TANEY COUNTY HEALTH DEPARTMENT

2012

CONTINUOUS

QUALITY

IMPROVEMENT

PLAN

Ashwin George Modayil M.H.A, M.P.H.

Robert Niezgoda, M.P.H.

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Table of Contents Introduction 3

Terms 9

Vision 13

Quality Improvement Program Structure 14

QI Training

Project Identification Process 15

Goals, objectives and measures with time-framed targets 16

Quality Assurance and the Monitoring QI Plan 17

QI Program Evaluation Process 19

Communication of QI activities 19

Appendix A: PDCA Checklist 21

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Introduction One of the opportunities for improvement that the Taney County Health Department (TCHD)

identified through the Missouri Institute of Community Health’s Accreditation Process in 2005

was a need for a Continuous Quality Improvement (CQI) program. The department was slated

for MICH reaccreditation in early 2008 and Quality Improvement was an arena that needed to

be addressed. The field of quality improvement is an extensive one. Information pertaining to it

is exceedingly vast with a plethora of options tailored to suit the needs of various business

structures. Therefore, it was important to identify and employ the most appropriate CQI

strategy for the department.

What is Continuous Quality Improvement?

Continuous Quality Improvement is the complete process of identifying, describing and

analyzing strengths and weaknesses and then testing, implementing, learning from and revising

solutionsi. It relies on an organizational culture that is proactive and that supports continuous

learning. CQI is firmly grounded in the overall, mission, vision and values of the agency. Most

importantly, it is dependent upon the active inclusion and participation of staff at all levels of

the agency, and stakeholders throughout the processii.

Which CQI strategy?

As was just mentioned, the topic of quality improvement was an extensive one. Therefore, one

of the first challenges was to find a process that would suit the needs of the agency. After an

exhaustive CQI literature review, it was felt that the Plan, Do, Check, Act (PDCA) or the

Deming/Shewhart Cycle would be the most conducive to meet the needs of TCHD. More

accurately, the process is referred to as the FOCUS-PDCA approach. Having originated in the

business industry, the FOCUS-PDCA approach has been tweaked for effective application in a

variety of healthcare institutions – including a public health department.

FOCUS:

Find a process to improve

Organize to improve a process

Clarify what is known

Understand variation

Select a process improvement.

After FOCUS has been achieved, a process improvement plan needs to be implemented. One

such plan is the PDCA cycle – or the Plan Do Check Act cycle.

Planning: Involves creating a timeline of resources, activities, training and target dates. During

this stage a data collection plan needs to be developed, tools for measuring outcomes need to

be identified, and thresholds for identifying when targets have been met need to be stipulated.

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Do: This involves the actual implementation of the various interventions as well as data

collection.

Check: This step includes an analysis of the results of the data and an explanation for the

reasons of variations – if any.

Act: Means that one can act on what was learned and then determine what was learned. If the

intervention was successful, then steps to make it a part of standard operating procedure need

to be implemented. If the intervention was not successful, then the various sources of failure

need to be identified. Once these are determined new solutions need to be designed and the

PDCA cycle needs to be repeatediii.

A studyiv showed that repetitive cycles of measuring outcomes followed by implementation of

interventions to improve outcomes could be effectively used to improve quality of care in rural

health clinics.

Why Continuous Quality Improvement?

In addition to increased productivity, improved service quality, enhanced customer

responsiveness and enhanced employee satisfaction, there are several other benefits of

incorporating CQI into the daily workings of the health department. Some of these arev:

Ownership of Process/Program Objectives CQI can bring about changes in attitudes towards a process/program. Employees can

see how a set of objectives helps to identify a process’s success or indications that a

program is moving in the right direction.

Inclusiveness/Consistency Implementation of a program on an organizational-wide level promotes a feeling of

inclusiveness in the organization. Employees feel part of a team, have similar

experiences, use the same CQI tools, as well as participate in organizational wide

training.

