Our PHAB site visit report cited our nascent QI program as one of our top 3 areas for improvement, so it was a priority for us postaccreditation to develop this program. As an accredited health department, we were fortunate to receive training and technical assistance from PHAB and Continual Impact LLC via the Quality Improvement Leaders Academy. Whereas our QI projects in prior years had been selected on a mostly ad hoc basis, in late 2015 to early 2016, we engaged in a comprehensive, data-driven process to develop a new QI plan. As part of this process, we identified the 2 main outcomes we hoped to achieve through our QI efforts over the coming year: promoting health equity and improving public awareness and utilization of our services. The NOHD's leadership team utilized a prioritization matrix to select 6 QI projects to undertake that were linked to those outcomes.
One of the specific problems we hoped to address through QI was the fact that local hospitals and health clinics would frequently discharge clients without an appropriate referral to other health or human services they may need, meaning that many of our most vulnerable residents were unable to experience a continuum of care or to benefit from services that were freely available to them. The aim of this QI project, which we called “Referrals 360,” was to increase referrals from hospitals and community-based clinics for NOHD's direct services including Health Care for the Homeless (HCH), Healthy Start, Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and Ryan White HIV/AIDS services.
Our Referrals 360 project team completed a cause-and-effect analysis to better understand the problem. The salient issue that emerged in this analysis was that many key staff at local hospitals and clinics did not know about our programs; were unaware of the range of services offered by our programs; or had misunderstandings about the eligibility requirements for our services. To solve this problem, the team compiled a list of contacts at all the hospitals and clinics that could potentially refer clients to us. We then developed a PowerPoint presentation providing essential information about NOHD's direct service programs that we e-mailed to these contacts in the spring of 2016. We also provided these agencies and the broader community with an “all-in-one” brochure that summarized all of NOHD's services and programs, developed contemporaneously by another NOHD QI project.
Because of difficulties tracking referrals, we utilized overall program participation as our metric. Our direct services programs all exceeded their goals for participation in 2016, and Ryan White, WIC, and HCH surpassed their participant numbers from the prior year by 13.0%, 3.6%, and 1.4%, respectively (Table 2). Medicaid expansion, which went into effect in July of 2016, was a confounding factor, so we were unable to attribute an increase in client numbers to the Referrals 360 project. Nevertheless, anecdotal feedback from partners indicated that they appreciated the information and that it helped them connect their clients to our services. This project also helped us strategically engage with other health service agencies across the city.
Engaging in a data-driven QI planning process enabled our department to identify QI projects that addressed our most pressing organizational priorities. Several of the QI projects initiated in early 2016 set the stage for deeper work in these areas. In fact, we incorporated our Referrals 360 project work into a grant application from a local foundation. We were subsequently awarded funding for a 3-year project to develop and implement a Uniformed Patient Referral System that will facilitate partnerships with other health care, behavioral health, and social services providers and will improve access to health care, behavioral health, and social services for individuals who need these services, including those who are homeless. Our community partners welcome this effort, as it fills a recognized need for a centralized referral system, while improving population health and ensuring continuity of care.
The Referrals 360 project helped promote internal collaboration among NOHD's programs—helping us ensure that we were leveraging our resources for our clients and that they were benefiting from all that NOHD had to offer—and laid the groundwork for future work in that area. We also have found that improving internal collaboration and coordination improves department morale.
Advice to Other Health Departments
Completing a thorough, data-driven QI planning process is time-consuming, but the resulting identification of organizational gaps, priorities, and improvement projects is a valuable outcome well worth the time investment. While major gaps can seldom be filled by a 6-month improvement cycle, starting with a small-scale project can interrupt organizational complacency and set the stage for larger-scale work. Because of limited resources, it was important for us to focus our QI efforts on organizational priorities. It was also beneficial that all of our QI projects selected in 2016 were aimed toward the same higher-level outcomes. This meant that all the projects were related in some way and that each could build on or benefit from the work of the other projects that were underway at the same time. Notably, we did not have ideal metrics for the Referrals 360 project initially as our internal systems were not set up to track referrals in the same way across programs. However, we have found it worthwhile to proceed with work we knew would advance us toward our goals using the best available data rather than to avoid progress because of a lack of a perfect metric.
The NOHD's enhanced capacity to conduct QI work is directly linked to our being accredited. We would encourage any health department to pursue accreditation, as PHAB's emphasis on QI will help your department engage in projects that will benefit your community.
In addition to implementing our Uniformed Patient Referral System, we are taking more steps to deepen the coordination among our own direct service programs and with key external partners. Our internal efforts are focusing on integration of our WIC and Healthy Start programs. While we have made significant strides in recent years to colocate these services, we are now working on developing a streamlined participant recruitment and referral process and coordinating community outreach and education efforts. We have also begun to engage more deeply with external partners in the early childhood sector to identify areas for increased collaboration and alignment. By coordinating efforts, our programs can promote health equity by reducing the administrative burden on participating families, maximizing the use of program resources, and increasing programs' effectiveness and impact.
1. Riccardo J, Parent C, DeSalvo K. New Orleans Health Department: using the accreditation
framework to transform a local health department. J Public Health Manag Pract. 2014;20(1):66–69.
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accreditation; quality improvement; referrals