quality improvement during a disruption louise a. kent health planning administrator, northern...

Quality Improvement During a Disruption

Louise A. KentHealth Planning Administrator, Northern Kentucky Health

Department

John W. MoranSenior Quality Advisor, Public Health Foundation and Senior

Fellow University of Minnesota School of Public Health

2010 Open Forum of the MLC: A National Conference of Leaders in Public Health Quality Improvement

September 15-17, 2010 / Washington, DC

The PDC/SA CycleAct

• What changes are to be made?

• Adopt• Adapt• Abandon

• Next cycle?

Plan• AIM• Understand process• Plan to carry out the cycle (who, what, where, when)• Plan for data collection• Understand Causes

Check/Study• Analyze the data

•Compare data to predictions

•Summarize what was learned

Do• Implement the Plan• Document problems and unexpected observations•Collect data

Reference: The ABC’s of PDCA, G. Gorenflo and J. Moran – PHF/NACCHO Websites

What Is Quality?

Today the most progressive view of quality is that it is defined entirely by the customer or end user and is based upon that person's evaluation of his or her entire customer experience.

The customer experience is the aggregate of all the Touch Pointsouch Points that customers have with the organization’s product and services, and is by definition a combination of these.

Customer View

An organization needs to understand what happens when their customer (internal/external) comes in touch with their processes.

What do they:

See? (Initial reaction?)

Feel?

Hear?

Experience?

“People will forget what you said.

People will forget what you did.

But people will never forget how you made them feel.”

Maya Angelou

When we have a major disruption to our daily schedule do we:

Use QI to plan and develop a response?

OR

Just jump to Do?

W. Edwards Deming said,

“A bad system will defeat a good person every time.”

A bad system grinds people down until they no longer care about the quality of the product or service delivered to the customer.

People using a bad system take out their frustrations on customers, who complain about the poor quality they receive. This is a never-ending, destructive cycle for the person using the bad process and those receiving the low-quality product or service

Plan

Do/Disrupt

Check

ActDisruption

Act

Plan

Do

Check ModularKaizen*

Reference: Modified Approach, J. Moran and G. Duffy, Six Sigma Forum Magazine, August 2010© 2010 Moran and Duffy

Using QI in a Disruption

H1N1 Clinic Flow

H1N1 Patient Flow

Enter Building

Enter Building

Greeter

Possibly not

Yes

Clerical

Screener

Okay to vaccina

te?Triage

RNOkay to vaccina

te?

Need medical attentio

n?

No

Exit Leave Building

EMT

Is patient able to leave

on own?

No

Yes

No

Yes

Yes

EMT transports patient to medical facility

Customer Satisfaction Survey:H1N1 Clinics


What is the one thing, in your opinion, we did well and should continue doing in these clinics?

Some Sample Comments:

• Workers were extremely friendly and informative.

• All was great. (12)• Went very well.• Very organized/smooth flow/efficient.

(7)• The organization made it very quick

and efficient! (5)• Good process setup – lines moved

quickly. (10)• No place to improve. A+• Make the person feel calm.• Well done, no suggestions.• Free vaccinations and superb services.


What is the one thing, in your opinion, we should do differently to improve our process?


• Nothing. It was great (14)• I think the clinic was more organized

than I could have imagined! Excellent job.

• More locations.• The organization set-up made us go to

one side then the other - should be a straight line.

• Have more people filling out applications.

• More screeners.• Make it a little faster.• More signage.


General Comments


• Great work. (15)• Thanks. (6)• Thank you so much for putting our

minds at ease.• The TV with cartoons was helpful for

the children.• Great staff!• Thank you - not a bad experience and

my kids left smiling.• Website was very informative also.• Everything was well organized and ran

smoothly.• For such an undertaking, it was a very

well-executed operation.

Start—Stop—Continue: H1N1 Clinics

Things We Should Start Doing:

Action To Be Taken:

Tissues for flu mist. Supply to be secured.

More signage with arrows. In future, more arrows will be used.

Provide restrooms at end of process so people do not go against traffic flow to restroom facility.

Potential sites are judged on the restroom adequacy for the population to be served.

Identify staff and volunteer sign-in location in advance for each location.

Location will be communicated before each clinic to staff.

Standardized answer for, "Which vaccine should I get?" and "What's the risk?"

Screening criteria were considered and developed. Continued training and refresher training before every event will continue.

More pens that write. Defective pens disposed of,replaced with new pens.

Start—Stop—Continue: H1N1 Clinics

Things We Should Stop Doing Action To Be Taken:

Change "serious egg allergies" to any egg allergy.

Changed.

Confusion about drinks for staff allowed in clinic areas.

Policy put in place and communicated to all involved in the clinics.

Starting before staff arrives. Community partner miscommunicated clinic start time, so 1st responders arrived early; NKHD accommodated in this instance. Will review start and end times with staff and community before the next clinic.

Handouts at exit will back up exiting process.

Element tried. Site logistics and various other elements determined this process not viable. Will not provide handouts at exit in future clinics.

