HIS Initiative Update QI and Performance Initiative Update PIHOA Board Meeting, March, 2015 A Mark Durand PIHOA Performance & Health Information Coordinator

HIS Extension Services- EHR- (Pohnpei)  Organizational readiness assessment,  System requirements,  Project scope of work,  Network upgrade proposal and a  PD recruitment of a manager for this project. Assistance with of cause-specific, age-adjusted NCD mortality from vital stats (Pohnpei) NCD Core Surveillance Profiles (Pohnpei, RMI, Palau) Data consultation for Million Hearts project (Palau)

HIS Highlights past 6 months Recruitment of Drs Cash & Hancock to work with PIHOA in the region Submission of a full DDM-FETP curriculum and delivery strategy proposal to FNU Pilot testing of DDM3 with multiple completed dataset analyses Partnerships

Delivery of 3-day Ebola Preparedness & Infection Control Workshop (RMI, FSM, Palau) Development of 1-day Ebola Preparedness & Infection Control Workshop Curriculum

DDM1) Outbreak surveillance and response DDM2) Basic applied epidemiology and data analysis DDM3) Intermediate applied epidemiology and data analysis DDM4) Public health surveillance DDM5) Special project DDM Courses:

DDM3 Intermediate Epi & Data Analysis- Oct, 2014 Incidence/Prevalence of Hepatitis in Guam Alcohol Prevention Messages in FSM (NOM Survey) Obesity in School Children in Kosrae Breast and Cervical Cancer Screening in Palau Current Drinking, Binge Drinking in Guam Oral Health Survey- Palau STEPs survey- Pohnpei Mortality in RMI Environmental Health Inspections in Palau

Next DDM Activities- Guam, May 4-15 DDM3 Intensive review and exam retake DDM4 Pilot DDM5 Project Kick-off Partners’ Retreat For Individual Board Member Consideration: o Nomination of participants > Previous DDM participants > New DDM candidates who have some epi/stats background

Proposed USAPI Regional Epi Capacity Building Unit (REU): Building blocks Workforce: Cohort of Epi Technicians at each health dept (DDM1-DDM5) At least 1 fully qualified, non-expat applied epidemiologist at each health dept (SHIP) Systems: Routine weekly communicable disease reports High quality SitReps during outbreaks NCD surveillance plan Annual NCD surveillance profile Annual Regional NCD and CD surveillance profile HIS capable of measuring preventive services coverage accurately

Proposed REU: Formal agreements Health Dept  REU New system elements to install Nominations of Epi Technician candidates Expectations of candidates Support to be provided by Director/Minister/Secretary

Proposed REU: Terms of engagement for REU staff Monitoring & Mentoring: REU staff  Epi Tech in-country work Sharing correspondence within REU Annual regional products: Evaluations of CD and NCD surveillance systems in each USAPI Regional profile of CD and NCDs- Progress and capacities Formal letters of notification through PIHOA ED for site visits of REU members For Board Consideration: o Consider endorsement of REU, communique to CDC and partners For Individual Board Member Consideration: o Nomination of Epi Technician candidates for your agency o Development of REU agreement

NCD Surveillance & Response ???

NCD Policy Toolkit

Other Good Frameworks: CDC Healthy People 2020 WHO NCD Global Monitoring Framework Framework Convention for Tobacco Control WHO “Best Buys” for NCDs WHO Pacific Roadmap for NCDs

Advantages of USAPI NCD “Products” 1) Commissioned by you 2) Developed by your Technical Working Groups 3) Pacific appropriate 4) Emergency-level intensity (Comprehensive) 5) Designed to fit with both CDC and WHO approaches 6) Gives you a place on the global stage

Out of 144 measurements: 14=improved, 15=worse, 33=no change, 82=not enough data USAPI NCD Core Surveillance Indicators TobaccoAlcoh ol ↑BMI Diseases (adult) Deaths (30-69 years) Cigs- youthCigs- adultChew- YouthChew- adultYouthAdultYouthAdultHTNDM↑CholesterolAll Cause CardiovascularCancerDiabetesChronic Lung Jurisdiction A↓N↓↑NNNNN Jurisdiction B↓N↓N↓N↑↑↑N↓ Jurisdiction C Jurisdiction D Jurisdiction E Jurisdiction FNNNNN↓N↓N Jurisdiction G↓↓↑N↓NNNNNN↑N↑↑↑ Jurisdiction H↑N↓N↓NNN↑↑↑NN Jurisdiction I↑↓↑↓N POPULATION

1) Update USAPI NCD Core Surveillance Framework: Change in age group for NCD STEPs CHL program monitoring of early child BMI Harmonize with Global Monitoring Framework 2) Update PIHOA “Progress in the Fight against NCDs in the USAPI” Evidence Brief Work Needed for NCD Core Surveillance For Board Consideration: o Guidance on re-convening the USAPI Technical Working Group to review and update the USAPI NCD Monitoring and Surveillance Framework For Individual Board Member Consideration: o Delegate a counterpart to update of NCD surveillance & policy profile

Medical Care (policy commitment Package) Community & Policy Health Promotion & Education

Preventive Services Delivery ???

