partnering for systems improvement: the role of public health institutes in quality improvement and...

Partnering for Systems Improvement: Partnering for Systems Improvement: The Role of Public Health Institutes The Role of Public Health Institutes

in Quality Improvement and in Quality Improvement and AccreditationAccreditation

December 4, 2008December 4, 2008

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Partnering for Systems Improvement: Partnering for Systems Improvement: The Role of Public Health Institutes The Role of Public Health Institutes

in Quality Improvement and in Quality Improvement and AccreditationAccreditation

December 4, 2008December 4, 2008

Background on NNPHI

Established in 2001 to enhance the capacity of the nation’s public health institutes

Vision: Fostering Innovations in Health Mission: To promote multi-sector

activities resulting in measurable improvements of public health structures, systems and outcomes

NNPHI Membersvisit www.nnphi.org for links to members’ websites

Statewide Nonprofit

University-Affiliated

Municipal / Sub-State

Provisional Member

Affiliate member

Attributes of PHIs

• Complement governmental public health system

• Convene multi-sector partners• Support health systems change and

improvement• Source of reliable health information• Nimble - able to leverage new resources• Rework boundaries and form creative

alliances

Competencies of Public Health Institutes

Population-based health programs Health policy development Training/Technical assistance Research and evaluation Health informatics Fiscal/administrative management Social marketing / health

communications

NNPHI Programs

Member Services Fostering Emerging Institutes National Programs (PHLS and NPHPSP) Multi-State Projects

BT Collaborative Preparedness Modeling Collaborative Multi-State Learning Collaborative: Lead

States in Public Health Quality Improvement

Brief History of Accreditation and QI in Public Health

2003 IOM Report: called for a national committee to examine the benefits of accrediting public health departments

2005 - 2006 Exploring Accreditation Project

2007 Public Health Accreditation Board established

2011 Projected launch of National Voluntary Accreditation Program

What is NNPHI doing to support accreditation & QI?

Co-coordinate NPHPSP partnership and promote use of NPHPSP

Manage the Multi-State Learning Collaborative: Lead States in Public Health Quality Improvement Project

Recently supported Public Health System Research Grants on Accreditation

Why is NNPHI involved in QI and Accreditation?

Session at 2005 NNPHI Conference and additional collaboration with PHIs identified that PHIs are working in partnership with state and local public health agencies to support their efforts to: Assess performance Prepare for accreditation Create a culture of quality improvement

How are the institutes partnering and collaborating with local, state and national partners to prepare

for accreditation and conduct quality improvement?

Supporting Use of NPHPSP

Institutes in New Hampshire, Maine, Texas and Illinois have supported the completion of state and local NPHPSP instruments by providing the following types of support: Orientation to public health and the assessment

process Facilitation of assessment and priority setting

sessions Analysis and presentation support Assistance in writing public health improvement plans

Supporting Accreditation Related Efforts Illinois Kansas Florida Michigan Missouri New Hampshire North Carolina Oklahoma Wisconsin

Convening stakeholders and building momentum for accreditation Illinois Public Health Institute staffs the Illinois

Accreditation Task Force (IATF) Goal: improve the performance of local

health departments in Illinois through accreditation strategies and quality improvement activities.

IATF Members includes the Departments of Public Health and Human Services, SACCHOs, IL Association of Boards of Health, UIC, IPHA

Careful process of building will for accreditation at the local and state level

Conducting research and evaluation of accreditation and quality improvement Missouri Institute of Community Health

Annual evaluation of Missouri’s voluntary accreditation program for local health departments

Michigan Public Health Institute Research Examining the Costs of Preparing and

Applying for Accreditation: Developing Cost Measures North Carolina Institute of Public Health

Evaluation of NC Local Public Health Accreditation Research on Incentives for Public Health Accreditation Research on Public Health Quality Improvement

Initiatives

Participating in PHAB Workgroups

Assessment Process Janet Canavese (Missouri) David Stone (North Carolina)

Equivalency Rachel Stevens (North Carolina)

Research and Evaluation Mary Davis (North Carolina) Laura Landrum (Illinois)

Creating tools and resources to help agencies prepare and conduct QI

NC Roadmap

Michigan QI Guidebook

Creating a quality improvement culture and field of practice

Organizing large and small group QI training sessions

Managing and providing technical assistance for QI projects

Communicating and Spreading QI Findings

MPHI and KHI created storyboards that describe each step of the QI process

KHI worked with local partners to share QI project findings with policy makers

Why is NNPHI involved in QI and Accreditation? Revisited Fits with our strategy to collaborate with

members and systems partners in effort to advance public health

Feedback/Recommendations for the Exploring Accreditation Steering Committee:

