Denver Public Health Center for Public Health Preparedness

Public Health Services Research, Moving to the Mainstream

Public health performance and quality improvement, one state’s experience

A. Davidson, MD, MSPH AcademyHealth, Annual Research Meeting

Hynes Convention CenterBoston, MA

June 26, 2005

• Historical context• Current efforts

Outline

• Historical context

• CO Health Data Advisory Committee (CoHDAC)• Colorado PH Education Committee• CO PH Capacity Building Steering Committee• Denver Center for Public Health Preparedness• Public Health Performance Improvement Collaborative

(PH-PIC)

Outline

Colorado Health Data Advisory Committee (CoHDAC)

Vision: Access to health data on as needed basis with an analytic toolset to generate information.

Result• [1994-present] created a competent, committed,

collaborative (local/state) problem-solving group• [1995] Colorado Health Information Dataset

(CoHID) CD-version, Weld County

• [1998 – present] Colorado Health Information Dataset (CoHID) on-line SAS IntrNet query tool (CDPHE), GIS capacities

Colorado PH Education CommitteeCharge: Create a strategy for improving education and training of

Colorado’s PH workforce.

Results• [April 2001] Colorado PH Professional Education Plan: Life-long

Learning System,. • [April 2002] Workforce educational needs assessment (UCHSC SON

survey) to set training priorities by gauging: • How important a skill area was to job,• How prepared staff felt in each skill area, and• What interest existed around training

• [2004] Implementation CO-TRAIN, (PHF)

CO PH Capacity Building Steering Committee

Charge: Workforce development was only a part of PH essential services delivery capacity; convened committee to create a strategy for enhancing Colorado’s capacity to do PH work.

Result• [2001] The committee recommended the use of the

NPHPS. – Post Sept 11, 2001, enabled NPHPS assessment

funding.

– OLL coordinated implementation of NPHPS assessment

• [February 2003]. NPHPS study completed for Colorado

Denver Center for Public Health Preparedness (CDC-funded Advanced Practice Center )

Mission: to…enhance operational readiness…• dual use perspective, operational readiness related to organizational capacity

• parallel skills for BT readiness and routine ES capacities

• operates at organizational or system level– PH community had individual readiness competencies (Columbia SON)

Issues:• Have we defined organizational competencies? How are they measured? Are they

being used? How would combined (individual and organizational) competency measures better evaluate our essential services delivery or BT readiness capacities?

Operational readiness

Organizationalcapacity

BT Supplement ChallengePH Needs – Dual Use

Routine BT

Denver Center for Public Health Preparedness (cont.)

Result: [June 2003, Conference ] Started the QI Collaborative

Goals:• Cultivate within Colorado’s PH community a culture of learning and QI• Facilitate PH quality improvement, capacity building and all hazards

preparedness in CO

Members: representatives of local/state public health departments (e.g., OLL, data, QI, academics)

Merger: QI Collaborative & the Capacity Building Steering Committee (2003).

• Articulated a new group identity (mission, vision and new name: PH-PIC).

Public Health Performance Improvement

Collaborative (PH-PIC)

• What is PH-PIC?: A workgroup from local/state health departments which adapts national initiatives to expand and improve local public health performance and all-hazards preparation and capacity.

• PH-PIC Premise: The process of setting priorities for performance improvement and all-hazards preparation should be driven by current Colorado data.

Merger: QI Collaborative & the Capacity Building Steering Committee (2003).

• Articulated a new group identity (mission, vision and new Articulated a new group identity (mission, vision and new name: name: PH-PICPH-PIC).).

• Analyzed and distributed the NPHPS Colorado results and other assessment data.

NPHPS Opportunities for Colorado

• To use results to improve public health practice and the public health system performance as a whole

• To provide a foundation for continuous quality improvement activities

• Encourages stakeholder communication and collaboration

– Promotes greater understanding of the available capacity and resources within a region

– Promotes the development of new and/or stronger partnerships

• Encourage greater inter-jurisdictional cooperation

Proportion of NPHPS Standards Being Met

Office of Local Liaison Colorado DPHE4

6872

50

70

48

68

5450

54

37

77

5145

56

24

76

40

54

19

33

0

20

40

60

80

100

Perc

en

t

Local State

Importance & Intent for QI (Survey)

Office of Local Liaison Colorado DPHE1

90 90

84

7470 68 68

64

52

40

6872

50

70

48

68

5450

54

37

0

20

40

60

80

100

Perc

en

t

Very importantProportion being metQI in next 12 months

Workforce Proficiency (SON Survey)

Office of Local Liaison Colorado DPHE2

6872

50

70

48

68

5450

54

37

31

45

30

46

25

41 40

22

0

20

40

60

80

Pe

rce

nt

Proportion being met Proficiency

NPHPS Priority Matrix

Mon

itor

Dia

gnos

is

Ed

uca

te

Par

tner

shi

p

Pol

icy

En

forc

e

Lin

k

Wor

kfo

rce

Eva

luat

ion

Res

earc

h

< 50% of model (locally) X X X X < 50% of model (state) X X X X X Rated most important X X X > 50% intend QI in 1 year X X X X Greatest discrepancy: importance vs. model

X X X X

Indicators < 50% (locally) X X X X X X Indicators < 50% (state) X X X X X X X X < 30% of local work force highly proficient

X X X

Merger: QI Collaborative & the Capacity Building Steering Committee (2003).

