Randolph, Greg D. MD, MPH; Stanley, Cappie RN, MPH; Rowe, Bobbie AMOA; Massie, Sara E. MPH; Cornett, Amanda MPH; Harrison, Lisa Macon MPH; Lea, C. Suzanne PhD
For many years, industries such as manufacturing and health care have used quality improvement methods and tools to reduce errors, improve efficiency and effectiveness, and improve customer satisfaction. More recently, public health organizations have also begun to focus on using quality improvement methods and tools to improve public health practice.1
Developing the organizational culture and infrastructure is critical for the sustainability of continuous improvement in any organization.2 To date, little is known about how to develop a supportive culture and infrastructure for continuous quality improvement (CQI) in public health settings. In this article, we offer readers the opportunity to learn from the experiences and approaches of a local public health agency in North Carolina that has been an innovative, early adopter of CQI. We describe Cabarrus Health Alliance's 10-year CQI journey, from getting started in quality improvement to developing a CQI infrastructure and changing the organization's culture. We also focus on the benefits of CQI for the organization's leaders, managers, frontline staff, and the clients/communities that they serve.
The Public Health Authority of Cabarrus County, known as the Cabarrus Health Alliance (CHA), is a public hospital authority and an accredited (through North Carolina's Local Health Department Accreditation Program) local health department in Cabarrus County, North Carolina. Although the CHA is an autonomous governmental entity rather than a traditional county health department, it fulfills the same functions as other local health departments in North Carolina.
Cabarrus Health Alliance's mission is “to achieve the highest level of individual and community health through collaborative action,”3 which emphasizes their belief that local public health problems are best addressed by local partnerships. Cabarrus Health Alliance operates as a public-private partnership and is governed by a 7-member board of directors that has ultimate responsibility for all operational and financial policies. Day-to-day budgetary and programmatic decisions on the basis of contractual obligations are made by program directors who report directly to the chief executive officer (health director).
Cabarrus Health Alliance's clinical services include comprehensive maternity and pediatric primary care; family planning; immunizations; dental care; case management; communicable disease services; and the Special Supplemental Nutrition Program for Women, Infants, and Children. Cabarrus Health Alliance also provides programs on heart disease and stroke prevention, teen pregnancy prevention, Latino youth development, tobacco prevention and cessation, faith-based exercise and nutrition, and childhood obesity prevention. In addition to these clinical services and programs, CHA provides public health services to the community, including environmental health protection, disease surveillance and prevention, nursing services for schools and child care facilities, and health education.
Cabarrus County, North Carolina, is home to 172 223 residents, making it the 12th most populous county (out of 100 counties) in North Carolina. The racial composition of the county is 82% white, 15% African American, and 3% other; 9% of the county's citizens identify themselves as Hispanic. In fiscal year 2008, 63% of CHA clients were uninsured/self-paid and 26% were Medicaid eligible.
Data for this case study were collected between November 2010 and January 2011. Two coauthors (G.R. and S.M.) conducted telephone interviews with 9 CHA employees (2 quality improvement leaders, 3 senior management staff, and 4 frontline staff) using semistructured interview guides consisting of approximately 15 questions. Interviewees were asked to reflect on their experiences at CHA since 1997 or the start of their employment at CHA, if subsequent to 1997. Additional data came from a review of CHA's quality improvement project records and documents related to strategic planning and the CQI infrastructure. One of the coauthors (C.S.), who led many of the quality improvement programs over the past 10 years, provided historical context and identified key informants to interview.
The institutional review board at the University of North Carolina at Chapel Hill reviewed this study and determined that it does not constitute human subjects research as defined under federal regulations [45 CFR 46.102 (d or f) and 21 CFR 56.102(c)(e)(l)] and does not require institutional review board approval. To protect the confidentiality of CHA staff responses, recorded interviews were saved on a password-protected server and direct quotations were not associated with interviewees' names or titles without permission.