“NNPHI supports a national voluntary accreditation system it the system is able to incorporate a strong focus on technical assistance supporting continuous quality / performance improvement efforts”

Commitment to innovation in health

Roles of PHIs in QI and Accreditation

Examples from the Field: New Hampshire North Carolina Kansas Michigan

Improving the Public’s Health in New Hampshire

A Partnership of the Community Health Institute and

the NH Division of Public Health Services

December 4, 2008

Our Partnership- DPHS/CHI

Community Health Institute (CHI) Established in 1995 by JSI Research and Training

Institute (JSI), in partnership with the NH Department of HHS RWJ Foundation

Provide community-based providers with expertise and resources to strengthen New Hampshire's health care system

Works with health departments, health care providers and organizations, community organizations, and foundations

Work with DPHS as contractor, partner, fiscal agent

Performance Based

Contracting

Technical Assistance to local

networks for performance

assessment and improvement

National Public Health

Performance Standards

Assessment and Planning

MLC preparing for accreditation,

measuring performance,

learning

collaboratives

PerformanceImprovement

Public Health Improvement Team

CHI

DPHSDPHS

DPHS

CHI

And now, a brief word about local assessment: the NH

Context Each of New Hampshire’s 234 cities and towns are

statutorily required to have a health officer

Together with the local administrative body, the health officer constitutes the local health board

Approximately 25% of New Hampshire towns rely on volunteer health officers; many others utilize code enforcement officers

Only five New Hampshire communities maintain public health departments (2 comprehensive); no county health departments

We have been working slowly to strengthen our local public health infrastructure

Strengthening the Public Health System-Locally

In 2001, NH began funding 4 local public health demonstration programs through the RWJF Turning Point Program.

The Community Health Institute assisted communities in the measurement of system capacity and performance built into the demonstration effort from the beginning as part of the local evaluation; adapted Turnock-Miller 20 questions instrument.

By 2005, the initiative grew to include 14 local public health partnerships covering 70% of the NH population.

Assessment activities continued to be a fundamental program expectation; graduated to use of NPHPS local performance assessment instrument and the creation of community public health performance improvement plans

Assessment of the National Public Health Performance Standards - 2005 led by DPHS

110 public health stakeholders participated attendance Led to the development of 6 strategic priority areas with

work groups and action plans combined into a statewide action plan for the public health system

DPHS staffs the legislatively created Public Health Services Improvement Council – CHI is a council member

CHI leads one workgroup –Mobilizing Community Partnerships – sits on other work groups

Strengthening the Public Health System-Statewide

2007 Quality Improvement Activities

for MLC-2 Articulate measures to monitor improvement

for New Hampshire’s performance on our 6 strategic priorities – and others

Develop automated data collection, storage and reporting processes for the 6 strategic priorities and other performance measures

Improve the quality of public health practice using existing standards to create a tiered approach to credentialing/ accreditation of local public health professionals

MLC-3:Lead States in Public Health

Quality Improvement

To bring state and local stakeholders to together in a community of practice to

Prepare local and state health departments for national accreditation & contribute to the development of national voluntary accreditation

Advance application of QI methods that result in specific measurable improvements, and institutionalization of QI practice in public health

MLC-3 Goals

1. Facilitate development and improvement of local public health agencies and systems through application of collaborative, evidence-based quality improvement processes

2. Prepare the State Health Department for voluntary accreditation by piloting national accreditation standards and institutionalizing enhanced quality improvement processes

3. Incorporate national accreditation standards and assessment activities within the cycle of performance management and quality improvement at the local level

4. Create quality improvement mini-collaboratives working toward linking public health capacity to population health outcomes

5. Share best practices and lessons learned, and disseminate findings across the larger public health community

Focus on MLC-3 Goal #3

Incorporate national accreditation standards and assessment activities within the cycle of performance management and quality improvement at the local level

builds directly upon the work of MLC-2 advances the process of regionalization and

developing regional public health infrastructure

Public Health Capacity Assessment

Working with 6 Public Health Regions to capture the capacity of regional public health systems

Requires information about the contributions of diverse partners with formal as well as informal linkages.

→ Modification of NACCHO Self-Assessment Tool to capture essential characteristics unique to NH’s regional public health systems

Why participate in these assessments?

