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Implementing an IHI Model Collaborative on Tobacco Use Screening in a state and local health department setting in South Carolina What we did and what we learned. Doug Taylor and Joe Kyle Office of Performance Management South Carolina Department of Health and Environmental Control Pam Gillam

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slide1

Implementing an IHI Model Collaborative on Tobacco Use Screening in a state and local health department setting in South Carolina What we did and what we learned

Doug Taylor and Joe Kyle

Office of Performance Management

South Carolina Department of Health and Environmental Control

Pam Gillam

Center for Healthcare Policy and Research

University of South Carolina

presentation overview
Presentation Overview

Overview SC DHEC and Health Services

Agency Strategic Plan and Priorities

Development of Tobacco Cessation Policy

IHI Collaborative Model

Implementing statewide tobacco cessation policy

sc dhec structure
SC DHEC Structure

7- Member Board appointed by Governor w/consent of Senate

Commissioner selected by the Board

Agency is not part of the Governor’s Cabinet

Four Deputy Areas

Centralized system/Vertically Integrated

State HD/Central Office

8 Regions

No local BOHs

health services
Health Services

Largest Deputy Area in DHEC

2.662 FTE’s statewide in 8 Public Health Regions with local health departments in all 46 counties and over 90 service delivery sites

Major areas of responsibilities include CDC/HRSA programs

Diverse team of health and environmental professionals to include:

Nurses, administrators, physicians, epidemiologists, nutritionists, pharmacists, administrative support, laboratory specialists, health educators, and social workers

general role of central office and role of regions
General Role of Central Office and Role of Regions

Central Office (State) Level

State level Health Improvement

Obtaining Resources

Development of Policies, Regulations, etc

Program Guidance & Oversight

Subject Matter Expertise – Consultations (public & private sector)

State, Federal and National relationships, partnerships

Region (Local) Level

Community level Health Improvement

Direct Service Delivery

Implementation of Policies

Region and local relationships, partnerships

agency priorities
Agency Priorities

SC DHEC’s Strategic Plan 2005-2010

5 Broad Goals

24 Strategic Goals

88 Objectives

Each Deputy Area monitors their Objectives through performance measures

Since 2007 all Deputy Areas began presenting performance related data to DHEC’s Executive Management Team

slide8

DHEC Strategic Plan

Goal

2:Improve the quality and years of healthy life for all

Strategic Goal

2-A:Promote healthy behaviors

Tobacco Related Objectives

2-A-1:Develop effective state and local partnerships to promote healthy behaviors including good nutrition, physical activity and tobacco use cessation.

2-A-3:Implement interventions to prevent tobacco use, promote cessation and reduce exposure to secondhand smoke.

2-A-4:Collaborate with public and private partners to develop and implement statewide prevention plans targeting diabetes, cardiovascular health, cancer, injury, tobacco, obesity or associated risk factors.

priority performance measure
Priority Performance Measure

DHEC Health Services will adopt policy to implement the Public Health Service Guideline (2As+R) for tobacco use and dependence with all of its clinical clients.

tobacco cessation policy development timeline
Tobacco Cessation Policy Development Timeline

HS Management Retreat prioritized Tobacco (and Tobacco Use Screening) as a public health issue (Jan 07)

Original draft policy developed in 2007

The updated Clinical Practice Guidelines were released from the Federal Government in May 2008

Tobacco Prevention and Control staff updated draft policy and submitted to DHEC’s Manual Oversight Committee for review and approval (summer 2008)

Policy deployment then delayed until Tobacco Collaborative results were in, since results would affect policy content and deployment strategies

After Collaborative, policy approved in November 2009 with an official implementation date of July 1, 2010 (1st time this way)

State level team organized to support implementation of policy

scdhec s use of the ihi s breakthrough collaborative for tobacco cessation

SCDHEC’s Use ofthe IHI’s Breakthrough Collaborative for Tobacco Cessation

Pamela S. Gillam, MPA

Center for Health Services & Policy Research

Arnold School of Public Health

University of South Carolina

presentation objectives
Presentation Objectives
  • To recognize the key components/phases of the IHI Breakthrough Series as a quality improvement methodology
  • Understand how SCDHEC adapted the IHI Breakthrough Series model to work in its environment
what is the ihi breakthrough series
What is the IHI Breakthrough Series?

