Creating a Culture of Quality Improvement Los Angeles County Department of Public Health Division of Quality Improvement Hello and welcome to An Introduction to Quality Improvement in Public Health, a course designed to provide you with a basic understanding of how quality is managed in a Public Health Department setting. Before we get started, please complete the pretest. -Next

Goal #1: Develop an understanding of what Quality looks like in Public Health

Quality in Public Health is… The degree to which policies, programs, services, and research for the population increase the desired health outcomes and conditions in which the population can be healthy -PHQF, 2008 Before we can define quality improvement, we must first understand what is meant by the term “quality” when it comes to public health. Quality in Public Health is the degree to which policies, programs, services, and research for the population increase the desired health outcomes and conditions in which the population can be healthy. In other words, is the work that we are doing to improve the health of Los Angels county residents actually making a difference? Have we seen improvements in the health of the population that can be attributed to the work that we are doing here at DPH? For example…

Quality at LACDPH Quality is the result of Worthy Work Well Done Worthy= We must have a clear direction (Strategic Plan) Work= Our work should have an intelligent direction based on evidence and best practices. Well Done= Our work should be carried out by a skilled and competent workforce and measured to track our performance.

Goal 2: Develop a clear understanding of Quality Improvement and why it is necessary

Quality Improvement Quality Improvement (QI) is an integrative process that links knowledge, structures, processes and outcomes to enhance quality throughout an organization. -National Committee for Quality Assurance Quality Improvement is an integrative process that links knowledge, structures, processes and outcomes to enhance quality throughout an organization. In other words….Quality Improvement is WORKING TO DO THE RIGHT THINGS RIGHT!

Why QI? In a time of decreased funding and increased demand, QI can help answer key questions in public health: Are we using our resources (staff, money, time) in the best way? We often hear “work smarter, not harder” Are we getting the intended outcomes?

Are we actually improving the health of the public in the most effective and efficient way possible? And if not, how can we do it better?

QA & QI -They are not the same!!! Quality Assurance: Quality Improvement: Reactive; works on problems after they occur Regulatory Led by management One point at a time Proactive – works on processes before problems occur Self-determined Led by staff Continuous Exceeds expectations Source: Public Health Foundation

3 Levels of Quality Improvement Topic Organization-Level Program-Level Individual-Level Improvement   System Focus Specific project focus Daily work level focus Quality Improvement Planning Tied to the Strategic Plan Performance Measures tied to program-level Strategic Plan Tied to yearly individual performance Evaluation of Quality Responsiveness to a community need Performance of a process over time Performance of daily work Processes Cut across all programs and activities Delivery of a service Daily work Quality Improvement Goals Strategic Plan Individual Program level Strategic Plans Individual Performance Evaluations

Importance of Quality Improvement Quality Improvement positions an agency to achieve: Customer satisfaction Efficient use of resources Measurable outcomes Community impact

Connect staff with the benefits of Quality Goal #3 Connect staff with the benefits of Quality

Quality in Public Health Benefits Everyone Customers/Clients Employees The Organization

Benefits of quality to clients Improved services Improved choices Expectations met or exceeded Client oriented employees Friendlier atmosphere Give examples

Benefits of quality to employees Pride in services delivered Job satisfaction Improved communications Streamlined work processes Happier clients Strong client relationships Give Examples

Benefits of quality to the organization Improved/expanded services Client oriented employees Improved client relations Improved community relations = better political relations Lower costs/cost contained Improved funding Give Examples

Goal #4 Develop a clear structure and framework for quality management

Continuous Quality Improvement Efforts

Determine Priorities and Goals What are the healthy behaviors and outcomes we want for people who live in LA County? What would these conditions look like if we could see them? Adapted from Mark Friedman’s “Results Accountability.” The questions on the left are the “big picture” questions that describe the general health goals we hope to achieve (Question 1) and specific conditions we plan to work on (Question 2). However, there will likely be more conditions to work on then we have time or resources to actually do. Here is where the need for strategic planning comes in... Currently, we have guidance from the LA County Strategic Plan and a newly released DPH Strategic Plan that helps us prioritize goals. In addition, Division Directors may require each program to create its own strategic plan.

