Harrison, Lisa Macon MPH; Shook, Edward D. REHS; Harris, Gibbie FNP, MSPH; Lea, C. Suzanne PhD; Cornett, Amanda MPH; Randolph, Greg D. MD, MPH
Public health has long found itself at the intersection of medical, social, political, environmental, and economic forces—it is a practice of serving communities through assessment, assurance, and policy development to produce better health outcomes across a population.1,2 Often, those working in public health practice have questions about how much and when to depend on formal research and evaluation and how much and when to adapt to the complex and ever-changing context of people in communities to best predict and respond to health needs. Ideally, many different kinds of data are considered in assessing and assuring the public's health.3–5 Often the practice of public health relies on rapid assessment and response to emerging threats such as a food-borne outbreak or the introduction of a new influenza strain where reaction time and solutions to address the public's health cannot wait for more time-intensive processes.
In an era when local and state public health departments are planning for a rapidly changing future while responding to unprecedented challenges within political and economic environments, quality improvement (QI) methods offer an alternative and more timely approach than traditional research and evaluation to help answer public health practice questions, “How do we know when a project or program really works, and, more importantly, how can we do it better?”
The Buncombe County Department of Health (BCDH) is one of 85 autonomous local health departments (LHDs) in North Carolina (NC). A decentralized public health infrastructure allows each of the 85 LHDs opportunity to have a unique culture and various implementation approaches to apply QI to public health programs, services, and projects. Beginning in 2009, a training program called “Public Health QI 101” or “QI 101” was designed to be suitable, practical, and engaging to help public health practitioners learn QI methods and tools. This training program has been offered to the public health workforce in NC through the NC Center for Public Health Quality. See Cornett and colleagues in this issue for more details about the training program.
The BCDH QI team was one of 4 pilot terms to test a QI 101 curriculum where participants in public health departments were introduced to the model for improvement (MFI) approach and practiced the application of small tests of change using plan-do-study-act (PDSA) cycles. The BCDH QI team incorporated this model on a project that aimed to improve communication about H1N1 influenza and personal preparedness awareness among senior citizens. During and after the BCDH project was implemented, members of the QI team relayed the MFI approach to other staff members in the health department, which helped translate and disseminate QI to other work areas.
This article will describe the application of QI in the BCDH by presenting 2 case studies. In sharing these case studies the authors would also like to exemplify how QI approaches can be implemented effectively across different specialty areas within a local health department.
Buncombe County, 1 of 100 counties in the state of North Carolina, has a population of more than 230 000 according to the 2009 census.6 Across Buncombe County, 15.9% of the population is 65 years or older, and the median household income for the population is $40 979.6 Of those 25 years and older, 86.3% are at least high school graduates while 30.6% have a bachelor's degree or higher.6 The population is composed of 16.2% living below poverty level. Asheville is the county seat of Buncombe County and is considered a metropolitan statistical area although the county is predominantly rural. The Buncombe County Department of Health (BCDH) has 189 employees and a presence in 6 physical locations throughout the county. BCDH also has a web presence within in the county government Web site that describes the organization as “an integral part of the quality health care system in Buncombe County that provides core public health services and innovative health care solutions.”7 Like so many local public health agencies, BCDH has a list of more than 25 different areas visitors may either click on electronically or visit in person including disease control, nutrition, adult health, child primary health, dental health, breast and cervical cancer, environmental health, health promotion, vital records, and many more. From the BCDH December 2010 Community Health Assessment, there are 6 priority areas the agency will focus on in 2011–2012 along with 5 guiding principles, which include equity/parity, access to resources, prevention, assets-based approaches, and results/impact/outcomes.7
Of the many QI models that public health can apply, one model often credited with being among the most relevant to public health practice purposes is the MFI (see Figure 1).8 The MFI was developed by associates in process improvement and is used regularly by the Institute for Healthcare Improvement. Both health care organizations and public health agencies have successfully used MFI regularly to approach QI, which includes 3 simple but effective questions that drive improvement processes and outcomes:
1. What are we trying to accomplish? [AIM]
2. How will we know that change is an improvement? [MEASURES]
3. What change can we make that will result in improvement? [IDEAS]
After identifying a QI project and selecting a multidisciplinary team, the team completes an aim statement with measurable goals and a list of related measures to assess progress toward these goals. The “action period” phase of testing ideas and making small changes begins through multiple PDSA cycles (see Figure 2), which facilitate learning and improvement. [The Plan-Do-Study-Act (PDSA) cycle was originally developed by Shewhart as the Plan-Do-Check-Act (PDCA) cycle. Deming modified Shewhart's cycle to PDSA, replacing “Check” with “Study.”]9 The QI team at the BCDH used the MFI approach driven by these questions to determine where Buncombe County senior citizens receive their preparedness information and in what format or delivery mechanism the message is best received.
