1. Quality Improvement: Causes and Effects March 18, 2009 Kathleen F. (Kay) Edwards, Ph.D. Quality Improvement Project Lead National Network of Public Health Institutes kedwards@nnphi.org 410-547-3050

2. Why is evaluation of public health work important? It shows others what is being done It should assist with resource allocation It can lead to improved methods It should lead to better decisions It can objectively suggest what is intuitively believed to be fact

3. Challenges for basing accountability on improving health outcomes… Interventions can take a long time before health effects of them are seen/known Evidence-based interventions may more likely be geared to impacting behaviors, rather than health Data collection and surveillance systems may not exist to measure the desired change in health Source: TFAH, 2008, p. 26

4. Performance management in public health….

5. Quality Concepts and Tools

6. POSSIBLE PROBLEMS PROBLEM DEFINED POSSIBLE CAUSES ROOT CAUSE IDENTIFIED POSSIBLE SOLUTIONS SOLUTION CHOSEN TO TEST EXPAND FOCUS “Expand-Focus Sequence,” p. 3, Nancy R. Tague, The Quality Toolbox, 2 nd Edition. 2005. (American Society for Quality, Quality Press, 2005) EXPAND FOCUS Do we need to Expand or Focus our thinking? Are we working with ideas or numbers? What will be the easiest tool that will do the job? EXPAND FOCUS Choosing the Right QI Tool

7. Getting to the Heart of Tough Problems Why pause to examine “root causes” of public health performance or quality issues?

8. Successful Improvement Efforts Analyze and Address “Root Causes” Why can’t we make progress on ______________? Is it because of: –Methods / procedures? –Motivation / incentives? –Materials / equipment –People (personnel, partners, providers, or patients)? –Information / feedback? –Environment? –Policy?

9. Root Cause Checklist Make sure all possible causes of a problem are identified Use list as a prompt to expand thinking if needed May be substitute method

10. Fishbone Technique Cause & Effect Diagram 1.Agree on Problem Statement 2.Generate Causes 3.Construct Diagram PROBLEM STATEMENT

14. Thank you…... Kay (Edwards)

15. Root Cause Analysis Peter Tabbot & Mitchel Rosen MLC Grantees Meeting March 18, 2009

16. Why Root Cause Analysis? Planning process not routinely conducted Upfront planning to collect “baseline” Tool for finding and correcting… …the most important reasons for performance problems …the most basic causal factors …underlying errors/failures

17. What did we do? Presented models of root cause analysis Presented many models Practice, practice, practice….

18. How to apply tool? Identifying causes of problems Identifying solutions

19. Examples Key stakeholders Barriers to vaccination

20. Lessons learned Practice, practice, practice Seems simple, but…takes a long time to get it right Time consuming process Stick with one or two models Involves deep analysis

21. 5 Whys Helps a team focus on same problem Trace chain of causality 5 iterations is generally sufficient Nature of problem & solution become clear Leads to statement of cause Team can take action

22. 5 Whys – Issues Tendency to stop at symptoms Inability to go beyond current knowledge Are we asking the right ‘Why’ questions? Results aren’t repeatable (different people produce different causes) If event is still occurring, you haven't gotten to root cause

23. 5 Whys Problem (Effect) Why?

24. 5 Whys Our influenza clinic was poorly attended Why?Residents had many opportunities Why?There was a lot of competition Why?Pharmacies are in on the action Why?It brings customers in Why?They can ‘multi-task’ in one stop

25. 5 Whys Our influenza clinic was poorly attended Why?Residents had many opportunities Why?We didn’t advertise it well Why?Inclement weather was a factor Why?Our price wasn’t competitive Why?The location wasn’t convenient

26. 5 Whys My off white carpeting must be replaced Why?The carpeting has been stained Why?My elder cat vomits periodically Why?She is upset about something Why?Her environment was compromised Why?I introduced a new kitten a year ago

27. 5 Whys – Expanding the Scope My off white carpeting must be replaced Why?The carpeting has been stained Why?My elder cat vomits periodically Why?She is upset about something Why?She is not brushed frequently enough Why?She is not hydrated Why?Frequency, location & quantity of food Why?Bowl has become a problem

28. 5 Whys I had to replace my car motor Why?The motor seized while in transit Why?There was insufficient oil Why?I have not maintained my car Why?I am an irresponsible boy

29. 5 Whys – Expanding the Scope I risk not affording my home construction Why? I had to replace my car motor Why?I had to install curtain drainage Why?I had to pay for a pres. dose septic Why?I changed the floor plan midstream Why?I prefer granite countertops

30. 5 Whys If event is still occurring, you haven't gotten to root cause

31. Getting to the “ Root ” of Root Cause Analysis Cathy Montgomery Florida Department of Health March 19, 2009

32. % of adolescents that are overweight (2006) Florida Target = 5%↓ Alachua Martin Okaloosa Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia De Soto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Miami-DadeMonroe Nassau Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St Johns St Lucie Sumter SuwanneeTaylor Union Volusia Wakulla Walton Washington Target Met NULL NO Opportunity N = 64

33. % of CHD programs conducting a customer satisfaction process (2008) N = 67

34. Baker (S) Clay (M) DeSoto (S) Duval (L) Glades (S) Martin (M) Monroe (S) Nassau (S) St. Johns (M) St. Lucie (M) Multi-County Learning Collaborative

35. Implementation – The Project Utilizing the QIC StoryUtilizing the QIC Story –PDCA model for improvement –Incorporates quality tools and methods Identifying root causesIdentifying root causes –target population –“focus groups” Selecting evidenced-based or model practicesSelecting evidenced-based or model practices

36. Successes Collaborative completed multiple attempts at root causeCollaborative completed multiple attempts at root cause Eight (8) of ten (10) CHDs have completed root cause analysisEight (8) of ten (10) CHDs have completed root cause analysis CHDs utilized information to select workplan activitiesCHDs utilized information to select workplan activities

37. Challenges Face-to-face training is a MUST!Face-to-face training is a MUST! Lack of participation in focus groupsLack of participation in focus groups Insufficient data to validate root causeInsufficient data to validate root cause Participants “backing into” solutionsParticipants “backing into” solutions Frustration level of participantsFrustration level of participants

38. Lessons Learned Assess audience knowledge of QI toolsAssess audience knowledge of QI tools Use multiple experts to provide technical assistanceUse multiple experts to provide technical assistance Don’t need to make the collaborative participants experts in root causeDon’t need to make the collaborative participants experts in root cause