MLC-3 States Teleconference/Webinar November 7th, 2008 The Key Components of Quality Improvement Project: A Step by Step Process John W. Moran – Senior.

MLC-3 States Teleconference/Webinar November 7th, 2008

The Key Components of Quality Improvement Project: A Step by Step Process

John W. Moran – Senior Quality Advisor

Public Health Foundation

Grace L. Duffy – Quality Consultant

Public Health Foundation

…PHF Mission: Improving public health infrastructureand performance through innovative solutions and measurable results. 

Innovative Solutions. Measurable Results.

Objectives

By the conclusion of this MLC-3 Call, participantswill develop a better understanding of how to:• Plan For A Quality Improvement Project• Build AIM QI Project Statements• Move from Priorities to Action• Track the Quality Improvement Project

Planning For A Quality Improvement Project

• Think about the end state before you start –

Telling Those Not Involved:– Why you picked the problem– What you focused on– How you analyzed it– Difficulties or roadblocks– How you improved it– What the improvements will accomplish

Planning For A Quality Improvement Project

• What are the key components of a quality improvement project?– Technical Content and Team Dynamics

Must Be In Sync

Questions?

Please change the “feedback” color to purple (top right side of your

screen) if you have a question.

Planning For A Quality Improvement Project

• Creating an AIM statement• Developing a theory for improvement• Testing the theory / intervention• Analyzing results• Standardizing improvements

Progression to the AIM Statement

Focusing Statement: Strategic data gathering level to describe current state of process(es) involved in the area of opportunity/discomfort.

Issue Statement: Strategic statement of desired future state once the opportunity/discomfort is successfully addressed.

Aim Statement: Operational definition of measureable outcomes that will move the current state situation to the future state desired by the project champions.

Current State: Future State:

Pathway

Consequences

Driving Forces

Benefits

Issue and Focus Statements

• Developing the AIM of the QI Project:– What is the Issue?– What are the current state conditions?– What is driving us to change?– What are the consequences of not changing?– What are the benefits of changing?– What will the future look like?

Developing Focusing, Issue, and AIM Statements

• When developing the Focusing and Issue Statements, stay at a strategic level in the explanation and try not to get too operational – let the participants move to the details.

• Also, try not to suggest or imply any solutions.

Focusing Statement – Current State

• Describe some background around the issue/problem that has been selected for those who will be working on it.– What is the current state?– Why is this important?– What is it costing us – time/dollars/staff/etc?– What is the impact on our clients?– What is the impact on our division/agency?

Focusing Statement – Current State Example

• Too few state and local public health agencies are measuring their success based on improvements in community health outcomes. Through development of agency-wide performance management systems and the routine employment of quality improvement (QI) techniques, public health agencies can improve their performance, become more accountable to the public and policy makers, and achieve better community health outcomes. At the present time, performance management and QI are not well-integrated into most public health agencies

Issue Statement – Moving To The Future State

• Want to give the participants working on the issue some of your thinking, in broad terms, on what the future state should look like. What needs to improve, change, or be created. Want to describe:– What are the important aspects of the future state?– What is driving us to this future state?– What might be the consequences of not moving to the future

state?– What might change?– What is the proposed timeline?

Issue Statement – Moving To The Future State Example

• To improve the current public health situation and begin moving public health to the "cutting edge of quality and innovation," how will XYZ accomplish this within the next 3 years?

Components of the Issue Statement

• Describe the components of the issue statement in discrete high level elements. In this section we want to answer the questions:– Do we as a group have complete control over the element?– Can we implement a solution to this element when we finally

develop it?– Do we have to involve and influence others to get the

element resolved?– Is this element outside our control and influence ability?

Components of the Issue Statement

Element Control Implement Involve &Influence

Outside OurControl &Influence

For each element check which column(s) applyFrom this, select the area(s) of focus, develop a ranking of the elements to focus on, and write the AIM statement for the Quality Improvement project to be started.

AIM Statement

• At this level we begin to look more operationally rather than strategically. Example:

• How to focus our department’s resources on the shifting socio-economic clients now requiring services from us.

• How will we serve people now needing health services?

• How will we implement a property maintenance program to preserve our community’s character?

Questions?

Please change the “feedback” color to purple (top right side of your

screen) if you have a question.

Measurement

How do we currently

measure this area and

what is the current

baseline data telling

us about the situation?

Time Frame

• What are the key critical dates when things must be completed?

• Who is responsible?• Use a Gantt Chart

Current State:

• What is the current state?• Why is this important?• What is it costing us – time/dollars/staff/etc?• What is the impact on our customer/clients?• What is the impact on our division/agency?

Future State:

• What are the important aspects of the future state• What is driving us to this future state?• What might be the consequences of not moving to the future state?• What might change?• What is the proposed timeline?