Improved Communication/Teamwork Regular management meetings involve sharing of information among programs and

services. Staff can offer suggestions on interventions for opportunities in other areas to

assist in needed improvement. This further fosters teamwork.

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Stakeholder Perception Reporting of trended information allows stakeholders to see performance levels on a

routine basis. They can see that the organization sets goals, evaluates data collected and

reviews the impact on organizational programs.

Proactive vs. Reactive CQI initiatives place the organization in a proactive mode. Under a CQI philosophy,

programs and services are aggressively monitored which assists with detecting problems

in a timely fashion. Analysis of data also helps to distinguish between acceptable and

unacceptable performance levels.

What is required?

The six Key Success Factors (KSFs) for CQI are as followsvi:

Key Success Factor 1: Visionary Leadership.

Key Success Factor 2: Commitment to Customers / Clients.

Key Success Factor 3: Trained Teams.

Key Success Factor 4: Employee Participation.

Key Success Factor 5: Total Quality Management Process (detailed below).

Key Success Factor 6: Alignment of Management Systems.

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The CQI Framework:

Fig. 1

M I S S I O N

VALUES

V I S I O N

ORG. CULTURE

Review,

analyze and

interpret

data

Train and

support leaders,

staff and

stakeholders

Apply

Learnings

Adopt

outcomes

indicators and

standards

Collect data

and

information

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The Crux of Continuous Quality Improvement

The central idea of CQI lies in the philosophies of scientific method which include hypothesis

generation, experimentation, observation and hypothesis testing. CQI is all about improvement

which can only be brought about by change. The PDCA cycle mentioned earlier is a proven tool

used to help agencies develop tests and implement changes. In other words, the PDCA is a

framework for efficient trial-and-error methodology. The cycle begins with a plan and ends with

an action based on the learning gained from the cycle. Improvement comes from the

application of the knowledge gained and generally, the more complete the appropriate

knowledge, the better the improvements will be when the knowledge is applied to making

changes. Any approach to improvement must be based on building and applying

knowledge.This view leads to a set of fundamental questions, the answers to which form the

basis of improvement:

1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in improvement?

These questions provide the framework for a “trial and learning” approach. The word “trial”

implies that the change is going to be tested.The term “learning” imples that the criteria that

are intended to be studied from the trial have been identified. This approach stresses learning

by testing changes on a small scalevii.

Plan of Action Proposal

Identify a process that needs improvement that is common to all departments

The literature emphasizes that CQI be adopted using a team based approach. This allows for

synergistic problem solving, assumed empowerment and can aid in consensus building. This

approach also forces participants to view how the agency operates as a unified system as

opposed to separate entities that just happen to be a part of the larger “whole.” A team-

based approach infuses a sense of purpose to the issue at hand and can also serve as a

platform for future problem solving initiatives.

Document current operating procedures.

This allows us to understand where we stand at the moment. This information will act as

the basis for formulating future improvement strategies.

Collect Data.

This step calls for data collection using existing standard operating procedures. Once

collected, this data will help us to analyze the effectiveness of the current methods of

operation.

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Brainstorm for improvement strategies.

This phase calls for taking a second look at the way things are currently done and to then

question whether any improvements can be made. If this is the case, then an exhaustive list

of how the various processes can be improved needs to be generated.

Meet to hammer out consensus for all proposed strategies.

Since this is a team-based and collaborative effort, buy-in by all employees and stakeholders

is a mandatory precursor for any measure of success. All parties need to cross evaluate each

other’s proposed solutions to ensure that no inter-departmental glitches come about once

the actual trial is rolled out.

Implement the new process / processes

This is where the ‘rubber meets the road’ or where the newly conceptualized process is first

put in action. The data collection structures or templates may also need to be fine-tuned to

reflect any procedural changes and related data collection points.

Collect data

Data collected here needs to be consistent with the type and format of data collected in the

initial data collection phase. This will allow for valid comparisons to be made of the ‘before’

and ‘after’ procedures.