Performance Measures

Results Based Accountability POPULATION INDICATORS (measures of population-level health outcomes) PERFORMANCE MEASURES (measures of program effort and output) AND DPH and the Chief Executive Office use Mark Friedman’s “Results Accountability” approach for selecting goals and measures to assess the services we provide to the residents and visitors of Los Angeles County. This approach includes a quick and easy way to gain consensus on long-term goals and the actions/business processes needed to achieve them over time. One of the benefits of this approach is that measures are separated into 2 categories: Population-level indicators (with shared accountability); answers the question “How is the population better off?” Program- and SPA-specific performance measures (program accountability); answers the question “How effective is the program?” DPH will continue to use these 2 sets of measures and apply other selected “Results Accountability” principles in its PI efforts. Four quadrant approach to program performance measures Data development agenda Headline measures Public Health Measures

Population Indicators Longer life span Increased quality of life Increased health equity Less disease Less premature death Healthier choices Safer environment Healthier homes POPULATION-LEVEL HEALTH OUTCOMES & BEHAVIORS How do we measure “success” in improving health at the population level? The list on the left includes currently accepted categories of health behaviors and outcomes. From these categories, Indicators can be created/written. The Indicator is the underlined portion, and we have specified the direction we want the Indicator to move in. Yellow indicates actual health outcomes, whereas white indicates upstream determinants of health (i.e. behaviors, built environment)

Population Indicators Percent of students who had at least one drink of alcohol in the past 30 days Rate of foodborne illness hospitalizations each year (per 100,000) Percentage of children covered by health insurance Death rate from colorectal cancer All of these examples of indicators were taken from the current set of DPH Public Health Measures (except #4). The respective categories are: Healthy choice/behavior Less disease Less premature death

Performance Measures Policies Created People Informed Improved Behaviors Surveillance Performed Investigations Completed Increased Access to Services Client satisfaction MEASURES OF PROGRAM EFFORT & OUTPUT How do we measure our work?

Performance Measures Percent of outbreaks (excluding scabies) investigated within standard timeframe Percentage of children under 6 years who participate in fully operational population-based [immunization] registries Number of cities that adopted a policy that prohibits smoking in outdoor areas All of these examples of indicators were taken from the current set of DPH Public Health Measures. The respective categories are: Investigations completed Surveillance completed Policies created

Reporting of Progress

Performance Improvement Process

Who Manages Quality at DPH?

Who Manages Quality at DPH Everyone Plays a Role in Quality Management: Director of Public Health Division of Quality Improvement Strategic Directions Council Executive Team Performance Improvement Team Program Directors Managers/Supervisors All Staff

In order to establish a lasting culture of Quality, you must: Have a clear direction of what quality should look like in your organization Understand Quality

Goal #5: Clearly communicate your Quality Improvement plan and efforts throughout the organization

Step 1: Create a Quality Improvement Program Description Document Give an overview of Quality at the organization Describe the structure for managing quality throughout the organization Establish roles and responsibilities for all levels of staff in relationship to Quality Improvement efforts. List and describe the organization’s QI efforts Establish QI goals for the organization

Step 2: Train staff Introduction to Quality Improvement for all employees Incorporate QI into existing trainings Conduct orientation sessions to orient staff to the QI Plan Provide advanced QI training to prepare staff to conduct quality improvement projects

Step 3: Provide Support Technical Assistance 1:1 Consultation Presentations at program-level meetings

Summary In order to establish a culture of quality, you must first decide what quality in your organization will look like and communicate that vision to others The structure and process for quality improvement should be visible and easily understood by everyone in the organization Buy-in and support at all levels is essential to successfully establishing a culture of Quality

Thank you! Emily Peach, MPH, CHES Performance Improvement Manager Quality Improvement Division (213) 989-7243 epeach@ph.lacounty.gov