1. Using Six Hat Thinking to Improve Childhood Immunization Rates National Immunization Conference, March 23, 2005 Barbara Boshard, BSN, MS Quality Improvement Team Leader Section for Communicable Disease Prevention Missouri Department of Health & Senior Services

2. Session Objectives Describe the Role of CQI to Improve Immunization Rates Describe the Role of CQI to Improve Immunization Rates Discuss the Missouri CQI Model Discuss the Missouri CQI Model Share Missouri Tools for Improvement Share Missouri Tools for Improvement

3. Missouri’s Immunization Program 2004 $21,500,000

4. Missouri VFC Program Medicaid Eligible Medicaid Eligible Un-Insured Un-Insured American Indian American Indian Alaskan Native Alaskan Native Less than or Equal to 18 years Old Less than or Equal to 18 years Old

5. Missouri Non-VFC Program Underinsured Pediatric Clients Underinsured Pediatric Clients Hepatitis A/B for Adults at Risk through STD Clinics Hepatitis A/B for Adults at Risk through STD Clinics Refugees and Immigrants Refugees and Immigrants Un- or Underinsured Students (does not include Meningococcal vaccine) Un- or Underinsured Students (does not include Meningococcal vaccine) Defined Disease Outbreaks Defined Disease Outbreaks Influenza and Adult Td Influenza and Adult Td State School Employees State School Employees

6. Missouri’s VFC Program Total VFC Providers = 731 Total VFC Providers = 731  LPHA = 113  FQHC/RHC = 184  Other Public = 35  Private = 399

7. VFC Site Visits 2004 LPHA LPHA FQHC/RHC FQHC/RHC Other Public Other Public Private Private Total Total = 97:113 (86%) = 132:184 (72%) = 11:35 (31%) = 165:399 (41%) = 390 (53%)

8. QI Questions/ PDCA Cycles Six Hat Thinking AFIX What do we want? P Blue Hat Assessment Who cares? P Red Hat Assessment What are we doing now? P White Hat Assessment Can we do better? P White Hat Assessment Why can’t we? P Black Hat Assessment What changes are needed? P Green Hat Feedback/ Exchange Info Do it! D Green Hat Action Plan Did it work? C/P White Hat Exchange Info Can we do it every time? C/A White Hat Assessment Learn/celebrate? P/A Blue &Yellow Hats Incentives

9. Principles of CQI Directed by “Customer” Needs Directed by “Customer” Needs Involves Frontline Staff in Solutions Involves Frontline Staff in Solutions Assigns No Blame Assigns No Blame Improved Decisions Based on Facts Improved Decisions Based on Facts Improved Results Improved Results Continuous Over Time Continuous Over Time

10. The Three Circles of CQI Customer Focus Outcomes Based Scientific

11. PDCA Short-term Success Cycles - Plan (Assess) Do (Implement Pilot) Check (Evaluate) Act (Implement Real Change) (Deming, Ishakawa,Shewhart) Act Plan Do Check

12. Traditional Quality Assurance Input  Input  Activity  Activity  Output = (Example: Number of shots given) Output = (Example: Number of shots given)

13. Quality Improvement Focus Benefits or changes for participants New Knowledge Increased Skill Changed Attitudes or Values Improved Condition Altered Status

14. PDCA Cycle One 2003-2004 Organized Workgroup Created Standards, Policies and Procedures Implemented Manual

15. Building the Workgroup Include Key Players Include Key Players Set Group Norms Set Group Norms Learn about CQI Learn about CQI Prioritize Prioritize Implement CQI Implement CQI Use CQI to Improve Immunization Rates in Missouri Use CQI to Improve Immunization Rates in Missouri

16. Workgroup Priorities Understand & Use CQI Create Specific Standards Use CQI to Improve Processes and Customer Service Comply with Grant Build Awareness of Immunization Program in Missouri

17. QI Questions 1. What do I want to accomplish? 1. What do I want to accomplish? 2. Who cares & what do they care about? 2. Who cares & what do they care about? 3. What are we doing now and how well are we doing it? 3. What are we doing now and how well are we doing it? 4. What can we do better? 4. What can we do better? 5. What prevents us from doing better? What are the underlying problems? 5. What prevents us from doing better? What are the underlying problems? 6. What changes can we make to do better? 6. What changes can we make to do better? 7. Do it. 7. Do it. 8. How did we do? If it didn’t work, try again. 8. How did we do? If it didn’t work, try again. 9. If it worked, how can we do it every time? 9. If it worked, how can we do it every time? 10. What did we learn? Let’s celebrate! 10. What did we learn? Let’s celebrate! (The Quality Improvement Process)

18. Blue=Pulling It All Together Green=Creating Red=Feeling White=Seeking Information & Data Black=Thinking Logically Yellow=Believing/Supporting CQI & Six Hat Thinking

19. Purpose of Six Hat Thinking* To Simplify Thinking To Simplify Thinking To Manage One Thing at a Time To Manage One Thing at a Time To Change if Change is Needed To Change if Change is Needed *DeBono, E, Six Thinking Hats, Little, Brown, & Co., Boston, 1999.

20. Beliefs About Six Hat Thinking You Must: Wear all Hats for Effective Change Wear all Hats for Effective Change Wear the Right Hat at the Right Time Wear the Right Hat at the Right Time

21. The Organizer Hat

22. Blue Hat Question What do we want to accomplish related to immunizations?

23. The Fact Hat

24. White Hat Questions What are we doing now? What are we doing now? How well are we doing it? How well are we doing it?