Start—Stop—Continue: H1N1 ClinicsThings We Should Continue Doing: Actions To Be Taken:

Positive, adaptive attitudes of staff. Leadership values this characteristic in all staff in all work environments. Staff thanked via emails on ongoing basis for their positive attitudes, flexibility and willingness to pitch in wherever and whenever needed.

To not ask the patient all of the questions about the mist ("yes or no") if they know that they want the shot.

Appropriate screening measures will continue to be implemented. Just in time and refresher training will incorporate most appropriate elements.

Assistance between nurses. Site logistics, staffing, continued staff availability and numbers of patient thru-put are all considered in development of the staffing plan. Site management is pleased that dispensers find the assistance helpful.

Thanks from the Clinic Director…

“I wanted to take this time to thank all who were involved in yesterday’s Bank of Kentucky H1N1 clinic and to those who helped us to get ready for the event. It was a huge success from the time we opened the doors until we closed at 6pm. I can’t tell you how many positive comments our agency has received about yesterday, both by e-mail, satisfaction surveys and word of mouth.

It is because of YOU that we, as a team, could pull this off and have received so many kudos. Each of you should feel so proud of your job and what you did for the community. Everybody worked at 100%, and it showed!!!!!...

…In the words of one of the patients who received her shot yesterday, “YOU GUYS ROCK!”

Results…

• Almost 14,000 vaccinated during 5 mass community clinics

• Targeted efforts to those at highest risk

“Time flu by in H1N1 line; not so in Target”[1]

Business Courier of Cincinnati Blog Lucy May, Senior Staff WriterMonday, November 30, 2009, 10:44am

Standing in a tortuous line at Target at 7 a.m. on Black Friday made me appreciate the H1N1 vaccination clinic I visited with my family just the weekend before.

It wasn’t because the shoppers were feverish and coughing, although being in line with the masses made me all the more happy that I’d gotten my shot.

It was because the Northern Kentucky Health Department’s clinic at an Independence middle school was so much more efficient than the check-out line at Target.

In about 40 minutes, my family moved quickly through a line of hundreds of people for our swine flu shots. My husband remarked more than once how impressed he was with the health department’s efficiency and professionalism. The staff was polite and kept things moving in a way that made me glad we had spent our Saturday afternoon waiting in line.

In contrast, the Target line crept along, inch by inch. And for what? So I could get a deal on some movies and save a few bucks on a gizmo?

After about 20 minutes and no progress, I did the unthinkable. I left my spot and went home to eat breakfast and enjoy my morning. Keeping my kids safe from the H1N1 virus, I decided, was worth the wait. A $10 copy of “Monsters vs. Aliens” was not.

Next year, I’m getting flu shots for everyone on my Christmas list.”

[1] May, L. (2009, November 30). Time Flu by in H1N1 Line; Not So in Target. Message posted to http://cincinnati.bizjournals.com/cincinnati/blog/2009/11/time_flu_by_in_h1n1_line_not_so_in_target.html

Thank You For Attending!

Q & A

NJ Collaborative for Excellence in Public Health

H1N1 Immunizations:Quality Improvement During

an Evolving Event

Colleen McKay Wharton, NJCEPH Project Coordinator

Kevin G. Sumner, NJCEPH Steering Committee Member

Health Officer, Middle-Brook Regional Health Commission

MLC-3 2010 Open ForumWashington, D.C.


A Little History…. Somerset County Health Officers Association

Formed in 1980 as 501(c)4 10 Health Departments / 23 municipalities Shared child health clinics, rabies clinics, Tb

services, messaging, sharing of information

2002 – Mutual Aid Agreements Developed


2003 – State Practice Standards Adopted Greater Somerset Public Health Partnership Requires Collaboration and Partnering; GPHPs Mandates Continuous Quality Improvement Health Assessment & Improvement Plan

2008/2009 - Reincorporation as a 501(c)3 begun; currently 7 LHDs

A Little History….


H1N1 Appears and Motivates Experience with natural disasters

Not used to slow moving events Recognition of need to go beyond our

limited/internal activities …. Saw an early impact due to cases in NYC Concerns of lack of resources and burnout

Unknown Panic in public and professionals


Initial Challenges 160,000 residents in initial target groups A severe shortage of nurses Competition for a limited pool of health

care workers and volunteers Fear, confusion, panic (both the public and

the PH workforce)


Help Sought… Planning

Conversations in place, but no implementation

Even exercises are limited

Escalate level of planning

Partnering External Partners New Partners


Greater Somerset H1N1 Collaborative Agreement to use existing structure (GSPHP)

to address response

CORE AGREEMENTS: Act/Respond with One voice Use Collective Wisdom to develop interim “Best

