Facilitators: Stacy Baker & Tiko Lieou
Applying Quality Improvement Techniques to Analyze Problems and Find Solutions (Session B-2, April 12, 2006)
National Public Health Performance Standards Program Annual Training
Steps in Performance Improvement
1. Organize participation for performance improvement.
2. Prioritize areas for action.
3. Explore “root causes” of performance.
4. Develop and implement improvement plans.
5. Regularly monitor and report progress.
Source: NPHPSP Users’ Guide, 2006
To Carry Out a Quality Improvement Process, “Plan-Do-Check-Act”
Source: Turning Point Performance Management Collaborative, From Silos to Systems: Using Performance Management to Improve the Public’s Health , March 2003.
Plan
DoCheck
Act
Plan Plan changes aimed at improvement, matched to root causes
Do Carry out changes; try first on small scale
Check See if you get the desired results
Act Make changes based on what you learned; spread success
See Problem Solving, p. 12
To Carry Out a Quality Improvement Process, “Plan-Do-Check-Act”
Plan
DoCheck
Act
Two Jurisdictions: Same Score, Different ReasonsLow Score on Essential Service 10
(Research for New Insights and Solutions to Health Problems)
Jurisdiction A Jurisdiction B
Reasons for Low Score
No university or research institution nearby
Don’t know how to link with research institutions, despite leadership interest
Little or no funding in budgets for research
No leadership support for research with local universities
No incentives for organizations or staff to identify innovations
No feedback from management to recognize staff research
Source: NPHPSP Users’ Guide, 2006
Two Jurisdictions: Same Score, Different ReasonsLow Score on Essential Service 10
(Research for New Insights and Solutions to Health Problems)
Jurisdiction A Jurisdiction B
Potential Improvement Actions
Identify out-of-state research partners
Access sample academic-practice linkage agreements
Try building 5% research time into two large programs, plus seek in-kind student/ faculty assistance
Meet with leaders to show benefits to local priorities
Recognition and grant incentives for innovative solutions
Prompt manager feedback on contributions via employee reviews
Source: NPHPSP Users’ Guide, 2006
Methods & Procedures Motivation Materials & Equipment People Information & Feedback Environment Policy
Common root causesof performance problems
Some QI Tools to Help Teams Analyze Performance
Technique to generate many ideas in a short period of time
Ideas solicited without judgment from team members
Set a high minimum number (e.g., 15-20) to push beyond the obvious
Brainstorming
IDENTIFY POTENTIAL CAUSES • SORT INTO CATEGORIES
State personnel shortages Limited state staff expertise Too many hurdles to request help Slow response to local requests No process to detect when help may be
needed Local staff forget whom to contact People don’t know what technical
assistance is available
Brainstorming Example
IDENTIFY POTENTIAL CAUSES • SORT INTO CATEGORIES
Why doesn’t the state public health system effectively assist local jurisdictions with epidemiologic investigations?
Too many steps to identify and correct missing data
Faxes checked weekly
Reports sent to wrong health department
No one assigned at doctor’s offices
No clear time standards
No follow-up from health department if late
Providers see no benefit to timeliness
Online form hard to use
No penalties
Affinity Diagram
Reasons for Reporting Lag
Affinity Diagram
Incentives/Consequences
Methods
People
Information
Materials
Reasons for Reporting Lag
No follow-up from health department if late
Providers see no benefit to timeliness
No penalties
No one assigned at doctor’s offices
Faxes checked weekly
Too many steps to identify and correct missing dataReports sent to wrong health department
No clear time standards
Online form hard to use
Fishbone Technique (Cause & Effect Diagram)Why doesn’t the jurisdiction produce a regular community health profile?
No Regular Community Health Profile (CHP)
PeopleMotivation/Incentives
Materials/EquipmentMethods/Procedures
Low priority in organizing CHP
Providers do not care if they report data in a timely fashion
No money budgeted for CHP
Necessary leadership not involved
Staff not hired with expertise
Lack of training for the staff about CHP
Difficult to use computer system to enter data for health assessment.
Difficult to generate information for health assessment
Still working with an incomplete document template for organizing into CHP
Lack of clear direction
Poor presentation and interpretation of data for community stakeholders and partners
No standardized format for data presentation
Lack of participation from partner organizations in data collection and use of CHP
Partners do not understand importance of CHP
Community partners do not see themselves as part of public health system
Lack of expertise on how to use and develop CHP
No experts or outside consultants to advise
Paper forms for data request too long
Data requests get lost or slow in reaching necessary people
System outdated -still uses DOS platform
Few people trained to use the system
No reward for CHP at state and federal levels
Never see how data are used in reports
No feedback on reporting
Provider reporting methods inconsistent for diseases and events
Lack of standardized procedures for reporting and collecting data
No system to check quality of data received
No QA process for data reports
Too many types of reporting systems (fax, email, paper)
Lack of outreach and education by public health agency
Takes time away from billable care
Complicated or no IT system for reporting
Staff not evaluated on CHP
Frequent system errors
No Regular Community Health
Profile (CHP)
aka - NCAA Chart
Health Problem Analysis Worksheet
Risk Factors
Health Priority
Indirect Contributing FactorsDirect Contributing
Factors
Practice Exercise:
Affinity Diagram orFishbone Diagram
Check assumptionsabout what causes the most,
or the most serious, problems
Ask those who know best to rank Use available data to test hypotheses Invest in a short test if needed (check sheet)
Helps to prioritize and create consensus from a list of potential causes or solutions
Allows every team member to rank choices
Nominal Group Technique
IDENTIFY WHICH CAUSES TO ADDRESS • GO FOR HIGHEST IMPACT
Nominal Group TechniqueWhy doesn’t the state public health system effectively assist local jurisdictions with epidemiologic investigations?
Sonya Patty Rashid Total
Few state personnel available
3 4 4 11
No process to detect local needs
2 1 2 5
Slow response 4 3 3 10
Locals don’t know what assistance is available
1 2 1 4
4= most important cause
1= least important cause
IDENTIFY WHICH CAUSES TO ADDRESS • GO FOR HIGHEST IMPACT
Pareto Principle: 20% of sources cause 80% of any problem
Reasons for delayed epi. assistance (2+ days)
Reasons #No one assigned 3Local refuses help 1Wait for approval 39Incorrect local contact 5Incomplete data 2
0
10
20
30
40
50
60
70
80
Reason
Approvalwait
Incorrectcontact
Notassigned
Incomplete data
Refusal
IDENTIFY WHICH CAUSES TO ADDRESS • GO FOR HIGHEST IMPACT
FlowchartStart
Process Step
Decision
End
No
Yes
• Use to check and clarify how processes work
• Helps to identify breakdowns and bottlenecks
• Examines relationships among process steps in systems
Help Teams Look for Root Causes and Solutions in…
NPHPSP Assessment Notes
MAPP or Similar Community
Initiatives or Assessments
Reports
Research Findings
NPHPSP Users’ Guide (CDC) www.cdc.gov/od/ocphp/nphpsp/ToolKit.htm
Memory Jogger II & Problem Solving Memory Jogger (Goal QPC) www.goalqpc.com
Public Health Infrastructure Resource Center (PHF) www.phf.org/infrastructure/performance
Searchable QI tools NPHPSP-related tools Sample action plans Publications Case studies