Beginning the quality improvement journey: The local problems and intended improvements
Before using quality improvement, one leader described CHA as having “a typical public health department culture focused on QA [quality assurance, generally defined as monitoring a service to determine if predetermined standards of quality are being met].” Management primarily focused on goals driven by funders and state program audits. Some of the barriers in CHA's clinical areas illustrate the challenges to achieving their mission:
* The CHA decision-making approach was largely top-down;
* The clinic area was physically separated from registration staff, leading to communication issues;
* The organization lacked essential equipment for efficient operations;
* There was little evidence of teamwork in clinic settings; and
* Managers were aware of problems but did not have adequate data to understand the sources of problems or to generate ideas for improvement.
In addition, according to one leader, the agency lacked a strong customer focus: “We were acting like we were not a business. ... We thought the customers would always be there.” As another leader said, “Our main focus was on passing audits.” Moreover, the health director was not satisfied that quality assurance or previous attempts with total quality management were resulting in adequate improvement and was eager to try new approaches to better serve the community. In his words, CHA “wanted to improve, we just didn't know how.”
In 1997, when CHA converted from a county health department to the Public Health Authority of Cabarrus County, the new entity conducted a community needs assessment, which identified access to primary care as one of the major challenges in the community. In addition, CHA hired several new clinicians and clinical staff from private pediatric offices who were attracted to CHA's mission and, importantly, more open to innovative ideas to improve primary care access and efficiency. The new focus on primary care led to a significant influx of new patients, resulting in an overwhelmed clinic schedule and patient flow processes. These changes were powerful motivators for CHA to look for new ways to improve their primary care and other clinical processes and reduce delays for care.
In 2001, the health director set a stretch goal: CHA would be the best health-related organization (ie, any organization in the public health or health care sector) in the country, not just the best public health organization. To do this, the organization would need to try new approaches to improvement. This led CHA to the Institute for Healthcare Improvement (IHI), a nonprofit organization that has been one of the most influential forces in the promotion of CQI in health care organizations, especially hospitals. The health director, in his words, “took a chance” and enrolled CHA's Child Health Clinic in an IHI learning collaborative aimed at improving clinic access and efficiency in outpatient clinics. Although the leadership at CHA knew that they were taking a risk, they believed that they would be more likely to succeed in quality improvement if they started this work in a clinical area rather than a nonclinical area because of IHI's experience and resources for improving access and efficiency in clinical settings.
The IHI collaborative provided quality improvement training to a 4-member team from CHA, including coaching from a quality improvement expert, evidence-based resources and tools to improve clinic access and efficiency, and a collaborative environment for learning new strategies from quality improvement experts and other participating organizations. Support and resources provided by the year-long collaborative helped CHA begin building its staff's quality improvement capacity. The 4-member CHA team was responsible for translating the learning during the collaborative to a team of 25 clinical staff (clinical providers, nurses, laboratory staff, medical records, and billing staff) as part of the collaborative process.
Lessons learned from the initial quality improvement experience
After successful completion of the IHI collaborative, the CHA improvement team achieved measurable improvements:
* Delays for routine appointments were reduced from 28 days to same day,
* Total clinic visit time was reduced from 100 to 89 minutes,
* Patient satisfaction with wait times rose from 53% to 59%, and
* Staff satisfaction increased from 80% to 100% of staff rating the agency as a great place to work.
Participation in the IHI collaborative not only affected clinic outcomes, but it also produced benefits for leaders and staff throughout the organization. Perhaps most important, according to the health director, was that CHA succeeded in their first quality improvement project: “We learned we could make drastic improvements [with quality improvement]. ... It had a wow factor.” The data-driven approach of the quality improvement project helped create the business case to hire an additional interpreter for the child health clinic. Visit times were shown to be much shorter when an interpreter was in clinic compared with when an interpreter was not available. The addition of a second interpreter was viewed widely as a successful outcome, which fostered buy-in from clinical staff. Moreover, leaders began to understand the importance of involving staff in creating solutions. As one leader commented, “quality improvement made me a better leader by really focusing me on getting input from frontline staff. ... I wish I'd learned this much earlier in my career.... I really enjoy the diversity of people coming together to work on solutions.”