The MFI QI approach was quickly adopted by the LHD multidisciplinary teams attending the QI 101 Course. Public health practitioners can make small incremental tests of change through QI methods that can be much more efficient than many traditional evaluation approaches often used in public health.
The BCDH QI team included an environmental health specialist, a health educator, an epidemiologist, and a preparedness coordinator who worked together to solve a real-time health communication challenge related to a project on public communication about personal preparedness plans in the midst of influenza season during heightened H1N1 awareness. In Buncombe County, the QI team worked to “...improve the penetration of communication, understanding, and response to personal preparedness messages in the senior (individuals aged 65 years and older) population in Buncombe County.” The message content asked individuals to make available supplies for a preparedness kit in preparation for a potential pandemic influenza. In addition to that specific aim and project to accomplish in the short term, the group had a secondary long-term goal to use the project as a springboard to spread QI application and the MFI approach within the BCHD.
Data collection and human subjects
The focus of this article is on the QI methodology implemented and experienced by the QI team at BCHD. Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines were applied in writing about these case studies. This case study approach incorporated a series of survey sampling methods that were applied to gather a representative response from the target population. Both qualitative and quantitative approaches were used. Data for these case studies were collected between November 2010 and March 2011. QI team members from the BCDH were consulted during each stage of the writing process and were also involved consistently in the editing process of this article. Additional data were obtained from a review of QI project records and documents submitted by the BCDH QI team. The Gillings School of Global Public Health Institutional Review Board (IRB) at UNC Chapel Hill determined that activities associated with this case study did not constitute human subjects research as defined under federal regulations and did not require the IRB approval.
The BCDH QI team began their application of PDSA cycles on survey questions during intercept interviews with senior citizens in a local mall and at a local baseball park. Before a communication message was finalized, the team carefully tested the message and delivery modes. The outcome after message testing was to produce a television commercial to reach the 65-and-older population about the importance of having a personal preparedness plan and supplies collected for a preparedness kit. A series of 3 PDSA cycles helped the QI team refine the survey, implement changes, and improve their reach among the targeted population. A summary of the PDSA cycles is listed in Table 1.
Three PDSA cycles at the onset of the preparedness communication project gave the Buncombe County QI team an opportunity to refine their message specifically for those older than 65 years. The words, images, the commercial spokesperson, media outlet, and time of the message airing were selected on the basis of survey answers and opinions from the target population. This series of PDSA cycles was effective in directing the BCDH QI team to make the right changes in designing preparedness messages. One team member said, “We learned a lot about the population we were targeting and a lot about how to word questions and messages so they resonated well with people for whom this message was intended.” Additional intercept interviews were conducted in a similar fashion after the message aired to inquire about the effectiveness and penetration of the communication effort.
The BCDH QI team documented results for their short-term preparedness project and for the longer-term goal of spreading QI to other areas of the health department in pursuit of a continuous QI (CQI) culture. PDSA cycles were applied to the initial project both as the team developed the survey and as they tested the success of the preparedness messages reaching the target population. Reflected in the final survey results with 349 interviews with senior citizens (see Figure 3), 37% had seen the preparedness commercial. Because of the commercial, 46 (13%) seniors added something to their existing preparedness kit, thought about assembling a kit, or actually started a preparedness kit.