The findings from these assessments will provide the evidence that drives public health

policy in NH.

This is a unique and valuable opportunity to register assets, document need, and learn from one another about the public health services and functions that exist in your

region.

Assessment Process

Identify a lead organization [or organizations for regions in more formative stages of evolution]

Capture perceived contributions of the lead organization to the greater region

Validate perceived contributions of the lead organization with regional partners

Capture additional contributions of regional partners

Capture contributions of the state (Division of Public health Services, Division of Environmental Services, Department of Education, etc.)

Process: Part I

Completed by lead organization Occurs at the operational indicators

level for each standard of each Essential Service.

Process: Part II

Completed by a convened group of regional public health system partners

Occurs at the standards level for each Essential Service

Entails answering 3 questions: Does the group concur with the self-assessment of

the lead organization? Are there additional expertise or services within the

regional public health system (regional partners)? How does the State of NH contribute to regional

public health capacity?

STANDARD I-B Develop relationships with local providers and others in the community who have information on reportable diseases and other conditions of public health interest and facilitate information exchange.

FOCUS: DISEASE REPORTING RELATIONSHIPS; MAKE DATA AND INFORMATION FLOW ROUTINE

Operational Definition Indicators

Operational Definition Indicators Score - Lead organization(s)

TopicDocuments and/or

Activities That Demonstrate Indicators Have Been Met

1. LHD staff can be contacted at all times.

Preparedness

A written policy/procedure exists that describes that assures LHD staff can be contacted at all times.

1. Providers and other appropriate health care system partners are educated and trained in collecting and reporting data to the LHD.

Data Record of presentations, evidence of meetings held, conferences organized (e.g. agenda), and/or educational materials distributed to promote provider and other public health system partner to promote knowledge and disease reporting procedures.

1. LHD uses a quality improvement process between LHD and providers to make it easy for providers to report.

Quality Improve

ment

Written quality improvement process available for evaluation of disease reporting between providers and the LHD. Results of evaluation shared and documentation that the process was improved, if needed, based on a quality improvement process.

1. Health care providers and other public health system partners receive reports and feedback on disease trends and clusters.

Communication

Has process for organizing data to determine trends and clusters and for providing the information to health care providers and other public health partners.

Log of distribution of reports, topics, to whom and any feedback.

Comments regarding regional partners providing services for this focus area:

Using the same criteria as the lead organization, score the existence/availability of the regional contribution to local public health capacity for this standard.

Please rate the adequacy of state planning, staffing, or other resources applied directly at the regional level for this standard:

0 = insufficient information to rate the contribution 1 = insufficient contribution 2 = sufficient contribution

ESSENTIAL SERVICE I: Monitor health status and understand health issues facing the

community

Staff can be contacted at all times.

Providers & other health care system partners are educated and trained in collecting and sharing data among PH system partners.

Uses a QI process between to make it easy for providers to report.

Health care providers & other PH system partners receive reports and feedback on disease trends and clusters. community

health institute

STANDARD I-B Develop relationships with local providers and others in the community who have information on reportable diseases and other conditions of public health interest and facilitate information exchange.

FOCUS: DISEASE REPORTING RELATIONSHIPS

Scoring Matrices- Lead organization and regional partners

Scoring Matrices-State Contribution

How does the State of NH contribute to regional public health capacity?

Continuous Quality ImprovementNACCHO Local Health Department Self-Assessment Tool (Rev.) - Regional Partners Evaluation Tool

1. The pace of the assessment was: Too slow Just right Too fast1 2 2.6 3 4 5 Improved over time

2. The process was:Painfully inefficient Extremely efficient Painfully efficient 1 2 3 3.2 4

3. How well did the poster boards keep the process moving?

Useless

Essential 1 2 3 3.4 4

4. How well did the PowerPoint slides keep the process moving?

Useless

Essential 1 2 3 3.3 4

6. The scoring methodology was: Muddy Crystal

Clear

1 2 3 3.3 4

7. Please share which aspect or aspects of this assessment process were most beneficial. Open discussion that was generated , group interaction Clear directions and process support Working the scores out together Slow process Negotiating to consensus PowerPoint, posterboards, and people who came to the meeting

8. Please share your ideas for improving the process. Use survey monkey More diverse/representative group- more participation from region

Other Important Details

Collaboration between CHI and NH Division of Public Health Services

Tool modification Shared facilitation of Regional Partner Process

Supporting Resources Modified NACCHO Tool PowerPoint Poster boards Evaluation tool