In addition to the support from the IHI collaborative, support from the health director as well as involvement of an enthusiastic physician champion from the child health clinic were cited as important ingredients for CHA's success in the IHI collaborative. The CHA quality improvement team learned 3 other lessons from the IHI collaborative. First, staff noted the importance of involving fewer leaders and managers and more frontline staff on improvement teams. Engagement of frontline staff generated some initial successes, which provided a solid foundation upon which to build. Second, it was noted that most, if not all, staff members needed quality improvement training. Third, leaders and managers learned that it was important to allot time for frontline staff to work on improvement projects, rather than adding it on top of their existing responsibilities.
Moving from initial successful quality improvement efforts to an organization supporting CQI
Following the initial successful quality improvement project, spread of quality improvement throughout the agency was slowed by organizational and leadership changes during 2004 to 2007. However, successful completion of an additional quality improvement project within the dental clinic generated positive momentum for quality improvement across the organization. The dental clinic's manager, who participated in the initial IHI collaborative, led a number of quality improvement projects within the dental clinic that applied evidence-based strategies to increase its patient flow efficiency and business processes. The projects resulted in a 25% increase in clients seen per year and an increase in net revenue over expenses of $74 419.00 within 1 year.
To ensure sustainability of their projects, several key staff working in the targeted improvement areas were allotted a small amount of time for conducting quality improvement work, including data collection, management, and analysis. In addition, all clinical services staff were trained about how to use the Model for Improvement, the improvement method that CHA learned in the IHI collaborative, through quality improvement trainings and annual refresher trainings led by staff who had developed quality improvement expertise. This method uses plan-do-study-act (PDSA) cycles to test new ideas for improvement on a small scale (rapid cycle testing). In addition, a quality improvement council that consisted of frontline staff from across all CHA clinics was developed to guide the improvement work in their clinics. The quality improvement council meets monthly. Its goals are to help achieve the goals set by the CHA board in the areas of customer satisfaction, access to care, provider productivity, financial outcomes, and staff turnover. The council standardized data collection efforts by deciding the type of tools to be used and frequency of use (eg, appointment delays weekly, clinic appointment capacity quarterly, staff satisfaction every 6 months, customer satisfaction quarterly). Individual program areas report on their PDSA cycles at these meetings and collaborate on ways to address issues common to multiple programs (eg, no show rates, increased waiting times because of electronic medical record conversion).
Cabarrus Health Alliance has learned and used a variety of quality improvement tools and methods over the years, including PDSA cycles, spaghetti diagrams, run charts, time studies, and staff and customer surveys. In the past few years, CHA has tried projects using Lean and Business Process Analysis as well as new tools such as gemba walks, value stream maps, and root cause analysis (Tague's The Quality Toolbox4 is an excellent resource for additional information about these and other quality improvement tools).
Leaders and managers noted 3 things that helped CHA continue to spread quality improvement. The first important strategy was engagement of frontline staff. When quality improvement is done right, it empowers frontline staff to come up with solutions to the problems that frustrate them every day. At CHA, quality improvement projects allowed staff to see that their ideas are valued, and the staff enjoyed witnessing the impact of the projects on the services they deliver. The second important strategy was constant communication about quality improvement and the success of the organization's quality improvement projects through “lunch and learns” and celebrations of milestones and successes. The health director noted that it was important for leaders and managers to be good role models and “live it [quality improvement] on a day-to-day basis.” Lastly, providing the aforementioned basic quality improvement training and annual refresher trainings for staff was another important strategy for spreading quality improvement. For the past 10 years, CHA has trained new staff during orientation and provided annual updates for all clinical staff.
In 2004, the health director decided to spread quality improvement to the entire organization. Over the ensuing years, CHA launched quality improvement projects in areas beyond clinical services, such as Special Supplemental Nutrition Program for Women, Infants, and Children and human resources. Importantly, CHA has used quality improvement to address population health issues in their community. For example, CHA has a community-based oral health screening, education, and treatment program aimed at reducing dental decay among children entering kindergarten. Various quality improvement strategies were used to work with community partners, including child care centers, Head Start programs, Special Supplemental Nutrition Program for Women, Infants, and Children, pediatricians, dentists, and the school system, in to promote evidence-based strategies to reduce caries. Other recent examples of population health-focused initiatives utilizing quality improvement include an initiative to reduce sexual and other risk behaviors while increasing protective factors among the middle and high school population and a community-based childhood obesity prevention project that includes pediatric providers, schools, the hospital, the city parks and recreation, day cares, and faith community to develop policies and programs supporting increased physical activity and improved nutrition.