IHI’s Breakthrough Series (BTS) is an improvement method that relies on spread and adaptation of existing knowledge to multiple settings to accomplish a common aim.

ihi breakthrough series 6 to 18 months time frame
IHI Breakthrough Series(6 to 18 months time frame)

Select Topic (develop mission)

Participants (10-100 teams)

Prework

Dissemination

Publications, Congress. etc.

P

Develop

Framework

& Changes

P

P

A

D

A

D

A

D

Expert Meeting

S

S

S

LS 1

LS 2

LS 3

Holding the Gains

Planning Group

AP1

AP2

AP3*

Supports

Email (listserv) Phone Conferences

Visits Assessments

Monthly Team Reports

*AP3 –continue reporting data as needed to document success

LS – Learning Session

AP – Action Period

ihi goals for a bts
IHI Goals for a BTS
  • Achieve results
  • Accelerate improvement– get results faster!
  • Define, document, and disseminate good ideas
  • Build clinical and public health leaders of change
the ihi breakthrough series is not
The IHI Breakthrough Series is NOT:
  • Research for new clinical knowledge
  • Single-setting (single team) focus
  • Small changes to existing systems
  • A benchmarking project
  • A consulting engagement
ihi bts 5 phases
IHI BTS- 5 Phases
  • Phase 1- Topic Section- General
  • Phase 2- Topic Selection- Development and Expert Meeting
  • Phase 3- Prework
  • Phase 4- Learning Sessions and Action Periods
  • Phase 5- Holding the Gains and Spread
ihi breakthrough series
IHI Breakthrough Series

Phase 1: Topic Selection

dhec tobacco collaborative november 2008 june 2009
DHEC Tobacco CollaborativeNovember 2008 - June 2009

Select Topic (develop mission)

Participants (7 teams)

Prework

Dissemination

Publications, Congress. etc.

P

Develop

Framework

& Changes

P

P

A

D

A

D

A

D

Expert Meeting

S

S

S

LS 1

LS 2

LS 3

Holding the Gains/ Spread

Planning Group

AP1

AP2

Supports

Email (listserv) Monthly Phone Calls

TA Visits Monthly Team Reports

LS – Learning Session

AP – Action Period

topic selection for tcc
Topic Selection for TCC
  • There is a gap between science (evidence) and practice; 2A+R identified as EBP;DHEC not doing it.
  • Examples of better performance exists; Other states using it.
  • A good “Business Case” exists for the topic; Seen as priority in 2 Regions participating in MLC3.
ihi breakthrough series1
IHI Breakthrough Series

Phase 2:

Topic Development

And

Expert Meeting

dhec tobacco collaborative november 2008 june 20091
DHEC Tobacco CollaborativeNovember 2008 - June 2009

Select Topic (develop mission)

Participants (7 teams)

Prework

Dissemination

Publications, Congress. etc.

P

Develop

Framework

& Changes

P

P

A

D

A

D

A

D

Expert Meeting

S

S

S

LS 1

LS 2

LS 3

Holding the Gains/ Spread

Planning Group

AP1

AP2

Supports

Email (listserv) Monthly Phone Calls

TA Visits Monthly Team Reports

LS – Learning Session

AP – Action Period

in this step experts are identified
In this step, Experts are Identified
  • Experts are knowledgeable in the subject matter/QI
  • Some experts are chosen to be Collaborative Faculty

For TCC, faculty were staff from Division of Tobacco Control and Prevention/Office of Performance Mgmt/USC/Regional Leadership

experts develop the following
Experts Develop the Following:
  • Collaborative Charter, that includes—
  • Change Package- 12 Changes in TCC Change Package
  • Measurement Strategy- Primary Measures used- # of smokers, # who accept referral, amount of time to implement intervention
ihi breakthrough series2
IHI Breakthrough Series

Phase 3: Prework

dhec tobacco collaborative november 2008 june 20092
DHEC Tobacco CollaborativeNovember 2008 - June 2009

Select Topic (develop mission)

Participants (7 teams)

Prework

Dissemination

Publications, Congress. etc.