Estimated Time to complete Lead Organization - 2-4 hours Regional Partners – 4-6 hours

Other collaborative activities…

MLC-3 Quality Improvement Learning teams

addressing nutrition and activity, links to Healthy Eating Active Living Initiative

Development of integrated Division of Public Health outcome measures [Reduction of tobacco-related chronic disease]

Re-Assessment of the National Public Health Performance Standards (2009-2010)

Next steps…

Continue to assess regional public health capacity improving the process based on feedback

Phase 1 will be completed by March 2009 Synthesis of financial and governance assessments

data to inform further progression of regionalized public health system

Eventually, each of the 15 public health regions will complete this capacity assessment, as well as the financial and governance assessments

Data will be analyzed to provide a complete picture of our public health capacity in each region, gaps and needs

Questions

Jascheim@dhhs.state.nh.usJoan AscheimBureau ChiefNH Division of Public Health ServicesBureau of Policy and Performance Management(603)271-4110http://www.dhhs.state.nh.us/DHHS/DPHS/iphnh.htm

Lea Ayers LaFave NH Community Health Institute/JSI(603)573-3335Lea_ayers-lafave@jsi.com

NC Local Health Department Accreditation

and the Role of the NC Institute for Public Health

NCLHDA Program Components

• Self-Assessment by the Agency• Site Visit• Board Adjudication

• The Accreditation Administrator notifies health departments

• 90 days to submit the Health Department Self-Assessment Instrument

• The Site Visit Team reviews the Self -Assessment, visits the health department and completes report

• The Accreditation Board meets and hears the report, granting a status of Accredited or Conditionally Accredited

Accreditation Process

Standard #1: Agency Core Functions and Essential Services (CF&ES)

Standard #2: Facilities and Administrative Services (F&AS)

Standard #3: Board of Health / Governance

41 benchmarks and 148 related activities

Health Department Self-Assessment Instrument

Role of the NCIPH

• Serves as the Administrator of the NCLHDA program– Direct and Oversee the Program

• By Statute, the Accreditation Board is “housed” within the NCIPH

Accreditation Partners

• NC Institute for Public Health• NC Division of Public Health• NC Association of Local Health Directors

• Partnerships continue with Board membership

History - Where have we been?• Work began on Accreditation in 2001-2002 with a joint NCALHD,

DPH, NCIPH committee• First standards were piloted in 6 local health departments• Revised tool - pilot II with 4 local health departments• Legislation to make system mandatory with 8 years for all to be

accredited• Commission for Health Services to adopt rules• Temporary Rules adopted in December, 2006 • Rules final in August, 2007

Where are we now?

• 40 Accredited Local Health Departments as of October 24, 2008

• 4 more will go before Board on December 19, 2008

http://nciph.sph.unc.edu/accred/

Health Departments participating in FY 2009

Health Departments participating in FY 2010

Health Departments participating in FY 2011

Health Departments proposed for FY 2012

Health Departments proposed for FY 2013

Accredited Health Departments

Other Support from NCIPH• Technical Assistance

• Program Evaluation• Consultation – Agency Assessment• Strategic Planning• Workforce Development – Training

• Maintain Firewall Between Accreditation & Other Services

NCIPH Support for National Accreditation

• Accreditation Road Map

• Research on incentives to encourage participation

• ASTHO toolkit

• PHAB Workgroups

Institute Opportunities

Questions?

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Greater than the sum of its parts: Challenges and growth of

alliances in the Land of Oz

Greater than the sum of its parts: Challenges and growth of

alliances in the Land of Oz

Gianfranco Pezzino, M.D., M.P.H.

Kansas Health Institute

OutlineOutline

Who we (KHI) are What is the KS environment like? What about accreditation? “Lessons learned”

KHI BasicsKHI Basics

Private, non-profit, 501(c)(3) Annual operating budget of $2.4 million Kansas Health Foundation core funding Additional $4+ million in grants since

1999 Half of grant revenue flows through to

other research partners 20 full-time positions Use of experts/consultants ad hoc

Kansas Local Health Departments:Population Served

Kansas Local Health Departments:Population Served

90 LHDs w/ <50,000(37% of pop.)

<

50,00010 LHDs w/ >50,000 people (63% of pop.)

15 Regions, 103/105 counties15 Regions, 103/105 counties

Alliances – The broader Public Health System

KS Association of LHDs

KS Dept. of Health and

EnvironmentKS Health Institute

University of Kansas Medical

Center

Alliances – The MLC-3 project

KS Association of LHDs

KS Dept. of Health and

Environment KS Health Institute

University of Kansas Medical

Center

• Solicit proposal for QI projects• Contract with regions

Provide teams for mini-collaboratives

• Administer grant • T.A.

