The governmental public health enterprise has increasingly been interested in using quality improvement (QI) tools and techniques that can improve its work. Health agencies are turning to QI to help streamline processes, work more effectively, and mitigate the impact of budget cuts. According to the Association of State and Territorial Health Officials (ASTHO) Profile of State Public Health, Volume Three, 96% of state health agencies are implementing formal QI activities in specific programmatic or functional areas.1 According to the National Association of County & City Health Officials' 2013 National Profile of Local Health Departments, more than half (56%) of local health departments have formal QI programs.2
ASTHO has seen the demand for cross-programmatic QI work within health agencies in the past. In 2012, with support from the Robert Wood Johnson Foundation (RWJF), ASTHO provided funding and support to health agencies pursuing QI projects focused on 3 topical areas: maternal and child health, environmental health, and chronic disease. While the grant did not require states to work across these areas, the selected agencies tackled improvement opportunities that focused on the interconnections between these programmatic areas. Through this work, state health agencies demonstrated that working across programs and traditional agency boundaries could lead to dramatic improvement in how the agency functioned.
Sharing this work with federal and national partners sparked interest in the opportunity to coordinate QI across various public health agencies. To build upon this momentum, RWJF convened representatives from federal, state, and local public health in a “QI Forum” to discuss opportunities for QI projects that cross jurisdictions and agency bounds and could affect the public health system as a whole. Ideas focused on the interconnectedness of public health systems and reducing administrative burdens. Projects were identified on the basis of priority, need, potential impact on the public health system, and the feasibility of completion. Over the past year, RWJF provided funding and QI experts (Continual Impact, LLC) to ASTHO to support the implementation of projects focused on the spread of QI, the transfer of death record data, and grant reporting.
Exploring the Spread of QI
The project focused on the Spread of QI researched the factors that help encourage and promote QI initiatives that span different agencies in the public health enterprise. The team included diverse governmental public health partners, including federal (Centers for Disease Control and Prevention and Health Resources and Services Administration), state (Vermont), local (Tacoma-Pierce County), and national partners (ASTHO and National Association of County & City Health Officials).
The team developed a definition for “cross-jurisdictional quality improvement”:
A cross-jurisdictional QI project is defined as an improvement activity that involves participation from more than one level of governmental public health (state, local, tribal, territorial, or federal) or from more than one health department at the same level (eg, multiple local health departments) and follows an improvement cycle based on data driven problem solving and application of QI techniques.
Using information gathered from the field and through interviews with public health practitioners who had been involved in cross-jurisdictional QI, the team developed a 1-page fact sheet3 that includes this definition, describes the value of working cross-jurisdictionally, and provides tips for consideration in the development of cross-jurisdictional QI projects.
The Data Utilization Projects
The Data Utilization project improved the transfer of timely identifiable death data from the state to local health departments. It was implemented first at the North Carolina State Center for Health Statistics. Representatives from the North Carolina and Minnesota health departments, National Center for Health Statistics (NCHS), National Association for Public Health Statistics and Information Systems, and 3 local agencies (Hartford, Connecticut; Maricopa County, Arizona; and New York City) participated in the project. By finding efficiencies within their process, the North Carolina team reduced the number of days from the death registration until the information was available for local health departments from 100 days to an average of 10-20 days. In addition, the team was able to improve timely data reporting to NCHS for national reporting purposes while complying with federal guidelines of increasing the percentage of records submitted within 25 days of death registration from 0% to 85%.
After participating in the North Carolina project, the Minnesota Department of Health was eager to replicate the project. The health department convened a team representing state agencies, including input from Arkansas and Mississippi, as well as federal and local agencies, medical examiners, and the National Association for Public Health Statistics and Information Systems. By incorporating diverse members, the team was able to identify strategies to improve data transfer time to and from NCHS and, ultimately, provide the finalized data in a more timely fashion to the local public health agencies. The Minnesota team is still in the process of implementing these changes: they anticipate that they will meet their goal of ensuring that 90% of all legal death record filings are within 10 days of the date of death, and by September 2015, the team had increased the daily percentage of auto-coded death records to 85%, surpassing the national average per NCHS of 80%.