Meet for feedback and see if the stipulated objectives were met.

This is the ‘learning’ phase. Participants need to meet and analyze what worked and what

didn’t. What did work needs to be documented and suggestions for further improvement

needs to be sought. Similarly, strategies that did not result in any significant improvement

also need to be documented for future reference.

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Key quality terms: CQI – Continuous Quality Improvement The ongoing improvement of products, services or

processes through incremental and breakthrough improvements. A philosophy and attitude for

analyzing capabilities and processes and improving them repeatedly to achieve customer

satisfaction

PDCA – Plan Do Check Act

FOCUS 1.) F – Find a process to improve 2.) O– Organize to improve a process 3.) C – Clarify what is known 4.) U – Understand variation 5.) S - Select a process improvement.

Brainstorming: A technique teams use to generate ideas on a particular subject. Each person on

the team is asked to think creatively and write down as many ideas as possible. The ideas are

not discussed or reviewed until after the brainstorming sessionviii.

Baseline measurement: The beginning point, based on an evaluation of output over a period of

time, used to determine the process parameters prior to any improvement effort; the basis

against which change is measuredix.

Benchmarking: A technique in which a company measures its performance against that of best

in class companies, determines how those companies achieved their performance levels and

uses the information to improve its own performance. Subjects that can be benchmarked

include strategies, operations and processes.

Best practice: A superior method or innovative practice that contributes to the improved

performance of an organization, usually recognized as best by other peer organizations

Big QI: This is where top organizational leaders address the quality of the system at a macro

level.

Capability: The total range of inherent variation in a stable process determined by using data

from control charts.

Chart: A tool for organizing, summarizing and depicting data in graphic form

Check sheet: A simple data recording device. The check sheet is custom designed by the user,

which allows him or her to readily interpret the results. The check sheet is one of the “seven

tools of quality” (see listing). Check sheets are often confused with checklists (see listing).

Checklist: A tool for ensuring all important steps or actions in an operation have been taken.

Checklists contain items important or relevant to an issue or situation. Checklists are often

confused with check sheets (see listing).

Common-Cause Variation: Any normal variation inherent in a work process.

Complexity: Unnecessary work; any activity that makes a work process more complicated

without adding value to the resulting product or service.

Compliance: The state of an organization that meets prescribed specifications, contract terms,

regulations or standards.

Consensus: A state in which all the members of a group support an action or decision, even if

some of them don’t fully agree with it.

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Constraint: Anything that limits a system from achieving higher performance or throughput;

also, the bottleneck that most severely limits the organization’s ability to achieve higher

performance relative to its purpose or goal.

Cross functional: A term used to describe a process or an activity that crosses the boundary

between functions. A cross functional team consists of individuals from more than one

organizational unit or function.

Employee involvement (EI): An organizational practice whereby employees regularly participate

in making decisions on how their work areas operate, including suggestions for improvement,

planning, goal setting and monitoring performance.

Empowerment: A condition in which employees have the authority to make decisions and take

action in their work areas without prior approval. For example, an operator can stop a

production process if he or she detects a problem, or a customer service representative can

send out a replacement product if a customer calls with a problem.

Facilitator: A specifically trained person who functions as a teacher, coach and moderator for a

group, team or organization.

Failure: The inability of an item, product or service to perform required functions on demand

due to one or more defects.

Feedback: Communication from customers about how delivered products or services compare

with customer expectations.

Five whys: A technique for discovering the root causes of a problem and showing the

relationship of causes by repeatedly asking the question, “Why?”

Focus group: A group, usually of eight to 10 people, that is invited to discuss an existing or

planned product, service or process.

Gap analysis: The comparison of a current condition to the desired state.

Group dynamic: The interaction (behavior) of individuals within a team meeting.

Groupthink: A situation in which critical information is withheld from the team because

individual members censor or restrain themselves, either because they believe their concerns

are not worth discussing or because they are afraid of confrontation

Histogram: A graphic summary of variation in a set of data. The pictorial nature of a histogram

lets people see patterns that are difficult to detect in a simple table of numbers

Improvement: The positive effect of a process change effort.