P

Develop

Framework

& Changes

P

P

A

D

A

D

A

D

Expert Meeting

S

S

S

LS 1

LS 2

LS 3

Holding the Gains/ Spread

Planning Group

AP1

AP2

Supports

Email (listserv) Monthly Phone Calls

TA Visits Monthly Team Reports

LS – Learning Session

AP – Action Period

prework
Prework

For Planning Group

For Collaborative Teams

Develop TCC teams

Discuss aims and focus work

Engage the senior leader

Initiate measurement and other information gathering

Begin development of storyboard

  • Develop materials- TCC change package, Prework materials
  • Present to Region leadership on TCC
  • Assist regions in developing teams
  • Plan LS1
tcc teams
TCC Teams

Region 4

Region 8

Beaufort Family Planning

Hampton Family Planning

Jasper WIC

Colleton WIC

  • Lake City Family Planning
  • Darlington WIC
  • Sumter WIC
ihi breakthrough series3
IHI Breakthrough Series

Phase 4: Learning Sessions and Action Periods

dhec tobacco collaborative november 2008 june 20093
DHEC Tobacco CollaborativeNovember 2008 - June 2009

Select Topic (develop mission)

Participants (7 teams)

Prework

Dissemination

Publications, Congress. etc.

P

Develop

Framework

& Changes

P

P

A

D

A

D

A

D

Expert Meeting

S

S

S

LS 1

LS 2

LS 3

Holding the Gains/ Spread

Planning Group

AP1

AP2

Supports

Email (listserv) Monthly Phone Calls

TA Visits Monthly Team Reports

LS – Learning Session

AP – Action Period

learning session objectives
Learning Session Objectives

Learning Session 1

Get Ideas

Get Methods

Get Started

Learning Session 2

Get More Ideas

Get Better at Methods

Get a “Stride”

Learning Session 3

Celebrate Successes

Get ready to Sustain and Spread

Test all

changes on

small scale

Test & implement all changes

Action Period 1

Action Period 2

learning session objectives1
Learning Session Objectives
  • Learn and “get” the Change Package
  • Learn method for accelerating improvement (PDSA)
  • Get connected to colleagues
  • Make solid plans for taking action quickly
tcc ls1 agenda
TCC LS1 Agenda

DAY 1

DAY 2

Orientation to The Model for Improvement/PDSA

Measurement and Reporting

Team Meeting time

Next Steps (Action Period 1)

  • Introduction to IHI BTS process
  • Review of Collaborative’s mission and goals
  • Intro of 2As + R
  • Intro of Change Package
  • Training in 2As + R
  • Intro to QI
  • Team Meeting time
slide37

Model forImprovement

What are we trying to accomplish?

AIM

How will we know that a change is an improvement?

MEASURE

What change can we make that will result in improvement?

CHANGES

Plan

Act

Study

Do

From: Associates in Process Improvement

sumter county hd
Sumter County HD

AIM 1:

By the end of the collaborative, 100% of Prenatal/Post-Partum WIC clients and Sumter Co. HD will receive the 2As + R.

AIM 2:

25% of Tobacco Users will accept referral to Quitline.

sumter county hd1
Sumter County HD

MEASURES:

  • Length of Client Visit– 1:1 time with NES
  • Average length of time to implement 2As + R with clients
  • Client Tobacco Use Rate
  • % of WIC PN, PP, BF clients who receive 2As + R with fidelity
  • % of tobacco users accepting referral to the Quitline
sumter county hd2
Sumter County HD

CHANGES: (taken from change package)

  • IB. Include tobacco use as a vital sign.
    • IC. Ask patients if they use tobacco and document tobacco-use status on a regular basis.
  • ID./IVB. Designate staff/clinicians to implement the 2 A’s and R.
sumter county hd3
Sumter County HD

CHANGES: (taken from change package)

    • IIA. Implement a tobacco-user identification system.
  • IIC./IIIB. Track the degree to which clinicians are identifying, documenting and treating patients who use tobacco and provide feedback to staff/clinicians about their performance.
  • IVA. Have tobacco cessation materials and other information in every exam room or room in which clients are seen.
hampton county hd pdsa cycle
Hampton County HD PDSA Cycle

PLAN PHASE (of PDSA)

WHO: Support Staff will be provided the necessary posters and cards for the Quitline

WHAT: Material placement and distribution of a set number of materials which will be counted at the beginning and the difference tabulated at the end of the PDSA cycle for the number of cards and the tear off on the posters

WHEN: Starting on December 15, 2008 and continuing through December 19, 2008

WHERE: In Health Departments clinic waiting room(s) and exam rooms

action period objectives
Action Period Objectives
  • Support teams in their improvement work
  • Build collaboration and shared learning
  • Assess collaboration and progress

This is the time of maximal learning

AND WHERE THE REAL ACTION IS!

ihi breakthrough series4
IHI Breakthrough Series

5th Phase:

Holding the Gains

and

SPREAD

dhec tobacco collaborative november 2008 june 20094
DHEC Tobacco CollaborativeNovember 2008 - June 2009

Select Topic (develop mission)

Participants (7 teams)

Prework

Dissemination

Publications, Congress. etc.

