

Service Count by Practitioner Summary Report

1/1/2013 Through 12/31/2013

RSCCounty Number Practitioner

Medicaid Units

Non-Medicaid Units Total Units

Medicaid Services

Non-Medicaid Services

Total Services

69 308 377 69 308 377

80 152 232 80 152 232

73 227 300 73 227 300

35 63 98 35 63 98

0 492 492 0 492 492

177 300 477 177 300 477

21 9 30 21 9 30

1 0 1 1 0 1

156 356 512 153 299 452

58 101 159 58 97 155

1,014 720 1,734 1,012 716 1,728

393 1,180 1,573 393 1,180 1,573

19 7 26 19 7 26

179 655 834 76 286 362

458 730 1,188 277 318 595

75 202 277 70 149 219

2,808 5,502 8,310 2,514 4,603 7,117

PM Data Dashboard Service Count by Program Summary

RSCCounty Number RRG Practitioner Medicaid Units

Non-Medicaid Units Total Units

Medicaid Services Total Services

Non-Medicaid Services

AH 39 19 58 39 58 19

AH 54 200 254 54 254 200

AH 17 18 35 17 35 18

AH 0 40 40 0 40 40

AH 101 73 174 101 174 73

AH 78 59 137 78 137 59

AH 23 26 49 23 49 26

AH 1 58 59 1 59 58

AH 0 43 43 0 43 43

AH 9 16 25 9 25 16

AH 23 16 39 23 39 16

AH 29 24 53 29 53 24

CH 2 35 37 2 37 35

CH 1 0 1 1 1 0

PM Data DashboardService County by Practitioner and CPT

Code

Practitioner = (Name of Practitioner will appear here)

Procedure Code Procedure Description

Medicaid Units

Non-Medicaid Units Total Units

Medicaid Services

Non-Medicaid Services Total Services

99202 99202-OFFICE/OUTPATIENT VISIT NEW 0 1 1 0 1 1

99212 99212-OFFICE/OUTPATIENT VISIT EST 1 2 3 1 2 3

99213 99213-OFFICE/OUTPATIENT VISIT EST 0 1 1 0 1 1

99385 99385-PREV VISIT NEW AGE 18-39 0 1 1 0 1 1

99386 99386-PREV VISIT NEW AGE 40-64 0 19 19 0 19 19

99395 99395-PREV VISIT EST AGE 18-39 0 1 1 0 1 1

99396 99396-PREV VISIT EST AGE 40-64 0 33 33 0 33 33

Practitioner Totals: 1 58 59 1 58 59

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PM Data DashboardExporting Instructions

To export the report, at the top of the page click the Export icon (circled in red below)

Then select the method the report should be exported.

“Export Document As” will export all report tabs.

“Export Current Report As” will export the report tab that is currently open.

The report can be exported as a PDF, Excel, or Text Document (exporting to Excel limits the report to 65K rows, Excel 2007 does not).

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Reduction per capita Cost of Health Care Public Health Productivity Benchmarks• Provider productivity benchmark:

Average 20 visits/day x 5 days/week x 48 weeks = 4,800/year

• Nurse Clinic productivity benchmark:Average 20 visits/day x 5 days/week x 48 weeks = 4,800/year

• Child Health Enhanced Role Nurse (with support) benchmark:Average 6 visits/day x 5 days/week x 48 weeks = 1,440/year

Practice Management Data

What are your questions regarding this fiscal picture?

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Practice Management Data

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18%

8%

58%

16%

Medicaid

Other

Local 101

State Funds

All Revenue Sourceswithout Cost Settlement

Focus on Customers & Stakeholders

How do our customers experience our “product” or services?

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Customer Focus

• Who are our customers?– WIC clients, community builders or

homeowners, clinical services patients

• What do our customers value in our product or service?– Friendliness, efficiency, accuracy?

– How do we know?

Customer Focus• Are we developing solutions with customer

values in mind?– Are schedules or hours of operations

convenient to our clients or meet staff needs

• Does our product or service meet our customer needs?– How do we know?

– How do we involve patients

in developing solutions

or services?

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How do organizational stakeholders experience improvement?

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Stakeholder Input

• To make real improvements we must understand the processes from the people who do them: stakeholders are the frontline staff who actually do the work

• Managers “think” they understand the issues or processes but do not always have stakeholder perspectives: assumptions should be validated with stakeholders

What’s the problem?

Stakeholder Engagement

• Stakeholders hold the keys to successful solutions if engaged in the change process

• Stakeholder engagement facilitates “adoption” and embedding of improvement strategies

• Engagement requires continuous feedback & reinforcement

What’s the solution?

Systems Change

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Testing our Change Ideas

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PDSA Cycle

Act Plan

Study Do

• Objective of cycle • Questions/predictions• Plan to carry out the cycle

(who, what, where, when)

• Carry out the plan• Document

problems/unexpected observations

• Begin analysis of data

• Complete the analysis of data

• Compare data to predictions

• Summarize what was learned

• What changes are to be made?

• Adapt? Or Abandon?• Next cycle?

Use the PDSA cycle to test changes

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Another Example PDSA CycleAim:

By December 1, 2013, we aim to increase the number of patient visits per staff discipline (see below) over 2012 capacity.