Individual qi: When staff members seek ways to improve their own behaviors and environments

it is referred to as individual qi.

Internal Customer: Anyone in the organization who relies on you for a product or service.

Key performance indicator (KPI): A statistical measure of how well an organization is doing in a

particular area. A KPI could measure a company’s financial performance or how it is holding up

against customer requirements.

Leadership: An essential part of a quality improvement effort. Organization leaders must

establish a vision, communicate that vision to those in the organization and provide the tools

and knowledge necessary to accomplish the vision.

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Little qi: When professional staff attack problems in programs or service areas by improving

particular processes, it is termed as (Little qi).

Mean: A measure of central tendency; the arithmetic average of all measurements in a data set.

Mission: An organization’s purpose

Objective: A specific statement of a desired short-term condition or achievement; includes

measurable end results to be accomplished by specific teams or individuals within time limits.

Outputs: Products, materials, services or information provided to customers (internal or

external), from a process.

Pareto chart: A graphical tool for ranking causes from most significant to least significant. It is

based on the Pareto principle, which was first defined by Joseph M. Juran in 1950. The principle,

named after 19th century economist Vilfredo Pareto, suggests most effects come from relatively

few causes; that is, 80% of the effects come from 20% of the possible causes. One of the “seven

tools of quality”.

Problem solving: The act of defining a problem; determining the cause of the problem;

identifying, prioritizing and selecting alternatives for a solution; and implementing a solution.

Process improvement: The application of the plan-do-check-act cycle to processes to produce

positive improvement and better meet the needs and expectations of customers.

Process improvement team: A structured group often made up of cross functional members

who work together to improve a process or processes.

Process map: A type of flowchart depicting the steps in a process and identifying responsibility

for each step and key measures.

Quality assurance/quality control (QA/QC): Two terms that have many interpretations because

of the multiple definitions for the words “assurance” and “control.” For example, “assurance”

can mean the act of giving confidence, the state of being certain or the act of making certain;

“control” can mean an evaluation to indicate needed corrective responses, the act of guiding or

the state of a process in which the variability is attributable to a constant system of chance

causes. One definition of quality assurance is: all the planned and systematic activities

implemented within the quality system that can be demonstrated to provide confidence that a

product or service will fulfill requirements for quality. One definition for quality control is: the

operational techniques and activities used to fulfill requirements for quality. Often, however,

“quality assurance” and “quality control” are used interchangeably, referring to the actions

performed to ensure the quality of a product, service or process.

Quality Circle: A small group of employees organized to solve work-related problems; often

voluntarily; usually not chaired by a department manager.

Quality: a customer's perception of the value of a product or service; organizations, theorists,

and dictionaries define it differently. Well-known definitions include: "conformance to

requirements" (Crosby) "the efficient production of the quality that the market expects"

(Deming) "fitness for use"; "product performance and freedom from deficiencies" (Juran) "the

total composite product and service characteristics of marketing, engineering, manufacturing,

and maintenance through which the product and service in use will meet the expectations of

the customer" (Felgenbaum) "anything that can be improved" (Imal) "meeting or exceeding

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customer expectations at a cost that represents value to them" (Harrington) "does not impart

loss to society" (Taguchi) "the totality of features and characteristics of a product or service that

bear on its ability to satisfy a given need" (American Society for Quality Control) "degree of

excellence" (Webster's Third New International Dictionary)

Root cause: A factor that caused a nonconformance and should be permanently eliminated

through process improvement; The prime reason(s) why an incident occurred. Root causes are

often related to deficiencies in management systems.

Run chart: A chart showing a line connecting numerous data points collected from a process

running over time.