P

Develop

Framework

& Changes

P

P

A

D

A

D

A

D

Expert Meeting

S

S

S

LS 1

LS 2

LS 3

Holding the Gains/ Spread

Planning Group

AP1

AP2

Supports

Email (listserv) Monthly Phone Calls

TA Visits Monthly Team Reports

LS – Learning Session

AP – Action Period

holding the gains and spread
Holding the Gains and Spread

Holding the Gains-- Continued tracking of improvements

Spread-- Adapting change to areas or populations other than your pilot populations

Part of the BTS Design!

for tcc thinking about spread important
For TCC, Thinking about Spread Important
  • 2 As + R was going to become a DHEC policy
  • Promising practices for implementing 2As + R in WIC and Family Planning
  • Talked about Spread in LS1 and LS2
beaufort county hd 2a r spread training plan
Beaufort County HD2A+R SpreadTraining Plan
  • WFD Coordinator presents @ site meetings
  • Ice Breaker
  • Policy
  • Power Point Presentation
    • Current Tobacco Cessation Programs
    • Smoking Prevalence & Disease Connection
    • Impact of Quitting & Success of Cessation Programs
    • 2A’s+R Protocol
  • Role Plays
ihi bts 5 phases1
IHI BTS- 5 Phases
  • Phase 1- Topic Section- General
  • Phase 2- Topic Selection- Development and Expert Meeting
  • Phase 3- Prework
  • Phase 4- Learning Sessions and Action Periods
  • Phase 5- Holding the Gains and Spread
slide52

Deploying and Implementing the Tobacco Use Screening Policy post Collaborative, throughout the SC system

state level planning
State level planning
  • By the Fall of 2009 data from the Tobacco Collaborative, describing impact in FP/STD and WIC clinics and promising ideas on how best to implement
    • DVD of 3rd learning session of major findings and recommendations
    • Final Report with detailed data, findings and recommendations (late summer 2009)
  • CO workgroup convened, all areas affected by policy (September-Nov 2009)
    • FP/STD, HH, NBHV, WIC, and TB with TA from Tobacco Division and Office of PM
    • Reviewed policy, findings from Collaborative
    • Made program specific recommendations on strategies to prepare for July 2010 full implementation
state level planning1
State level planning
  • For WIC and FP/STD (programs in the Collaborative):
    • Reviewed results, made additional recommendations to improve upon results (i.e. WIC drop down menu to document intervention rather than write in under Alerts tab)
  • For HH, TB and NBHV (programs not in the Collaborative):
    • Began to design test of changes to figure out best way to implement within their program areas
  • Challenge:
    • Develop implementation strategies for all affected programs
    • Get staff trained in implementation
    • Develop evaluation plan to monitor policy once implemented on July 1, 2010
region and state level planning
Region and State level planning
  • Regions were required to develop testing, training and deployment plans (see plan template handout)
    • To take advantage of unprecedented planning time allowed prior to full policy implementation (Nov 09-June 10)
    • Plans submitted by mid March 2010
  • CO, Tobacco Division developed and implemented a TOT
    • Targeting Region lead Tobacco staff, covered policy, protocol, and program specific steps and requirements
    • TOT materials sent out to regions for all staff training
region and state level planning1
Region and State level planning
  • Monitoring (see handout)
    • Each program responsible for ensuring policy is followed within their area, through site visits and program reports
    • Performance measure developed to monitor program implementation
    • Quitline data reported on to include:
      • Fax referral volume
      • Referrals not reached by Quitline
      • # of referrals enrolled/registered with Quitline
region and state level planning2
Region and State level planning
  • Evaluation (see handout)
    • 7 and 30 day quit rates of clients receiving Quitline services
    • Prevalence of tobacco use among DHEC clients compared to baseline
    • 7 and 30 day quit rates for non referred SC Quitline clients
    • Client satisfaction
use of ihi model in other areas
Use of IHI model in other areas
  • No, for simple, mundane, small (organizationally) level work
  • Yes, if evidence known and how to implement needs to be figured out, for a large system deployment
    • SC: Implementation of FastTrack for STD customers
      • Pilot (to confirm evidence), IHI Collaborativelike 8 teams (one per Region), statewide deployment
  • Yes, if evidence not known
    • Pilot first (to generate the evidence)
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