Initiatives” Address community fear/panic with a steady,

rational response


Collective Decision Making Uniform Policies

Appointment based program

Common Messaging Hired Health Educator /

Staff / translator Staggered Scheduling Identified priority

vaccinators outside of government

Uniform Actions Staff Contract

Templates Master scheduling of

nursing staff Advertising / social

media Interpretation of

“high risk” for early vaccination


Shared Resources Appointment Service

Regardless of jurisdiction Vaccine

Enabled Advanced Planning Addressed Early Vaccine Shortage

Staff / Volunteers Clerical Staff Shared; Nursing Services Coordinated MRC volunteers / local volunteers coordinated


32,000 Website Hits

60 Clinics: A Few Outcomes…26,000 online appointments


12,000 Calls to the “Shotline”

60 Clinics: A Few Outcomes…

28,000 Vaccinations


Collaboration Demonstrates Use of QI

‘Real-life’ QI Classroom Chance to see QI…

…not as an ‘add-on’ …not as a ‘burden” …barely even as a conscious effort


Why QI ? Streamlines efforts; reduce waste & $$ Measures results & outcomes; Ensures

accountability Improves customer satisfaction Boosts morale/teamwork Increases public support Ultimately changes health outcomes


Our ‘QI Reality’ At least 1/2 had no QI experience; 1 - 2 had

some direct exposure Didn’t realize it … but were doing it

Collectively sought out and evaluated ‘best’ practices; planned strategy

Implemented strategy Evaluated throughout informally and formally Made changes accordingly


Quality Improvement--at Warp Speed

Do

Study

Plan

Act

Rapid Quality Improvement Cycle (Deming Cycle)


Rapid Cycle Quality Improvement A natural 4-week improvement cycle Informal hotwash post-clinic Mid-December: formal staff/volunteer feedback

hotwash Better guidance on appointment site re: eligibility, and

stress adequate vaccine supplies - don’t double book! Exact clinic locations not clear (Which site entrance to

use? Where to park?) Pediatric nurse shortage

Needed CUSTOMER Feedback as well


Electronically distributed to ~ 9,300 vaccine recipients on Dec. 16 & 17 (zoomerang.com)

Reminders sent out Dec. 27 - Jan. 1

1,865 surveys completed

Customer Satisfaction Survey


What We Asked Where did you hear about the H1N1

vaccination clinics? How did you schedule your appointment to

receive the H1N1 vaccine? Please tell us how user-friendly you found the

online-system to be Would you recommend the online system to

someone… How convenient was using the ‘shotline’ operator

to schedule an appointment?


What We Asked Did you receive the H1N1 vaccine at your

scheduled appointment? If you did not attend your scheduled appointment,

please tell us why How well-organized did you find the clinic

process? Did you have all of your questions answered

during the clinic? Please share any comments / concerns


Why We Asked As a QI tool, provided clear indicators for

areas for improvement - as long as changes are acted upon; Must own both + and - feedback

Serves as a ‘check’ for less formal evaluations (can validate or invalidate)

Feedback can validate the need for service


Provides a venue for the public to share considered, thoughtful feedback

Reflects a local government that strives to improve -- bucking public perceptions

Provides a valuable opportunity for staff to hear objective feedback from those being served

Demonstrates that success can - and must - be measured by more than numbers

Why We Asked


And The Survey Said…..


How Well-organized Did You Find

The Clinic Process?

Very well organized 1527 (88 %)

Somewhat well organized 184 (11 %)

Not very well organized 14 (1 %)

Completely disorganized 9 (1 %)


Key Areas to Improve… Too few pediatric lines / pediatric nurses Unable to cancel appointments online Website overwhelmed Revising website messages – needed more

specifics, location details, etc Validated most earlier hotwash points…


800+ Comments…

“Do not ever think that you are not needed...that your work is unappreciated or that you have no support in the communities. Thank you so much for all that you do.”

Thanks very much for making this possible and for looking for feedback so soon after to make responsive public policy… good job!


Why QI? Quality improvement is a mindset, a way of

functioning - not an add-on A Quality Improvement mindset continually

focuses our thinking on the goal in front of us

Disciplines the Mind


The Takeaway - Collaboration Collaboration can drive us toward consensus Process can lead to stronger and more diverse

and more effective partnership Collaborative activities MAY promote

accountability Personalities play a role! Collaboratives take work, but are worth the

effort


The Takeaway - Quality Improvement Quality Improvement Embedded in All

Greater Efficiency Greater Effectiveness Greater Respect & Recognition

QI activities DO promote accountability Recognition by Others

Local Departments Value QI Public Values Local Public Health

Public Health Visibility


Creating Certainty in Uncertain Times

“Uncertainty makes one tentative, and tentative steps may not overcome significant obstacles. To be a scientist requires the courage to accept—indeed, embrace—uncertainty; to move forcefully and aggressively even while uncertain.”

--John Barry, the Great Influenza


Collaboration & Quality Improvement

EMPHASIS CHANGES FROM WHAT

DIVIDES US TO WHAT UNITES US

quality improvement during a disruption louise a. kent health planning administrator, northern...

Documents

disruption slide

duffy slide

service slide

dc slide

medical facility slide

process plan

maya angelou slide

h1n1 clinic flow slide