The CQI infrastructure and culture today
The quality improvement council has expanded to include nonclinical areas of CHA. The quality improvement council now meets monthly to select new quality improvement projects and reviews the organization's performance measures quarterly. The performance measures, which had been in place since 2003, have been updated to include a more comprehensive set of performance metrics, which are reviewed by the CHA leaders and its board of directors. (Figures 1 and 2 show examples of the agency performance measures and a unit's performance measures. Note that these measure sets are very similar; they illustrate how a unit's [in this case dental services unit] performance measures are aligned with the agency's and thus can be “rolled up” to feed the agency's performance measures.) Aspects of the organizational performance measures have been incorporated into all employees' work plans and linked to employees' performance bonuses. Improvement targets were also added to management work plans and performance appraisals. In fact, leaders and managers can be terminated if the areas they supervise are consistently not meeting their improvement goals. Finally, staff members are empowered to change their daily work processes independently, without their managers' permission, using PDSA cycles. One of the important roles of the quality improvement council is to identify strategic quality improvement projects, which are then approved by the CHA leadership team, comprising the health director, senior leaders, and a staff representative.
Today, staff and leaders at CHA describe the culture as being very different from 2001, when they first embraced quality improvement. Leaders stressed that one of the biggest changes is that employees regularly make changes in their daily work to continuously improve. As one leader explained, “change is expected of all of our staff.” Staff members throughout the agency have also become more customer focused. Another commonly mentioned change is the greater focus on data and evidence-based practice, with both frontline staff and managers using data to inform decisions. Improvement in data collection and analysis is now required of all CHA programs. “We look at QI first in decision-making ... and we ask, how will this affect our quality?” according to the health director. Other leaders mentioned that managers are expected to look at benchmarks to make their data more meaningful.
Reflections on CHA's 10-year CQI journey
The health director shared several key points for other leaders who want to succeed with CQI:
1. Learn about quality improvement first; take the time you need to educate yourself;
2. Listen to your employees, especially frontline staff, for identifying opportunities for improvement;
3. Look to outside leaders and resources;
4. Set audacious goals; and
5. Ensure your organization's leaders are sponsors of projects and are constantly supporting quality improvement.
Other leaders stressed many of these points, especially the need for leadership support and involving frontline staff in problem solving. Another key point raised by one leader was to be sure to begin small when getting started with quality improvement work: “You don't have to have an enormous plan, just get started with small projects.”
When asked about the things they were most proud of, nearly all leaders and managers cited the benefits of CQI for their staff. They noted that their quality improvement work created a better work environment, raised staff satisfaction, decreased staff stress, reduced staff turnover, and helped staff see better ways to do things. Several leaders also mentioned that leaders, managers, and staff all appreciate the fact that through their quality improvement work they are able to provide more services with the same number of staff and resources and, moreover, the services that they provide are of measurably higher quality and better meet the needs of their customers.
The impact of CQI on CHA and the community and clients they serve has been quite broad and remarkable. Some notable results include the following:
* The rate of dental decay among children entering kindergarten in the county decreased from 26 to 13 over the past 10 years;
* Staff turnover at CHA decreased from 17% in 2001 to 11% in 2010;
* The Dental Clinic went from an annual net loss of $248 653 to a net gain of $462 370 from 2004 to 2010;
* The number of dental patients served increased 311% from 2001 to 2010, with 14 969 patients receiving dental services in 2010;
* The Women's and Children's Clinics increased third-party reimbursements from 57% of the budget in 2001 to 68% in 2010 and now serve 59% more patients than in 2001; and
* Between 2005 and 2008, pediatric services' reliance on county tax revenues decreased by 72% and contributed to CHA being able to place school health nurses in every public school in the county.