• Articulated a new group identity (mission, vision and new Articulated a new group identity (mission, vision and new name: name: PH-PICPH-PIC).).

• Analyzed and distributed the NPHPS Colorado results and Analyzed and distributed the NPHPS Colorado results and other assessment data.other assessment data.

• Created a BT-focused training opportunity in Feb 2004 to learn QI/PI process and use the NPHPS data.

Denver Public Health Department

Performance topics: • Emergency notification system

• System to divert workforce to function in specific emergency response roles, while maintaining core public health functions

• Selection of sites for dispensing mass vaccinations/prophylaxis

Denver Public Health Department

Performance topic: • Emergency notification system

How decided is important:• Contractual obligation (BT preparedness)• No current system

Specific aim or purpose:• Develop an alert/notification system• Inform PH workforce of roles/responsibilities• Insure a functioning system

Desired outcome or target improvement:• 100% of employees aware of emergency number• 98% of employees contacted within 24 hours• 100% of contacted employees follow emergency

notification procedures• Quarterly test of efficiency system

Denver Public Health Department: 2/11/04

Number:149

101 (68)98 (97)48 (32)

34 (23)1.2

2.2 hrs3.1 hrs.

3723

Results: • Total employees

• Employees contacted• Performed action

• Employees not contacted

• Employees beneath 1 caller • Mean contacts per employee• Mean time to contact• Mean time to return call• No. corrected phone numbers• No. of alternative numbers

Merger: QI Collaborative & the Capacity Building Steering Committee (2003).

• Articulated a new group identity (mission, vision and new Articulated a new group identity (mission, vision and new name: name: PH-PICPH-PIC).).

• Analyzed and distributed the NPHPS Colorado results and Analyzed and distributed the NPHPS Colorado results and other assessment data.other assessment data.

• Created a BT-focused training opportunity in Feb 2004 to Created a BT-focused training opportunity in Feb 2004 to learn QI/PI process and use the NPHPS data. learn QI/PI process and use the NPHPS data.

• Presented PH-PIC methods, activities & the “Primer on PH-PI” at CPHA (September 2004).

Quality Improvement

• What are we trying to accomplish?

• How will we know that a change is an improvement?

• What changes can we make that will result in an improvement?

Four Steps of Improvement (IHI Model)

• Plan

• Do

• Study

• Act

Plan

Study Do

Act

Performance Improvement TOPIC:

How did you decide this is important (what baseline data is being used?) 

Specific Aim or Purpose  

Desired Outcome or Improvement Target   

Plan to Achieve Target - Action Steps (who, will do what, by when)

What will be done? (brief description) Who will do it? By When?

   

   

   

   

   

   

   

   

How will you measure success and continue to monitor the process? (measures tracked, how often)     

Example of a Basic Plan

Repeated Use of the Cycle

Pla

n

Stu

dy

Do

Act

Plan

StudyDo

Act

Plan

Stud

yD

o

Act

Plan

Study Do

Act

DATA

Hunches, theories, ideas

Changes that result in

improvement

Denver Public Health Department: 6/24/04

Number:11

11 (100)--0

--1

NA4.1 hrs.

----

Results: • Total employees

• Employees contacted• Performed action

• Employees not contacted

• Employees beneath 1 caller • Mean contacts per employee• Mean time to contact• Mean time to return call• No. corrected phone numbers• No. of alternative numbers

Merger: QI Collaborative & the Capacity Building Steering Committee (2003).

• Articulated a new group identity (mission, vision and new Articulated a new group identity (mission, vision and new name: name: PH-PICPH-PIC).).

• Analyzed and distributed the NPHPS Colorado results and Analyzed and distributed the NPHPS Colorado results and other assessment data. other assessment data.

• Created a BT-focused training opportunity in Feb 2004 to Created a BT-focused training opportunity in Feb 2004 to learn QI/PI process and use the NPHPS data. learn QI/PI process and use the NPHPS data.

• Presented PH-PIC methods, activities & the “Primer on PH-Presented PH-PIC methods, activities & the “Primer on PH-PI” at CPHA (September 2004).PI” at CPHA (September 2004).

• Created the “Colorado Public Health Performance Improvement Plan”. http://www.cdphe.state.co.us/as/ollhom.asp

Colorado’s PI choices clustered around three

Essential PH Services • Monitoring

– 3 state system plans– 27 local system plans

• Diagnosing– 29 local system plans– 5 state system plans

• Evaluating– 12 state system plans– 5 local system plans

• 39 local and state plans targeted All-Hazards

PH-PIC Assessment (Fall 2004/Winter 2005)

• Clustering of PI priorities • Results of NPHPS matrix

Should Learning Communities be developed to support quality improvement/ performance improvement in Colorado’s Public Health systems?