MD/NP/PA = 20 patient visits/day (2012 = 12)¹RN (General Clinic/Mandated Services) = 20 patient visits/day (2012

= 6)Rostered CH RN = 6 patient visits/day (2012 = 3)PP/NB HV = 5 patient visits/day (2012 = 3)

¹If STD service visits are not included in the RN (General Clinic/Mandated Services) numbers, then the benchmark would be 8 patient visits/day.

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PDSA Cycle Example: Schedule

Act Plan

Study Do

• If we set the staff schedules up to accommodate the increase in patient visits, will staff be able to sustain the load?

• Design schedules to reflect target and test for one day in clinic.

• Current clinic flows didn’t support additional patient load.

• Was able to see more patients but didn’t achieve Aim.

• Change flows to decrease non-value added processes (hand-offs, stops, etc.) and try again.

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PDSA Practice Management Example

PDSA Cycles:Improve Health Outcomes by Improving

Clinic Efficiency and Cost Effective Services.

1. Test new schedule which supports desired benchmark of patient visits/provider. (PDSA #1)

2. Test Flow (PDSA #2)

3. Test staffing model (PDSA # 3)

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Testing Changes

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Ideas

Changes that result in

improvement

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How Have You Used PDSAs?

• What was the aim of your project?

• What change did you test using a PDSA cycle?

• What did you learn from the first PDSA cycle?

• What were the benefits of using a PDSA cycle

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PDSA Tip #1: Scale Down

• Years

• Quarters

• Months

• Weeks

• Days

• Hours

• Minutes

• Number of clients

“Drop 2”

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PDSA Tip #2: “Oneness”

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Key Points for PDSA Cycles• Successful tests

– As move to implementation, test under as many conditions as possible

– Special situations (e.g., busy days)

– Factors that could lead to breakdowns (e.g., different staff involved)

– Things “naysayers” worry about (e.g., “It will not work on Wednesdays”)

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Try It!

• Think about a change you want to test to improve the meeting process

• Use the PDSA cycle template to develop a plan for how you would test the change

Small Group Work Applying what you have learned

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Ongoing MeasurementContinuous Quality Improvement

Why Should we Continue to Monitor?

Practice Management• Ongoing monitoring of trends in productivity

& revenue & data-based response– Joint performance objectives & data dashboards

provide structure & information to identify issues and make appropriate improvement decisions

• Improvement opportunities:– Strategies to optimize revenue:

• Billing & coding audit training & monitoring of practice’s coding

• Maintain current billing & follow-up of denials

• Accept credit & debit cards

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What is Return on Investment?

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Terminology/Formula

ROI (return on investment): A performance measure used to evaluate the efficiency of an investment

ROI = (Benefits-Costs)/Costs

EI (economic impact): Refers to costs and benefits of an activity.

EI = Benefits-Costs

*

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ROI/EI – Why do it?

• Earns the respect of Stakeholders and Leaders

– Justification for implementing an intervention/project

• View public health as an investment vs. expense

– Helps to “sell” the concept of public health

• Part of evaluation…accurate, credible, and widely used process

– Based on facts or evidence so it’s believable

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Change Planning & Communication

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Planning for Implementation of Change

• Clear AIM and measures

• Leadership sponsor which can articulate the change imperative and AIM & secure resources

• Practice Management Team with clear joint performance objectives

• Implementation plan which includes detailed steps, resource requirements, accountabilities, and monitoring data set

• Build change capacity on early successes or “low hanging fruit”

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Organizational Structure & Change

• Leaders = point the managers towards the vision and mission of the agency and leverages the funds to make it happen

• Managers = plan for, designs and controls factors that affect work

• Supervisors = over-sees or directs people at work– Line of Sight Supervision = supervisors can see

employee performance in the work flows– Standardize = policies, procedures, environment,

work flows, job description, work plans.

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Change Management Process

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Change CommunicationCommunication must •Clearly define impetus for change

•Clearly define assessment process & change process

•Be consistent from health director to middle managers to front line

– Communication structure: all staff meetings, team meetings, huddles, data reports re: progress toward objectives

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Change CommunicationCommunication must: •Recognize change process & implications for and concerns of all stakeholders:

– Example: the goal of the clinic efficiency is to optimum use of resources: staffing resources “freed” by reducing duplication & increasing efficiency & productivity will be redeployed to other value added services

– Address resistance and anxiety with multiple changes in status quo

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Where do you go from here?

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Next Steps

How will you use what you’ve learned in the next 2 weeks?

• AIM

• Team

• Identify specific agency strengths

• Identify and address barriers

• Develop a plan & work the plan

Questions, CommentsDebriefing

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Resources Available• Center for Public Health Quality

(http://centerforpublichealthquality.org/)• Institute for Healthcare Improvement

(ihi.org) • The Public Health Foundation• DPH Practice Management Resources

(http://publichealth.nc.gov/lhd/)• DPH Administrative &

Nurse Consultants

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Contact Info

Susan LittlePhone: 919-215-4471susan.little@dhhs.nc.gov

Tara LucasPhone: 919-624-6652tara.lucas@dhhs.nc.gov

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Kathy BrooksPhone: 336-212-1678kathy.brooks@dhhs.nc.gov

Amanda CornettPhone: 919-707-5013amanda.cornett@phquality.org