Facilitators : Stacy Baker & Tiko Lieou

1. Applying Quality Improvement Techniques to Analyze Problems and Find Solutions(Session B-2, April 12, 2006)National Public Health Performance Standards Program Annual Training Facilitators: Stacy Baker & Tiko Lieou

2. Steps in Performance Improvement • Organize participation for performance improvement. • Prioritize areas for action. • Explore “root causes” of performance. • Develop and implement improvement plans. • Regularly monitor and report progress. Source: NPHPSP Users’ Guide, 2006

3. Act Plan Check Do 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.

4. Act Plan Check Do To Carry Out a Quality Improvement Process, “Plan-Do-Check-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

5. Source: NPHPSP Users’ Guide, 2006

6. Source: NPHPSP Users’ Guide, 2006

7. Methods & Procedures Motivation Materials & Equipment People Information & Feedback Environment Policy Common root causesof performance problems

8. Some QI Tools to Help Teams Analyze Performance

9. Brainstorming • 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 IDENTIFY POTENTIAL CAUSES • SORT INTO CATEGORIES

10. Brainstorming Example Why doesn’t the state public health system effectively assist local jurisdictions with epidemiologic investigations? • 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 IDENTIFY POTENTIAL CAUSES • SORT INTO CATEGORIES

11. Affinity Diagram Reasons for Reporting Lag No follow-up from health department if late Providers see no benefit to timeliness No penalties Too many steps to identify and correct missing data Reports sent to wrong health department No clear time standards Faxes checked weekly Online form hard to use No one assigned at doctor’s offices

12. Affinity Diagram Reasons for Reporting Lag Incentives/Consequences Information Providers see no benefit to timeliness Methods No clear time standards Faxes checked weekly No follow-up from health department if late Too many steps to identify and correct missing data Materials No penalties Online form hard to use People Reports sent to wrong health department No one assigned at doctor’s offices

13. Motivation/Incentives People Necessary leadership not involved No reward for CHP at state and federal levels No money budgeted for CHP Partners do not understand importance of CHP Lack of clear direction Low priority in organizing CHP Takes time away from billable care Complicated or no IT system for reporting Lack of participation from partner organizations in data collection and use of CHP No experts or outside consultants to advise Lack of expertise on how to use and develop CHP Providers do not care if they report data in a timely fashion Staff not evaluated on CHP Lack of training for the staff about CHP Community partners do not see themselves as part of public health system Lack of outreach and education by public health agency Staff not hired with expertise No feedback on reporting No Regular Community Health Profile (CHP) Never see how data are used in reports Too many types of reporting systems (fax, email, paper) No standardized format for data presentation Data requests get lost or slow in reaching necessary people Frequent system errors System outdated -still uses DOS platform Poor presentation and interpretation of data for community stakeholders and partners Lack of standardized procedures for reporting and collecting data Difficult to use computer system to enter data for health assessment. Difficult to generate information for health assessment Few people trained to use the system Provider reporting methods inconsistent for diseases and events Paper forms for data request too long Still working with an incomplete document template for organizing into CHP No QA process for data reports No system to check quality of data received Materials/Equipment Methods/Procedures Fishbone Technique (Cause & Effect Diagram)Why doesn’t the jurisdiction produce a regular community health profile? No Regular Community Health Profile (CHP)

15. Practice Exercise:Affinity Diagram orFishbone Diagram

16. 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)

17. Nominal Group Technique • Helps to prioritize and create consensus from a list of potential causes or solutions • Allows every team member to rank choices IDENTIFY WHICH CAUSES TO ADDRESS • GO FOR HIGHEST IMPACT

18. Nominal Group TechniqueWhy doesn’t the state public health system effectively assist local jurisdictions with epidemiologic investigations? 4= most important cause1= least important cause IDENTIFY WHICH CAUSES TO ADDRESS • GO FOR HIGHEST IMPACT

19. Pareto Principle: 20% of sources cause 80% of any problem Reasons for delayed epi. assistance (2+ days) Reasons # No one assigned 3 Local refuses help 1 Wait for approval 39 Incorrect local contact 5 Incomplete data 2 IDENTIFY WHICH CAUSES TO ADDRESS • GO FOR HIGHEST IMPACT

20. Flowchart Start • Use to check and clarify how processes work • Helps to identify breakdowns and bottlenecks • Examines relationships among process steps in systems Process Step No Decision Yes End

21. Help Teams Look for Root Causes and Solutions in… NPHPSP Assessment Notes MAPP or Similar Community Initiatives or Assessments Reports Research Findings

22. NPHPSP Users’ Guide (CDC)www.cdc.gov/od/ocphp/nphpsp/ToolKit.htm Memory Jogger II & Problem Solving Memory Jogger (Goal QPC)www.goalqpc.com

23. Public Health Infrastructure Resource Center (PHF)www.phf.org/infrastructure/performance • Searchable QI tools • NPHPSP-related tools • Sample action plans • Publications • Case studies