Denver Public Health Center for Public Health Preparedness Public Health Services Research, Moving to the Mainstream Public health performance and quality improvement, one state’s experience A. Davidson, MD, MSPH AcademyHealth, Annual Research Meeting Hynes Convention Center Boston, MA June 26, 2005

Historical context Current efforts Outline

Historical context CO Health Data Advisory Committee (CoHDAC) Colorado PH Education Committee CO PH Capacity Building Steering Committee Denver Center for Public Health Preparedness Public Health Performance Improvement Collaborative (PH-PIC) Outline

Colorado Health Data Advisory Committee (CoHDAC) Vision: Access to health data on as needed basis with an analytic toolset to generate information. Result [1994-present] created a competent, committed, collaborative (local/state) problem-solving group [1995] Colorado Health Information Dataset (CoHID) CD-version, Weld County [1998 – present] Colorado Health Information Dataset (CoHID) on-line SAS IntrNet query tool (CDPHE), GIS capacities

Colorado PH Education Committee Charge: Create a strategy for improving education and training of Colorado’s PH workforce. Results [April 2001] Colorado PH Professional Education Plan: Life-long Learning System,. [April 2002] Workforce educational needs assessment ( UCHSC SON survey ) to set training priorities by gauging: How important a skill area was to job, How prepared staff felt in each skill area, and What interest existed around training [2004] Implementation CO-TRAIN, (PHF)

CO PH Capacity Building Steering Committee Charge: Workforce development was only a part of PH essential services delivery capacity; convened committee to create a strategy for enhancing Colorado’s capacity to do PH work. Result [2001] The committee recommended the use of the NPHPS. –Post Sept 11, 2001, enabled NPHPS assessment funding. –OLL coordinated implementation of NPHPS assessment [February 2003]. NPHPS study completed for Colorado

Denver Center for Public Health Preparedness ( CDC-funded Advanced Practice Center ) Mission: to…enhance operational readiness… dual use perspective, operational readiness related to organizational capacity parallel skills for BT readiness and routine ES capacities operates at organizational or system level –PH community had individual readiness competencies (Columbia SON) Issues: Have we defined organizational competencies? How are they measured? Are they being used? How would combined (individual and organizational) competency measures better evaluate our essential services delivery or BT readiness capacities?

Operational readiness Organizational capacity BT Supplement Challenge PH Needs – Dual Use Routine BT

Denver Center for Public Health Preparedness (cont.) Result: [June 2003, Conference ] Started the QI Collaborative Goals: Cultivate within Colorado’s PH community a culture of learning and QI Facilitate PH quality improvement, capacity building and all hazards preparedness in CO Members: representatives of local/state public health departments (e.g., OLL, data, QI, academics)

Merger: QI Collaborative & the Capacity Building Steering Committee (2003). Articulated a new group identity (mission, vision and new name: PH-PIC).

Public Health Performance Improvement Collaborative (PH-PIC) What is PH-PIC?: A workgroup from local/state health departments which adapts national initiatives to expand and improve local public health performance and all- hazards preparation and capacity. PH-PIC Premise: The process of setting priorities for performance improvement and all-hazards preparation should be driven by current Colorado data.

Merger: QI Collaborative & the Capacity Building Steering Committee (2003).

NPHPS Opportunities for Colorado To use results to improve public health practice and the public health system performance as a whole To provide a foundation for continuous quality improvement activities Encourages stakeholder communication and collaboration –Promotes greater understanding of the available capacity and resources within a region –Promotes the development of new and/or stronger partnerships Encourage greater inter-jurisdictional cooperation

Proportion of NPHPS Standards Being Met

Importance & Intent for QI (Survey)

Workforce Proficiency (SON Survey)

NPHPS Priority Matrix

Merger: QI Collaborative & the Capacity Building Steering Committee (2003).

Denver Public Health Department Performance topics: Emergency notification system System to divert workforce to function in specific emergency response roles, while maintaining core public health functions Selection of sites for dispensing mass vaccinations/prophylaxis

Denver Public Health Department Performance topic: Emergency notification system How decided is important: Contractual obligation (BT preparedness) No current system Specific aim or purpose: Develop an alert/notification system Inform PH workforce of roles/responsibilities Insure a functioning system Desired outcome or target improvement: 100% of employees aware of emergency number 98% of employees contacted within 24 hours 100% of contacted employees follow emergency notification procedures Quarterly test of efficiency system

Denver Public Health Department: 2/11/04 Number: (68) 98 (97) 48 (32) 34 (23) hrs 3.1 hrs Results: Total employees Employees contacted Performed action Employees not contacted Employees beneath 1 caller Mean contacts per employee Mean time to contact Mean time to return call No. corrected phone numbers No. of alternative numbers

Merger: QI Collaborative & the Capacity Building Steering Committee (2003).

Quality Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement?

Four Steps of Improvement (IHI Model) Plan Do Study Act Plan Study Do Act

Team Specific Process and Quality Improvement Projects Team: _____________________________________Date:________________________________ Performance Improvement TOPIC: How did you decide this is important (what baseline data is being used?) Specific Aim or Purpose Desired Outcome or Improvement Target Plan to Achieve Target - Action Steps (who, will do what, by when) What will be done? (brief description)Who will do it?By When? How will you measure success and continue to monitor the process? (measures tracked, how often) Example of a Basic Plan

Repeated Use of the Cycle Plan Study Do Act Plan Study Do Act Plan Study Do Act Plan StudyDo Act DATA Hunches, theories, ideas Changes that result in improvement    

Denver Public Health Department: 6/24/04 Number: (100) NA 4.1 hrs. -- Results: Total employees Employees contacted Performed action Employees not contacted Employees beneath 1 caller Mean contacts per employee Mean time to contact Mean time to return call No. corrected phone numbers No. of alternative numbers

Merger: QI Collaborative & the Capacity Building Steering Committee (2003).