By working with other state and local agencies, NCHS, and the National Association for Public Health Statistics and Information Systems, the teams were able to identify improvements that will have a wider impact and reduce the burden on other agencies in the public health system.
The Grant Reporting Project
Recognizing that various federal grants have similar guidance, performance reporting requirements, and many opportunities for collaboration and sharing, the team focused on grant reporting chose to focus on 2 grants: the Title V Maternal and Child Health Services Block Grant funded through the Health Resources and Services Administration, and the State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health funded by the Centers (1305) Grant funded by the Centers for Disease Control and Prevention.
Team members, including representatives from state health agencies in Alabama, Rhode Island, and Mississippi; Association of Maternal & Child Health Programs; National Association of Chronic Disease Directors; and ASTHO considered strategies to share data and information, establish clear roles, and focus on the aligned sections between the 2 grants to reduce the time required to write the reports. The Centers for Disease Control and Prevention and the Health Resources and Services Administration provided consultative support on grant requirements to the team. Over the next year, the team will implement these changes and track time saved. The team estimates that by coordinating and streamlining these processes, they could reduce grant reporting time by approximately 25%.
Learnings and Findings
ASTHO's work on the RWJF QI Forum demonstrated the impact of working cross-jurisdictionally and including multiple agencies in seeking common system improvements. While there are other examples of QI projects that involve varied public health representation, the QI Forum was a focused effort to ensure that multiple agencies were included and that the impact of incorporating these varied perspectives was understood.
The results we have seen thus far are encouraging. By working cross-jurisdictionally, we have an opportunity to demonstrate significant results beyond 1 program or agency, to reduce the time spent on administrative processes, and to increase the time spent on program deliverables. Cross-jurisdictional public health is particularly powerful when considering those unique processes that cross agency lines, such as grants and procurement processes, and addressing shared problems in improving health outcomes. In addition, by including multiple agencies in a project, there are increased opportunities for replication. Finally, collaborative work can build stronger working relationships and a deeper understanding of the perspective of colleagues in different agencies and is a key factor in achieving results.3
There are significant challenges to working cross-jurisdictionally, however, and those should not be minimized. Cross-agency coordination can be complex, requiring the input of multiple stakeholders, and the team can lack a clear hierarchy for making difficult decisions. In a project involving external partners and stakeholders, the decision-making process takes longer and may be nearly impossible without buy-in from the key players. Health department leadership can have an integral role in this process as a project sponsor or champion. Significant resources may be necessary to ensure that team members can meet in person. In addition, projects with federal, state, and local participants will involve team members whose agencies' work often relies on funding from other team members' agencies. To ensure that team members are comfortable openly sharing challenges, the group must develop a safe space for discussion. With QI that crosses agency lines, building a safe space can take longer than in an internal QI project, but is a pivotal step to ensuring that participants can share concerns without fear of reprisal.
Finally, another significant challenge to cross-jurisdictional QI is identifying resources to support this work. Funding streams in public health tend to be siloed. It can be hard to identify funding to support improvement work that spans different programmatic areas within an agency; identifying funding for work that spans across different agencies is an even greater challenge. This project was funded by RWJF, a driving force in the field of public health quality and improvement. Since the benefits span across the public health system, there is not one natural funding source to support continued improvement across the public health enterprise and without a dedicated funding source to support ongoing cross-jurisdictional QI, this work is hard to sustain.
Cross-jurisdictional QI has great potential to improve the public health system. By working outside of their own agency, health agencies have the opportunity to learn from their stakeholders, customers, and funders and better align their work to do the most good most efficiently. Federal, state, and local agencies generally lack the opportunity to work together to implement QI processes. The QI Forum provided an initial opportunity for representatives from these agencies to explore the possibilities of breaking down barriers, streamlining processes, and increasing efficiencies. By implementing 4 projects that cross agency lines, the project provided an example of the power of collaboration and how QI tools and techniques can improve the state of public health. Future opportunities to support cross-jurisdictional QI will continue to strengthen the public health enterprise.