Scatter diagram: A graphical technique to analyze the relationship between two variables. Two

sets of data are plotted on a graph, with the y-axis being used for the variable to be predicted

and the x-axis being used for the variable to make the prediction. The graph will show possible

relationships (although two variables might appear to be related, they might not be; those who

know most about the variables must make that evaluation). One of the “seven tools of quality”

(see listing).

Seven tools of quality: Tools that help organizations understand their processes to improve

them. The tools are the cause and effect diagram, check sheet, control chart, flowchart,

histogram, Pareto chart and scatter diagram (see individual entries).

Six Sigma: A method that provides organizations tools to improve the capability of their

business processes. This increase in performance and decrease in process variation lead to

defect reduction and improvement in profits, employee morale and quality of products or

services. Six Sigma quality is a term generally used to indicate a process is well controlled (±6 s

from the centerline in a control chart).

Special-Cause Variation: Any violation arising from circumstances that are not a normal part of

the work process

Stakeholder: Any individual, group or organization that will have a significant impact on or will

be significantly impacted by the quality of a specific product or service.

Standard deviation (statistical): A computed measure of variability indicating the spread of the

data set around the mean

Values: The fundamental beliefs that drive organizational behavior and decision making.

Vision: An overarching statement of the way an organization wants to be; an ideal state of being

at a future point.

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Vision of quality in the organization:

The phrase ‘Continuous Quality Improvement’ as well as its abbreviated form – CQI have become

common parlance within the Taney County Health Department. Today we can safely say that most

employees have a fairly good idea of what CQI is and how it applies to their various work areas. Little ‘qi’

efforts are almost automatic in some parts of the organization. In fact, some staff members have a

tendency to say “CQI it” when they feel the need to trouble shoot problems within their work areas.

Several work flow process improvements have been initiated and completed without the requirement of

any sort of management intervention. Many of these successes have been presented at the

department’s monthly staff meetings.

However, the big “QI“projects still need support from the CQI Manager. We feel that these system-wide

projects are best conceptualized and executed at the management level with full support of the top

leadership. These larger QI initiatives require the use of some of the more advanced QI concepts and

tools and training towards this end will need to be administered or required.

The Goal of the CQI program is to continuously improve the systematic use of the CQI process with the

process becoming more automatic, more sophisticated, and a routine job responsibility of every staff

member at every level of the organization. The program will also focus on more cycles of the CQI

process in order to facilitate “fine-tuning” of performance and processes. Additionally, the program will

focus on more, larger department-wide systemic Quality Improvement projects that would involve more

of the management team to facilitate organizational improvement.

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Quality Improvement Program Structure:

Organization structure, roles and responsibilities

The Taney County Health Department Quality Improvement Manager is responsible for the

development, review and implementation of the CQI program and initiatives for the department with

assistance from the CQI team which consists of the management team and Performance Management

Team. The CQI Team is made up of members of management, staff, and senior leadership. The CQI

Team is then tasked with the implementation of department-wide CQI initiatives or the identification of

program specific projects. Management staff also encourages staff members to identify “qi” projects to

focus on process specific issues. These staff driven “qi” projects are communicated to the CQI Manager

for feedback, further input, technical development, and assistance with the final presentation. The CQI

Manager is also responsible for review of CQI projects, the CQI Program overall, and QI training needs of

management and staff.

Membership

The CQI Team consists of all members of the TCHD Management Team which represents each division of the organizational chart, including: the director, assistant director, clinical services division manager, finance and HR division manager, dental division manager, environmental health supervisor, WIC division manager, community outreach division manager, CQI and IT manager, and animal control supervisor. Program staff are included in the CQI process through “qi” and “QI” projects routinely. Quality improvement Training Process

Quality improvement training is an ongoing process that reflects the philosophy of the TCHD and the CQI

program. Training is incorporated into staff meetings, manager meetings and board meetings routinely.

Each “qi” or “QI” project is reviewed by the CQI manager who provides guidance to the person(s)

involved in the project. This allows for the direct delivery of project specific training to those involved in

the project and helps with the learning process as the CQI project becomes a learning example. Formal

training is also provided to new employees, existing employees, management and the CQI Manager.