Curriculum, faculty, C.E.

“What about accreditation?”

Some Issues Around Accreditation in a Rural State

Some Issues Around Accreditation in a Rural State

KS public health “universe” is very diverse

How to define common levels of standards for LHDs with diverse capacity: “Minimum” common denominator? Technical assistance to “weak” sites? Multiple tiers of accreditation?

Focus on Standards and Performance ManagementFocus on Standards and

Performance Management

“Everyone, no matter where they live, should reasonably expect the local health department to meet certain standards”

Define the standards, then discuss how each LHD can get there

Establish performance management system to monitor progress towards standards

Focus on Standards and Performance ManagementFocus on Standards and

Performance Management

“Everyone, no matter where they live, should reasonably expect the local health department to meet certain standards”

Define the standards, then discuss how each LHD can get there

Establish performance management system to monitor progress towards standards

READY FOR ACCREDITATION!

Performance Management in Kansas – Related Projects

Performance Management in Kansas – Related Projects

•MLC

1 2

3 4

•NACCHO

•PROPHIT

•PROPHIT

Role for KHIRole for KHI

Increase capacity in state for applied research, assessment, evaluation, technical assistance

Independent, authoritative entity Credible voice Mediate among competing needs and resources

of other partners

More flexible structure than government agencies Manage some projects on behalf of all partners

Lessons LearnedLessons Learned

The “Blessing”: K.H.I. is not “in charge”

The “Curse”: K.H.I. is not “in charge”

The Solution: It takes patience, time and consensus

building Personal relations are paramount

Healthier Kansans through informed decisionsHealthier Kansans through informed decisions

Embracing Quality in Local Public Health: Embracing Quality in Local Public Health: Michigan’s Quality Improvement GuidebookMichigan’s Quality Improvement Guidebook

Michigan Public Michigan Public Health InstituteHealth Institute

- - Kanchan Kanchan Lota, MPH Lota, MPH

- Julia Heany, - Julia Heany, PhD.PhD.

http://www.accreditation.localhealth.net/

Michigan Local Public Health Accreditation Program Partners

MDCH

LHDsMPHI

Accreditation Program

MDA MDEQ

Embracing Quality in Local Public Health: Embracing Quality in Local Public Health: Michigan’s Quality Improvement GuidebookMichigan’s Quality Improvement Guidebook

http://www.accreditation.localhealth.net/

Plan

DoStudy

Act

Guidebook: Content and StructureGuidebook: Content and Structure

Overview of the PDSA approach to Quality Overview of the PDSA approach to Quality Improvement (QI)Improvement (QI)

Sections on:Sections on: Customers & StakeholdersCustomers & Stakeholders The Importance of DataThe Importance of Data Writing an Aim StatementWriting an Aim Statement QI Tools & PH Measures of ImprovementQI Tools & PH Measures of Improvement PH Example of PDSAPH Example of PDSA Storyboards & Case Studies from the 4 MLC-2 QI Storyboards & Case Studies from the 4 MLC-2 QI

projects at the Local Health Departmentsprojects at the Local Health Departments Program Evaluation, QI Resources, & MoreProgram Evaluation, QI Resources, & More

Why Develop a QI Guidebook for Why Develop a QI Guidebook for Public Health?Public Health?

Addressing

an

ABSENCE

in

the

Marketplace!

Coordination Coordination Coordination Coordination Coordination! Coordination!

Managed entire Managed entire process from process from development to development to completioncompletion

Set up meetingsSet up meetings Tracked content Tracked content

developmentdevelopment Ensured deadlines were Ensured deadlines were

being metbeing met All graphicsAll graphics FormattingFormatting Final editsFinal edits Publishing Publishing

“The road to quality is never smooth, but

it’s the only one that leads to long-

term success.”-Author unknown

The Road to Quality

Embracing Quality in Local Public Health: Embracing Quality in Local Public Health: Michigan’s Quality Improvement GuidebookMichigan’s Quality Improvement Guidebook

Lessons LearnedLessons Learned

- Public health Public health applicationapplication

- Provide resourcesProvide resources- Build on Build on

relationshipsrelationships- Facilitate Facilitate

collaborationscollaborations- Share successesShare successes

http://www.accreditation.localhealth.net/

Questions?

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Thank You!