Pathway

Consequences• Could become irrelevant• Others drive the agenda• Those in need still struggle

Driving Forces:• Economy• Practice Standard• Morally Right

Benefits• Understand true costs• Better able to respond• Qualify for grants• Increased budget•Those in need get services

Planning For A Quality Improvement Project

• Developing a theory for improvement• Testing the theory / intervention• Analyzing results• Standardizing improvements

Plan–Do–Check–Act

Do

Act Plan

Check

Plan Plan changes aimed at improvement, matched to root causes

Do Carry out changes; try first on small scale

Check See if you get the desired results

Act Make changes based on what you learned; spread success

Also called Plan-Do-Study-Act (PDSA), PDCA, PDCA Cycle, or Shewhart Cycle

Plan–Do–Check–ActExpanded in 7 Steps

Select the problem or improvement opportunity

Describe the current process

Describe all of the possible causes of the problem, and agree on the root cause(s) to address

Develop a workable solution and action plan, including targets or measures to know if the change is an improvement

Plan

Plan–Do–Check–ActPLAN: 3 questions to use in any order

Model for Improvement*

What are we trying to accomplish?

How will we know that a changeis an improvement?

What change can we make that will result in improvement?

*Associates in Process Improvement. (Langley, Nolan, et al, 1996.)

What happens when we need to just sustain current practice?

Plan–Do–Check–Act

⑤ Implement the solution or process change

⑥ Review and evaluate the result of the change

⑦ Reflect and act on learnings

Do

Check

Act

CAPACITY• Health dept.

workforce turnover

• Completion of annual health profile by every LHD

Measures of changes that lead to improvement in…

PROCESS• No-show WIC

appointments• % women

who receive adequate prenatal care

OUTCOME• Influenza

deaths• Multi-drug

resistant tuberculosis cases

Continuous Improvement

Act

DoCheck

PlanThe continuous improvement phase of a process is how you make a change in direction. The change usually is because the process output is deteriorating or customer needs have changed

Maintenance and Standardization

Standardize

Check

Act

Do

The Maintenance and Standardization phase of a process is how we hold the Gains. If our process is producingThe desired results we standardizeWhat we are doing.

Integrated CycleThe SDCA and PDCA cycles areseparate but integrated. Once we have made a successful change we standardize and hold the gain.

When the process is not performingcorrectly we go from SDCA to PDCAand once we have the process performing correctly we standardize again.

This switching back and forth betweenSDCA and PDCA provides the opportunity to keep our processcustomer focused.

• Know if you are on track to reach your destination

• Make mid-course adjustments

• See how one thing affects another

Successful improvement efforts “check in” along the way

Questions?

Please change the “feedback” color to purple (top right side of your

screen) if you have a question.

Integrating the Gantt Chart and the PDCA Cycle

Milestones Year 1(2008-2009)

Year 2(2009-2010)

Year 3(2010-2011)

Quarters 1 2 3 4 1 2 3 4 1 2 3 4

Achieve measurable improvements in health department performance through application of quality improvement methods

Select Target Areas

Conduct RFP process for mini-collaborative participation

Hold 2-day kickoff QI training for mini collaborative grantees (for grantees and other interested LHDs)

Develop collaborative work plans

Hold routine technical assistance teleconferences with collaborative participants

Conduct 1-day follow-up QI training

Rapid cycle improvements in participating LHDs

Develop semi-annual progress reports on mini-collaborative QI activities, through storyboards and other approaches

Promote and sustain QI efforts statewide through the IPHI Center for Community Capacity

Development and the “ambassadors” program

Integrating the Gantt Chart and the PDCA Cycle

Plan

Check

Act

Do

Select Target Areas – 1st Qtr 2008Conduct RFP Process – 2nd Qtr 2008

Original Concept developed by Livingston County Department of Health , NY

Hold 2-day Kickoff QI Training3rd Qtr 2008Develop Collaborative Work Plans 4th Qtr 2008Hold Routine Technical

Assistance Calls 4th Qtr 2008

Develop Semi-Annual Reports 2nd Qtr 2009

Helpful Resources• MLC Webpage: www.nnphi.org/mlc• NNPHI eCatalog: www.nnphi.org/eCatalog• NPHPSP User Guide: Fall 2007:

www.cdc.gov/od/ocphp/nphpsp/Documents/NPHPSPuserguide2004Apr.pdf

• Guide to Community Preventive Services: www.thecommunityguide.org/

• Healthy People 2010 Information Access Project: phpartners.org/hp/

• NACCHO Model Practices: www.naccho.org/topics/modelpractices/index.cfm

• NPHPSP Online Resource Center: www.phf.org/nphpsp/

• Public Health Infrastructure Resource Center: www.phf.org/infrastructure/

• Public Health Memory Jogger II: www.goalqpc.com/shop_products_detail.cfm?PID=754&PageNum_GetProducts=1&ProductShopBy=7

Thank You

For additional information:• Jack Moran, Senior Quality Advisor, PHF:

202.218.4423; [email protected]• Grace Duffy, PHF Consultant;

352.406.8262; [email protected]

Questions?

Please change the “feedback” color to purple (top right side of your

screen) if you have a question.

Announcements

Additional Opportunities for Sharing: Your input is requested

RWJF Call for Proposals Update on Site Visits MLC Wiki Important Dates

Quarterly Report due 11/17 Semi-annual financial report due 11/17 December 12th at 12:00 ET: Planning Call for Open Forum December 12th at 1:00 ET: Webinar by Spitfire Strategies January 9th, 2009 at 1:00 ET: Teleconference (Accreditation

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