Formalized training includes:

1. New employee orientation presentation materials

2. Introductory Presentation for new staff

3. Online courses for all staff through Heartland Centers

4. Advanced training and resources for CQI Team

5. Continuing staff training on QI

6. Other training as needed – position specific training (MCH, Epidemiology, etc.)

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Project identification process: Improvement areas are identified through several methods. The simplest method involves an

intuitive process where employees or managers identify a process, policy, or procedure that is

creating difficulties or is thought to be inefficient. This will result in the initiation of the PDCA

cycle and is likely to result in a “qi” project or may develop into a more involved problem leading

to a “QI” level project. The managers can also initiate a “QI” project after the identification of

an issue through the performance management program (PMP) or the “Pressing Need”

approach. The “Pressing Need” Approach (PNA) is a process whereby a supervisor or manager

identifies priorities in the program area which need to be addressed to further the improvement

of their program or area of responsibility. The most involved process involves system-wide

projects which includes multiple programs or cross-functional team members in the

organization. These projects are long-term and more complicated in their development and

completion. The system-wide “QI” projects are identified by the director, management team, or

Board members through data captured by specific programs, the PMP, identified priorities, or a

possible “crisis” that impacts functioning of the department.

The basis of the TCHD CQI plan is based on the Mission and Vision of the health department to

provide quality and effective programs to members of the community and visitors to the area.

The Mission and Vision are the foundation of the goal of the Strategic Planning process and the

CQI projects are developed to ensure that program delivery is meeting the stated goals and

objectives formulated in the program planning and strategic planning processes. For instance, if

the data collected through the PMP determines that a program area is not functioning at the

appropriately level during anytime during the year, a CQI process is initiated to determine the

reason behind the decreased performance and to implement corrective actions. The CQI

program is therefore, the chosen method which is utilized by management to ensure that the

goals and objectives of the strategic plan are achieved. Additionally, CQI projects may be

expressly identified as a goal within the strategic plan to review and improve a specific function,

program, etc. of the department. This would normally involve a substantial, long-term “QI”

project involving multiple program areas or divisions.

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Goals, objectives and measures with time framed targets

The performance measures that the CQI program seeks to achieve includes the following:

i. Ensure that the PDCA cycle is fully recognized and acknowledged in each project

ii. Ensure that the CQI projects become more sophisticated with additional data

elements utilized and more advanced quality improvement concepts and

methodologies implemented

iii. Ensure that additional PDCA cycles are implemented after the initial PDCA

iv. Increase training opportunities for management team and staff

v. Develop and implement quality improvement process

vi. Revise Standard Operating Procedures (SOP) for CQI program at the end of the year

to include new standards and methods developed.

Responsibilities

The CQI manager is responsible for evaluating the CQI program and ensuring that the objectives of the

CQI program are being met through assistance by the TCHD management team. As CQI is a component

of the TCHD culture, the philosophy has always been that management and senior leadership

involvement is crucial to the overall success of the program. Employees will be provided guidance by the

management team, supervisors and CQI manager on specific projects. Training will be provided at staff

meetings periodically through formal training and presentation of ongoing CQI projects.

Time frames associated with CQI Objectives

The following timeline will be managed by the CQI program manager. These timelines will be the basis

for evaluation of the CQI program as well.

Objective Timeframe

Ensure that the PDCA cycle is fully recognized and acknowledged in each project

Quarterly

Ensure that CQI projects become more sophisticated and more advanced QI concepts and methodologies implemented

Annually

Ensure that additional PDCA cycles are implemented after the initial PDCA Conclusion of each project

Increase training opportunities for management team and staff Quarterly

Develop and implement quality improvement process Annually

Revise Standard Operating Procedures (SOP) for CQI program at the end of the year to include new standards and methods

Annually

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Quality Assurance and Monitoring QI Plan

TCHD’s CQI Program is integrated into the Department’s Performance Management Program (PMP)

and Strategic Plan. The Performance Management Program has been designed to showcase critical

program related quantitative data on a monthly basis. During the development phase of the PMP,

managers identified data elements that represented the goals and objectives in programmatic

areas. For example, the number of clients seen on any particular day could be construed as the

most important performance related program data for the WIC, Immunization and Dental programs.