• Current efforts• Learning communities• Regional Health Information Organization

(RHIO)

Outline

• Hear and log our stories• Recognize common statewide issues• Work to define and solve problems • Assure dual purpose/use of our efforts• Consider developing a learning community • Use as opportunity to guide new BT supplemental

planning process

What might we accomplish today?

June 2, 2003

Learning Community

“Learning communities are developed where groups of people, linked geographically or by shared interest, collaborate and work in partnership to address their members’ learning needs… Learning communities facilitated through adult and community education are a powerful tool for social cohesion, community capacity building and social, cultural and economic development.”

Department of Education, 2003, p 12.

Barriers to Organizational Learning

• Silo style of work and work groups• Unsupportive leadership• Lack of legitimacy• Failure to build in time and structures for

learning• Defensive communication patterns• Limited ability for reflection and generative

learning• Lack of the 6 “C’s” in group members

What It Takes to Create and Sustain A Learning Community

• Capability: have the skills, knowledge and personal qualities to renew themselves and reinvent a future through skillful discussion

• Commitment: people are an integral part of creating a community they value together

• Contribution: members must see how their work contributes to community; provide opportunities for diversity of talents and contributions

(Brown and Isaacs, Fifth Discipline Fieldbook, 1994, p 508-517)

Creating and Sustaining Learning Communities (cont.)

• Continuity: develop an institutional memory, careful orientation of new members

• Collaboration: develop interdependence, share vision and strategy, free flow of information, able to act autonomously to achieve common goals

• Conscience: guiding principles, ethics, values (e.g., trust, mutual respect)

(Brown and Isaacs, Fifth Discipline Fieldbook, 1994, p 508-517)

PUBLIC HEALTH PERFORMANCE IMPROVEMENT COLLABORATIVE

Title: Demonstrating success: User-friendly evaluation for public health programs

Learning objectives• Increase familiarity with useful evaluation terminology.• Identify evaluation resources.• Practice using basic evaluation skills

Short DescriptionThis user-friendly, interactive workshop will allow participants to gain

knowledge and skills to demonstrate the success of their programs. Commonly used evaluation processes and resources will be presented with opportunities for practice.

EVALUATION LEARNING COMMUNITY

CPHA Abstract Draft – June 3, 2005

• Initiating work around cataloguing available data sources and identifying data gaps.

• Adjunct work by Colorado Health Information Exchange

MONITORING LEARNING COMMUNITY

Goal: Create a local health information infrastructure for clinicians to access patient information across individual health care institutions

Colorado Health Information Exchange 2 Complementary Initiatives

Build upon what exists• Denver Health (DH)

• 150,000 residents (25% of population)

• Kaiser Permanente of Colorado (KPC)• 3rd largest CO HMO (350,000 members)

• The Children’s Hospital (TCH)• Largest pediatric specialty care provider

• University of Colorado Hospital (UCH)• Largest Metro area teaching hospital

COHIE to CORHIO

COHIE

Learning

Laboratory

Steering Committee

Working groups:• Technical• Clinical• Evaluation• Legal• Organizational

Community Advisory Council

Colorado Regional Health Information Organization

A sharing, self-sustaining non-profit structure that:

Promotes legal

agreements for

participation and access

Maintains a robust

technical environment

Defines clinical value

through policy and procedures

Manages the budget and

sustainable business

model

Supports national

standards and public

health interfaces

PROJECT

(10/2004)

VISION

(10/2009)

COHIE: 2005 plan

COHIE: Linking independent clinical data into a “virtual” patient-centered view

1. Accountable and OPEN participation

2. Clinical data sharing between different platforms

3. Data sharing and degree of participation remains under local control

Mesa County

The Children’s Hospital

Boulder

Larimer

Weld

Denver Health

El Paso County

MedSouth IPA University Hospital

Kaiser Permanente

Exempla

Rose Medical Group

Colorado Care Collaborative (RMD)

Payor # 1 – RMHP ???

RxHub ???

COHIE:

“Community” patient index

common (standard) messaging

Vendor independent (neutral)

Rural small MD access ?

CHCN - Health Center?

Clinical Data Contributor TBD ?

CORHIO Process

• Colorado Health Institute (neutral convener)• Legal support • Explore/define relationship COHIE ⇔ CORHIO• Working Group

• Business plan

• Articles of incorporation (501c3)

• Defining the board

• Education/public relations

• Community Advisory Council (greater than 40 members, most HIT projects going on in Colorado

Future activities/use cases

• Public Health • Registries and evaluation of care quality• Active surveillance due to recent events• Immunization tracking and reminder/recall• Others ??

• Use of global-level decision support• Continuity of care record (CCR) for effective

care transitions (acute -> treatment centers -> home)

• Patients controlling EHR access

Conceptual Framework

State/Local Partnerships

Leadership Development

Performance Improvement

If the conceptual work is successful,

we should focus on….

And if true leaders emerge,

we should generate ….

Then partners will agree to emphasize…

And then tools/methods and measures will evolve to

support/revise the…

COLORADO TEAM - VISUAL MODELNational Public Health Leadership Institute

Draft V1.1, June 20, 2005

• 10 Essential Services• Clear PH message

• Systems thinking• Change management

• Respectful relations• Inclusive planning

• Accountability targets• Unified measurement process