One member of the improvement team remembers, “The PDSA-cycle approach gave us the template to test potential solutions without investing a tremendous amount of time or resources. We have already observed staff using these principles to tackle every-day problems in a systematic way.” The experience of applying MFI to this preparedness project spurred on discussion within the health department and across different work areas. The successful use of PDSA cycles did not stop with this first project but spread quickly and continues throughout the health department as the culture shifts to include CQI.
Spreading QI to other areas of the health department
The Buncombe County QI team established an ongoing approach to train others in the agency working through regular leadership team meetings and developed an expanded QI team to address other projects in different areas in the health department. For example, in the maternal and child care clinic, a project came about as clinic staff noticed a backlog of prenatal appointments (see Table 2). Through observation, BCDH staff learned that collection of prenatal histories was slowing the flow of patients through the clinic and appointed a team of maternal and child health care staff to improve access to prenatal appointments. Given budget reductions in the county, no additional staff members were available or could be hired. Having identified the bottleneck to accessing care, maternal and child health care staff were quickly able to adapt the MFI approach after only a few meetings with the pilot team, and it was easy for these individuals with a clinical or science-related background to create a hypothesis about a process, create an aim, collect data to measure where they were, and then test small changes in the process to see how they could change the outcome.
The task of obtaining the patient's prenatal history was essentially divided into 2 areas, one that addressed psychosocial issues and was completed by the Social Work staff, and the other that addressed medical issues and was completed by a registered nurse (RN). The RN was always available if the social work staff had questions or if staff were not certain how to address a specific question or response. As a result, within a 5-week period, the backlog was reduced from 54 patients waiting to 15 (see Figure 4). Staff on the QI team were continually updated on the success the project yielded over time which created a sense of urgency to make further changes and helped persuade the more skeptical staff to participate. The new QI team continues to meet on a regular basis to reduce the waiting time and prevent its recurrence of a backlog.
Whether working on the preparedness project, or training additional staff in other areas of the agency, the Buncombe County QI team enjoyed early and continued success. Their own words summarized the experience of the training and application of QI as “QI is essential and achievable.” They added that QI can be a simple, nonburdensome process. The team reflected that all the members together bring valuable insight and knowledge to the table when beginning a QI project. In their own words, the BCDH QI team learned:
Depending on the specific project, the QI team needs to be flexible as to its membership (multiple disciplines represented). Also, never assume anything or project results before a PDSA is completed. When a QI project is underway in an agency, it is always a good approach to update all staff as to progress and success. Even the setbacks can be used to unify staff in a common effort of quality improvement. This staff involvement allows more individuals share in the success and lay a better foundation for future QI efforts. The most evident way that we are already using QI skills is by testing with small groups and very limited processes. This saves a tremendous amount of time and resources and can provide quick results, especially if you are heading in the wrong direction. We as a team will continue to use our bi-monthly leadership team meetings as a forum for QI and update staff on QI projects and ongoing PDSAs.
The BCDH QI team continues to build on early successes in their application of the MFI. Additional projects emerge as staff discover new opportunities to connect QI to their daily work. One member of the original BCDH QI team is attending a new curriculum for developing expert QI advisors to build internal capacity for health departments to apply QI methods. A second team member is eager to begin the next cohort of QI advisor training. Effective leadership that supports the spread of QI in an organization along with access to continued skill building and encouragement like those included in programs offered through the NC Center for Public Health Quality will help maintain a new culture across the public health workforce and sustain QI in LHDs in North Carolina.