These numbers are provided to the PMP coordinator to be entered into the PMP system which

automatically updates associated Dashboard charts and graphs for review by management and the

board monthly. The PMP Dashboard evaluation range identifies “poor”, “moderate” and “optimal”

performance. The represented “dashboard” of “speedometers” provides a quick visual method of

identifying performance within any division. If performance is shown to be suboptimal, CQI cycles

are initiated and executed until performance once again falls within the optimal range. An optimal

value is one that falls between 85% and 100% of the established range for that data element.

Based on the PMP process, the CQI program and initiatives are monitored through the effects that

CQI initiatives have on the overall performance management numbers. The more programs the

department has running optimally, the fewer CQI projects are triggered under this mechanism. As

CQI initiatives are implemented and completed, they are tracked utilizing the CQI monitoring tool.

The CQI monitoring tool allows the collection and analysis of data from each CQI project: whether a

standardized process has been achieved; how many cycles have been completed or if benchmarks

have been achieved to become a Standard Operating Procedure (SOP); what PDCA phase the project

is in; the percentage of project complete; and timeframe for next CQI report. Stated goals and

objectives within each CQI project are utilized to determine the percentage of project completion.

By utilizing this method the CQI Manager is able to quickly monitor progress of each CQI project that

is in progress and what has been achieved.

Because of the continued development of the TCHD CQI Program, additional components and

improvements to the CQI Performance Management Plan are being implemented. Currently, the

management team is in the process of becoming more familiar with the fundamental aspects of the

PMP and CQI system using quantitative data. The implication is that the department is moving

toward a point where quantitative data will be increasingly utilized to measure and reflect program

effectiveness. Challenges still exist when it comes to designing apt data collection mechanisms for

TCHD programs that do not lend themselves as well to quantification. For instance, “How do you

measure communications for the Public Information Division?” is one example among several for

the department. These kinds of problems are where the second CQI mechanism is triggered.

For these more ambiguous problems, the CQI philosophy is drawn upon extensively to help program

managers delve into the most important component of TCHD programs. Once this has been clearly

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identified, managers are challenged to design a data collection methodology that can be used within

the Performance Management Program.

Monitoring of the effectiveness and efficiency of the CQI program itself is achieved through a

Quality Assurance (QA) program that takes into account the goals and objectives of the CQI

Program, as well as the timeframes identified.

# Objective Timeframe

1 Ensure that the PDCA cycle is fully recognized and acknowledged in each project Quarterly

2 Ensure that CQI projects become more sophisticated and more advanced QI concepts and methodologies implemented

Annually

3 Ensure that additional PDCA cycles are implemented after the initial PDCA Conclusion of each project

4 Increase training opportunities for management team and staff Quarterly

5 Develop and implement quality improvement processes Annually

6 Revise Standard Operating Procedures (SOP) for CQI program at the end of the year to include new standards and methods

Annually

The following QA processes will be utilized to monitor the associated Objectives:

# Quality Assurance Tool Utilized By Objective

1 Each project is monitored utilizing the PDCA Checklist (Appendix A). Quarterly the CQI Manager reviews the completion rate of the PDCA cycle to ensure that each project has fully utilized the PDCA Cycle to include the necessary PDCA elements. This is represented by the CQI Monitoring tool percentage complete data element.

2 Annually, the CQI program manager will review the current ongoing and completed CQI initiatives for opportunities to apply more advanced CQI concepts. This report will be forwarded to the management team with recommendations for implementation. Once approved, the CQI manager will provide additional training for the management team and staff on additional CQI methodologies. The goal will be to increase awareness regarding more complex CQI methods and to use these methods when appropriate. However, the implementation or utilization of more complex CQI strategies and concepts on projects will continue to be dependent on the needs of individual projects.