Over the past 10 years, CHA has steadily and successfully integrated CQI into its organizational operations and culture. Cabarrus Health Alliance has built a supporting infrastructure for CQI that includes a quality improvement council to select and support targeted improvements, performance measures, incentive plans tied to performance, quality improvement training, and protected time for quality improvement work. Cabarrus Health Alliance has also focused its leaders and managers on using quality improvement to better serve their customers. As a result, CHA has successfully ingrained CQI into the culture of its organization, with a substantial impact on customer service, efficiency, effectiveness, and staff satisfaction and turnover.
A number of important strategies stand out in the evolution of CHA's successful integration on CQI over the past decade:
1. Set stretch goals that are measurable;
2. Build staff capacity to use quality improvement tools by using outside resources (if there is no internal expertise);
3. Choose low-hanging fruit for initial projects (in other words, start small, with projects that have a high likelihood of being successful);
4. Choose projects of strategic importance, related to the strategic plan of the organization;
5. Focus primarily on developing strong leadership support for quality improvement and focus leaders on empowering frontline staff to make changes;
6. Communicate and celebrate often about quality improvement and the resulting successes;
7. Keep the momentum going by launching new quality improvement projects;
8. Spread quality improvement to the entire organization (in other words, avoid quality improvement remaining in silos within selected departments such as clinical areas);
9. Sustain and integrate CQI by developing a supporting infrastructure, which includes a quality improvement council, performance measures, staff training, and related incentives.
Many of these strategies are consistent with the recommendations of Kotter in his seminal paper, “Leading Change–-Why Transformation Efforts Fail.”5 Kotter outlines 8 critical steps to any transformation effort, and, indeed, CHA's experience aligns quite well (Table 1). Similarly, many of the strategies CHA successfully used over the past decade are consistent with the work of Everett Rogers on the diffusion of innovations.6 For example, Rogers stresses the importance of establishing and communicating the relative advantages of a new approach as well as assuring the observability of the new approach. Cabarrus Health Alliance spends a lot of time communicating about their quality improvement results and celebrating their successes. Rogers also stresses the importance of making the new approach simple and easy to try, which CHA achieved by starting with small projects that were thought to be highly likely to be successful. Rogers also highlights the need for new approaches to be compatible with existing work processes. Cabarrus Health Alliance provides a small amount of protected time for staff to build quality improvement into their work effort.
This case study is limited in that it reviews a single organization with its own unique set of contextual factors such as its governance structure, leaders and staff, the community it serves, and its external environment. It is not possible for the authors to tease out which strategies may be generalizable to a wide range of local public health departments versus those that may be more specific to the situation at CHA. Nevertheless, the similarities between the CHA experience and the empirical observations in other industries by organizational experts such as John Kotter and Everett Rogers suggest many of the strategies used to develop and support CQI at CHA may be relevant to other local health departments.
In this case study, we chose to do purposeful sampling, in this case purposefully oversampling leaders and staff involved in QI over the past 10 years, and other qualitative data gathering approaches rather than randomization and quantitative methods. A random survey of all CHA employees would give a more representative view of the degree of involvement and commitment to QI at CHA. However, this was not the purpose of this case study. We used qualitative data collection to better understand how CHA developed their QI culture over time, why they did, and what factors helped or hindered them in the process.
Conclusion and Implications
Cabarrus Health Alliance's health director concisely summed up the importance of CQI to CHA by saying, “It's the most beneficial thing we've ever engaged in.” This case study demonstrates that it is indeed possible to implement CQI within local public health departments, and that quality improvement can be applied to a broad range of public health services beyond clinical services. As is often noted by quality improvement experts, this degree of organizational transformation requires both extraordinary focus (“audacious” goals and clear vision) as well as the patience to build the foundation incrementally (often over 5–10 years).7 Furthermore, this case study demonstrates the potential impact of CQI for local public health departments and the communities they serve. Finally, it outlines in detail how CHA was able to integrate CQI into its operations and culture. Other local health departments may find many of CHA's strategies to be beneficial to their own efforts to introduce CQI to their leaders, managers, and frontline staff.
© 2012 Lippincott Williams & Wilkins, Inc.