25. The Feeling Hat

26. Red Hat Questions What is my gut feeling about how our immunization program works in our office? Who cares? What is my gut feeling about how our immunization program works in our office? Who cares?

27. The Careful & Cautious Hat

28. Black Hat Questions What are the risks if we change how we do business? What are the risks if we change how we do business? What prevents us from doing better?

29. The Sunny & Positive Hat

30. Yellow Hat Questions Can we do it? Sure we can! Can we do it? Sure we can!

31. The Creative Hat

32. Green Hat Questions What changes can we make to do better? What changes can we make to do better?

33. The Organizer Hat

34. Blue Hat Summary Questions What have we accomplished? What have we accomplished? Where do we need to go now? Where do we need to go now?

35. CQI = AFIX Assessment Assessment Feedback Feedback Incentive Incentive eXchange of Information eXchange of Information

36. Remember This Main Concept: A + + + EQUALS CQI F I X

37. What is AFIX? The single most effective strategy documented by CDC for improving immunization rates. The single most effective strategy documented by CDC for improving immunization rates. AFIX is a provider-level continuous quality improvement process AFIX is a provider-level continuous quality improvement process

38. Assessment Assessment of a sample of patient records using CASA (Clinical Assessment Software Application) Assessment of a sample of patient records using CASA (Clinical Assessment Software Application) Sample 50 Client Records Sample 50 Client Records

39. Feedback Feedback of assessment results/reports to clinic staff Feedback of assessment results/reports to clinic staff Present findings to people who can make a change Present findings to people who can make a change Use CASA reports as a tool to stimulate discussion and as bench marks to measure future change Use CASA reports as a tool to stimulate discussion and as bench marks to measure future change Offer positive reinforcement and suggestions Offer positive reinforcement and suggestions

40. Incentive Incentive – offering ideas, tools, and other support to help the clinic improve rates Incentive – offering ideas, tools, and other support to help the clinic improve rates What would be an incentive for your immunization clinic?

41. eXchange of Information Collaboratively developing improvement strategies, implementation plans, and ongoing support/follow-up needs Collaboratively developing improvement strategies, implementation plans, and ongoing support/follow-up needs Clinic specific Clinic specific Clinic driven Clinic driven

42. Main Priorities Create & Implement Specific Standards for CASA/AFIX Create & Implement Specific Standards for CASA/AFIX To Move Program from QA (CASA) to CQI (AFIX) To Move Program from QA (CASA) to CQI (AFIX)

43. Performance is Measured CDC ’ s National Immunization Survey (NIS) CDC ’ s National Immunization Survey (NIS)

44. National Immunization Survey (NIS) Conducted by CDC every 6 months Conducted by CDC every 6 months Random sample by state Random sample by state Determines immunization status of children Determines immunization status of children Phone interviews of parents Phone interviews of parents Confirmed by follow-up with physicians Confirmed by follow-up with physicians Includes all children – not only VFC Includes all children – not only VFC

45. Missouri’s NIS Rates Missouri Rates vs National Average 1996- Mid-Year 2004 Completed 4:3:1:3:3 series (full ACIP-recommended series, pre-Varicella)

46. 5 Year Tracking and Trending

47. Other CQI Tools Tracking and Trending Providers with 90% and above coverage for 4:3:1:3:3:1 Tracking and Trending Providers with 90% and above coverage for 4:3:1:3:3:1 Standardized Action Plans Standardized Action Plans Ordering History Ordering History Vaccine Inventory/Accountability Vaccine Inventory/Accountability

48. VFC Providers 2004 Immunization Rates 90% or Greater 22:390 = 6%

49. Major Obstacles to CQI Supporting CQI from Top Down Supporting CQI from Within the Group Involving all Levels Determining Adequate Measures Allotting Adequate Time Committing to CQI Process Following-through

50. The Future – PDCA Cycle 2 Achieve New Level 1 AFIX Standards from CDC Achieve New Level 1 AFIX Standards from CDC Address Parking Lot Issues Address Parking Lot Issues Restructure to be more Effective Restructure to be more Effective Build Day Care and School Review Systems Build Day Care and School Review Systems Improve Registry Improve Registry

51. Provider Action Plan Identify one thing you can do in your practice setting to improve your immunization program in 2005. Identify one thing you can do in your practice setting to improve your immunization program in 2005. We/I will ______________________ [action step(s)] [action step(s)] To increase the current immunization rate from _______ (rate) to _______ (rate) to _______ (rate) by December 31, 2005.

52. Vision for 2005 and Beyond To provide AFIX for 100% of Missouri’s childhood immunization providers each year in order to improve the state’s childhood immunization rates

53. “Never doubt that a small group of thoughtful, committed people can change the world. Indeed it is the only thing that ever has.” (Eleanor Roosevelt)

54. Presented by: Barbara Boshard, RN, BSN, MS Barbara Boshard, RN, BSN, MS QI Team Leader QI Team Leader Section for Communicable Disease Prevention Section for Communicable Disease Prevention Division of Environmental Health and Communicable Disease Prevention Division of Environmental Health and Communicable Disease Prevention Missouri Department of Health and Senior Services Missouri Department of Health and Senior Services 930 Wildwood Drive, Jefferson City, MO 65102 930 Wildwood Drive, Jefferson City, MO 65102 T: 573-751-6439; FAX: 573-751-6447 boshab@dhss.mo.gov T: 573-751-6439; FAX: 573-751-6447 boshab@dhss.mo.gov