Local governmental public health agencies serve the community offering health promotion programs, disease-prevention services, population-focused surveillance and intervention, and in some cases, clinical care for individuals as well. As Riley and Brewer point out, despite the multiple layers of operations, services, programs, enforcement powers, agendas, stakeholders, data systems, reports, and political demands placed on local public health agencies and their committed workforce, there are few resources available to accomplish it all and... “Successful performance is a dynamic non-event”—when we do our jobs well in public health, like in other government service areas, it often goes largely unnoticed. Still, there is always room for improvement.10(p147)
The BCDH QI team built on the strengths and assets of the health department, despite diminishing resources and increased demand for services, and the added burden of an unpredictable influenza season. Staff learned the benefits of applying MFI to a project that needed to be accomplished quickly in response to the H1N1 influenza preparedness. The team reflected that actually making time to focus on the QI approach was a challenge initially, because the work itself was being constantly interrupted by all the new work associated with the H1N1 pandemic during a reorganization of the health department. This is a difficult time for most LHDs; however, in the most challenging times, many health departments may find that investment in QI is worth the effort, just as BCDH did. There are opportunities related to applying QI, such as communicating to staff and customers that QI is a means to improve service to our citizens, conserve resources, and better utilize staff of the organization. Through the maternal and child health clinic example, staff realized a more fluid approach to working together across social work and nursing roles. When social work staff was unavailable, the RNs completed psychosocial components, and there were times that the social workers were able to provide extra screenings for the nurses. A positive consequence of approaching a system-level QI project can be that staff work better, faster, and smarter together as happened in the BCDH maternal and child health clinic example.
Quality improvement and its utility have been well established—there are many tools and approaches that have been shared across industries. Now too, in public health, QI is being applied to discover innovative and efficient approaches to public health programs and services so that we can better serve communities.10 Quality improvement in general, and the MFI specifically, is not simply a way to manage or save costs. In fact, one BCDH QI team member noted that it has been important in their agency to qualify the importance of using QI for collecting data and solving problems and improving outcomes, not for streamlining staff or justifying a reduction in force. This is an important distinction in implementing QI effectively and having staff gain enthusiasm for adopting and sharing QI approaches.11 In applying MFI in particular, conducting small tests of change can yield quick results and improvements that staff notice and feel in control over immediately—that too, can be a motivator to keep making change and further improvements. The more enthusiasm staff have, the faster they can affect or start to sense a change in the culture of the organization. Alternatively, if the small changes realized of MFI application do not result in an improvement, or result in failure, it is better to know sooner rather than later to minimize the impact of resources utilized. There is a careful balance to strike for public health in realizing that the MFI approach and the PDSA cycle series have great utility for short-term change measurements that allow staff to respond efficiently, make informed decisions to improve, and adapt a process and focus on necessary or discrete activities (see Figure 5). However, the data collection effort is not often as rigorous, long-term, and complete, potentially, as a formal research-influenced evaluation may be for a project over all—both approaches are important to making improvements in public health practice.
Prioritizing QI is first a commitment of leadership and then, as Gorenflo discusses in Achieving a Culture of Quality Improvement, a way to achieve a culture change in an organization where “each individual acts with an eye toward improvement.”12(p83) It takes dedicated time and a collective effort to gain buy-in for using QI approaches. Riley and Brewer reiterate this point from their analysis of spreading QI in police departments that there should be “a comprehensive QI management philosophy” and a commitment from top leadership when spreading QI into and through public health agencies.10 The BCDH succeeded in the beginning of a culture change and attribute this change to assigning a member of the senior leadership team as the champion for QI in the department. In addition, they are still careful to recognize that frontline staff who do the work should always be involved in their QI efforts. Culture change is not easy, is not instant, and sustaining change is a challenge; however, there are local agencies that can illuminate a path (see Randolph et al in this issue).
The Public Health Quality Improvement Handbook (2009) includes a case study of a public health collaborative in Minnesota also applying the MFI. They, too, noticed that dedicating staff time was a significant challenge and that successful QI implementation requires continuous commitment from leaders and team members alike. The author of the Minnesota case study reflected, “It is difficult to prioritize quality improvement in the midst of multiple competing interests that require immediate time and attention.”11(p350) Indeed deciding to commit human capital toward improving health outcomes makes sense intellectually, yet it is not always easy to remain steadfast during crises. In fact, this delicate balance of resource allocation is the very reason QI should be a continuous approach in public health practice. QI methods can help improve efficiency and health outcomes while incorporating many of the resources already available to local health departments.
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local public health agency; model for improvement; performance improvement; plan-do-study-act; quality improvement; quality improvement approaches; quality improvement methods in public health; quality improvement tools
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