Colorado’s PI choices clustered around three Essential PH Services Monitoring –3 state system plans –27 local system plans Diagnosing –29 local system plans –5 state system plans Evaluating –12 state system plans –5 local system plans 39 local and state plans targeted All-Hazards

PH-PIC Assessment (Fall 2004/Winter 2005) Clustering of PI priorities Results of NPHPS matrix Should Learning Communities be developed to support quality improvement/ performance improvement in Colorado’s Public Health systems?

Current efforts Learning communities Regional Health Information Organization (RHIO) Outline

Hear and log our stories Recognize common statewide issues Work to define and solve problems Assure dual purpose/use of our efforts Consider developing a learning community Use as opportunity to guide new BT supplemental planning process What might we accomplish today? June 2, 2003

Learning Community “Learning communities are developed where groups of people, linked geographically or by shared interest, collaborate and work in partnership to address their members’ learning needs… Learning communities facilitated through adult and community education are a powerful tool for social cohesion, community capacity building and social, cultural and economic development.” Department of Education, 2003, p 12.

Barriers to Organizational Learning Silo style of work and work groups Unsupportive leadership Lack of legitimacy Failure to build in time and structures for learning Defensive communication patterns Limited ability for reflection and generative learning Lack of the 6 “C’s” in group members

What It Takes to Create and Sustain A Learning Community Capability: have the skills, knowledge and personal qualities to renew themselves and reinvent a future through skillful discussion Commitment: people are an integral part of creating a community they value together Contribution: members must see how their work contributes to community; provide opportunities for diversity of talents and contributions (Brown and Isaacs, Fifth Discipline Fieldbook, 1994, p )

Creating and Sustaining Learning Communities (cont.) Continuity: develop an institutional memory, careful orientation of new members Collaboration: develop interdependence, share vision and strategy, free flow of information, able to act autonomously to achieve common goals Conscience: guiding principles, ethics, values (e.g., trust, mutual respect) (Brown and Isaacs, Fifth Discipline Fieldbook, 1994, p )

PUBLIC HEALTH PERFORMANCE IMPROVEMENT COLLABORATIVE Title: Demonstrating success: User-friendly evaluation for public health programs Learning objectives Increase familiarity with useful evaluation terminology. Identify evaluation resources. Practice using basic evaluation skills Short Description This user-friendly, interactive workshop will allow participants to gain knowledge and skills to demonstrate the success of their programs. Commonly used evaluation processes and resources will be presented with opportunities for practice. EVALUATION LEARNING COMMUNITY CPHA Abstract Draft – June 3, 2005

Initiating work around cataloguing available data sources and identifying data gaps. Adjunct work by Colorado Health Information Exchange MONITORING LEARNING COMMUNITY

Goal: Create a local health information infrastructure for clinicians to access patient information across individual health care institutions Colorado Health Information Exchange 2 Complementary Initiatives Build upon what exists Denver Health (DH) 150,000 residents (25% of population) Kaiser Permanente of Colorado (KPC) 3 rd largest CO HMO (350,000 members) The Children’s Hospital (TCH) Largest pediatric specialty care provider University of Colorado Hospital (UCH) Largest Metro area teaching hospital

COHIE to CORHIO COHIE Learning Laboratory Steering Committee Working groups: Technical Clinical Evaluation Legal Organizational Community Advisory Council Colorado Regional Health Information Organization A sharing, self-sustaining non-profit structure that: Promotes legal agreements for participation and access Maintains a robust technical environment Defines clinical value through policy and procedures Manages the budget and sustainable business model Supports national standards and public health interfaces PROJECT (10/2004) VISION (10/2009)

COHIE: 2005 plan

COHIE: Linking independent clinical data into a “virtual” patient-centered view 1. Accountable and OPEN participation 2. Clinical data sharing between different platforms 3. Data sharing and degree of participation remains under local control Mesa County The Children’s Hospital Boulder Larimer Weld Denver Health El Paso County MedSouth IPA University Hospital Kaiser Permanente Exempla Rose Medical Group Colorado Care Collaborative (RMD) Payor # 1 – RMHP ??? RxHub ??? COHIE: “Community” patient index common (standard) messaging Vendor independent (neutral) Rural small MD access ? CHCN - Health Center? Clinical Data Contributor TBD ?

CORHIO Process Colorado Health Institute (neutral convener) Legal support Explore/define relationship COHIE ⇔ CORHIO Working Group Business plan Articles of incorporation (501c3) Defining the board Education/public relations Community Advisory Council (greater than 40 members, most HIT projects going on in Colorado

Future activities/use cases Public Health Registries and evaluation of care quality Active surveillance due to recent events Immunization tracking and reminder/recall Others ?? Use of global-level decision support Continuity of care record (CCR) for effective care transitions (acute -> treatment centers -> home) Patients controlling EHR access

Conceptual Framework State/Local Partnerships Leadership Development Performance Improvement If the conceptual work is successful, we should focus on…. And if true leaders emerge, we should generate …. Then partners will agree to emphasize… And then tools/methods and measures will evolve to support/revise the… COLORADO TEAM - VISUAL MODEL National Public Health Leadership Institute Draft V1.1, June 20, Essential Services Clear PH message Systems thinking Change management Respectful relations Inclusive planning Accountability targets Unified measurement process