3 The CQI monitoring tool will be used to track the progress of each project. After the project is complete a determination will be used as to whether additional CQI cycles are necessary to improve processes further. The goal will be to ensure that additional cycles are implemented until an optimal Standard Operating Procedure is identified and monitoring is established to ensure optimal performance is maintained.

4 Training will be provided to the management team, staff and board members on a regular basis. For quality assurance purposes, the CQI Manager will work to provide one training each quarter with documentation on the training and outcomes. An annual report will be submitted to the management team.

5 The benchmark standards established by PHAB and the Public Health Foundation will be utilized to measure and critique the CQI Program. A quality improvement review will be implemented annually to identify areas of improvement within the CQI Program and Projects. This QI review will be based on the Quality Assurance data, training program outcomes, CQI Monitoring tool, or other identified priorities by the CQI Manager in coordination with the Management team and Board. These QI Processes will also be in alignment with the TCHD strategic plan and priorities.

6 After completion of the annual reports and QI processes, the CQI Manager will submit recommendations and revisions to the management team for the Continuous Quality Improvement Plan SOPs to include new standards, concepts, and methodologies.

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CQI Program Evaluation Process The CQI annual report will focus on reporting the accomplishments of the CQI Program, the completed

projects for the year, the lessons learned, training provided, new processes implemented and activities

which may need to be implemented during the coming year. The process to assess the effectiveness of

the quality improvement plan and activities may include:

1. Review of the process and the progress toward achieving goals and objectives

2. Efficiencies and effectiveness obtained and lessons learned

3. Customer/stakeholder satisfaction with services and programs

4. Description of how reports on progress were used to revise and update the quality

improvement plan

Communication of quality improvement activities Communication of quality improvement activities in the Taney County Health Department will be

completed through presentations provided during monthly staff meetings, management team meetings,

and board meetings. In depth CQI Training is conducted on various topics. However, during each staff

meeting, CQI presentations from various programs focusing on accomplishments and lessons learned

are provided. During staff meetings and board meetings, CQI projects that address administrative or

substantial programmatic outcomes are presented. These presentations allow management and board

members to discuss CQI initiatives, ask questions, and learn from the CQI presentations and projects.

20

References: i Casey Family Programs and National Child Welfare Resource Center for Organizational Improvement. “Using

Continuous Quality Improvement to Improve Child Welfare Practice – A Framework for Implementation.” [Online]

14 August, 2007 http://muskie.usm.maine.edu/helpkids/rcpdfs/CQIFramework.pdf

ii Ibid

iii

Center to Advance Palliative Care. “Continuous Quality Improvement” [Online] 14 August, 2007

<http://64.85.16.230/educate/content/development/cqi.html>

iv Salman, Ghassan F. “Continuous Quality Improvement in Rural Health Clinics.” [Online] 14 August, 2007 <

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1490210>

v Crawford, Shirley and Colangelo, Michael. “Methods in Implementing an Effective CQI Program in a Social

Services Setting.” [Online] 11 December, 2007

<http://www.cwla.org/programs/trieschman/2003toolsfiles/2003toolswkshopD2slides.ppt>

vi Melum, Mara Minerva. “How to Make CQI Work For You – Continuous Quality Improvement of Healthcare.”

[Online] 7 December, 2007 < http://findarticles.com/p/articles/mi_m0843/is_n6_v17/ai_11647230>

vii

Slavin, Lee and Bennett, Leo. “Continuous Quality Improvement: What Every Healthcare Manager Needs to

Know” [Online] 15 September, 2007 < http://www.case.edu/med/epidbio/mphp439/CQI.htm> viii

(Quality Improvement Course, 2007) ix

Ibid

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Appendix A

PDCA Checklist