Clinic-based interventions (eg. PEN- CCM) Community Screening & Outreach Other clinics NCD Clinic Not attending clinics

UDS Clinical Indicators Access to Prenatal Care (% with 1 st visit in 1 st trimester) Low birth weight (%) Cervical Cancer Screen coverage (past 3 yr 24-64yo) Adolescent Weight screening & f/u (%) Adult weight screening & f/u (%) Tobacco screening % Tobacco counselling % Colorectal Ca screening 2yo immunization coverage (%) Asthma- appropriate Rx (%) Lipid Rx for heart disease (%) Aspirin for ischemic vascular disease (%) BP control (% under control) Diabetes control (% with A1C test less than 9)

84 measurements: 23=better, 10=worse, 45=No change, 5=not enough data CHC Preventive Services Indicators Early PNT Care% Low birth weight Cervical Ca ScreengYouth weightAdult weightTobacco use screenTobacco counsel2 YO ImmunizationColon Ca screeningAsthma Rx Lipid Rx for Ht DiseaseAspirin for vascular diseaseHigh BP ControlDiabetes Control CHC- AWNBWNBBWNNNBB CHC- BNNWNBBNNNWNNB CHC- CNWNBNNNNBNNNNN CHC- DBNBNWNWNNNNNBN CHC- EBNNNBBBNNNBBWN CHC- FNBBNNBBWNN CHC- G Range (%) B= Better W= Worse N= No change Health Services

CHC Preventive Services Indicators Early PNT Care% Low birth weight Cervical Ca ScreengYouth weightAdult weightTobacco use screenTobacco counsel2 YO ImmunizationColon Ca screeningAsthma Rx Lipid Rx for Ht DiseaseAspirin for vascular diseaseHigh BP ControlDiabetes Control Heavy work burden4/73/76/7 5/65/73/76/7 5/6 4/6 Perceived accuracy7/75/72/7 3/72/71/63/7 2/7 2/64/6

Take Home Messages Population Level: Many gaps in surveillance picture Some progress, especially tobacco and alcohol Lots of room for more progress Health services level: Must “ramp up” preventive services delivery  move beyond pilot projects in NCD clinics Information systems are a key element Both levels: Dis-coordination among technical assistance agencies is a big handicap NCD surveillance plans at jurisdiction level need reinforcement

Hopes for next 6 months Update the USAPI NCD Surveillance Framework Update USAPI NCD Progress Profile, and policy uptake mapping Bring at least some DDM participants through entire DDM series to Epi Technician certification Accelerate data and epi systems development across the USAPI with the assistance of Drs Cash and Hancock Identify stable, core funding for DDM-SHIP to allow wider dissemination of EpiTech

Board guidance requested o On Concept Brief for a Regional Epi Capacity Building Unit & Framework (with possible endorsement and communique) o On re-convening the USAPI Technical Working Group to review and update the USAPI NCD Monitoring and Surveillance Framework o Whether USAPI NCD “products” are still relevant (if yes, how to promote them with TA partners) For Individual Board Member Consideration in your Jurisdiction Nominees to upcoming DDM4 Nominate a cohort of Epi Technician candidates in your jurisdiction Formal Data & Surveillance Capacity Agreements with REU Delegate a staff member to update of NCD surveillance & policy profile

QI and Performance Management ???

QI-PM Extension Services- Pharmacy procurement & inventory improvement (Pohnpei) Quality Improvement policies and procedures development (Pohnpei, Palau CHCs) Management strengthening consultation (RMI) UDS QI workshop held with USAPI CHC managers at PIPCA meeting

International Council of Nurses Leadership for Change Program Summary, Outcomes, Lessons learned and Next Steps Pacific Island Health Officers Association Republic of Palau March 9, 2015 Kristine Qureshi, PhD, RN, CEN, APHN-BC Technical consultant, PHIOA

ICN-LFC Recap Training program designed to build leadership capacity among mid/senior level manages 17 participants from USAPI (9 PIHOA funded, 8 jurisdiction support) Three 5 day sessions in HNL All selected a change project that was approved by their supervisor

ICN LFC Projects Decubitus ulcer reduction X2 OPD waiting time reduction Organizational leadership capacity X2 Midwifery career ladder Organizational leadership capacity Access to IUD technology Expansion of HIV / STI services Development of a strategic plan Strategic plan for management & leadership Cervical Ca. screening follow up Standardize pt. referral across MOH Move administration of daily insulin from ED to the community (home) setting

Outcomes (see handout) All projects initiated Most at initial implementation phase Examples of successful QI change projects: ◦ Ebeye team: Of 82 pts. receiving 2 X day daily insulin from ED, moved 62 to home administration, goal to address remaining 20. ◦ AS team: Three yr. gradual increase in readmission rate. Revised discharge planning process. Now 89% (from 23%) discharge planning initiated on admission, developed a medication reconciliation policy, started caregivers classes.

Factors that influenced project success Topic deemed very relevant to senior leadership in the organization Strong support and engagement from senior leadership Management skills of participant

Lessons learned (relative to this project) Organizational change requires support from the very top Leadership is not the same as management, and management skills need to be cultivated Managers need to be “supervised, managed & supported”… stay on target & on task, have barriers addressed along the way Most managers know the principles and mechanics of QI, but some are not formally supervised and or lack the organizational support to really effect improvement change

Lessons learned (continued) Managers should be focusing efforts on the priority areas of senior management– that are linked to the strategic plan Sustainability requires abilities to hand off projects and assure accountability

Next steps…… Dissemination: Invitation letter from nursing management journal for publication – needs to be written up Projects have been initiated, but not yet completed– ongoing management support and supervision of progress Ongoing PIHOA technical support requires jurisdiction level will and support (example: Kosrae has budgeted funds for roll out across their management workforce) DISCUSSION, what are your thoughts ???

Mahalo Questions???? Contact: Kristine Qureshi A Mark Durand