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
Outline
• 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)
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?
BT Supplement Challenge
PH Needs – Dual Use
Organizational
capacity
Operational
readiness
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 allhazards 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).
• Articulated a new group identity (mission, vision and new
name: PH-PIC).
• Analyzed and distributed the NPHPS Colorado results and
other assessment data.
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
100
77
68
60
72
51
76
68
70
56
54
50
45
54
50
48
54
40
40
24
37
33
19
20
Local
State
4
Rese
arch
Polic
y
Partn
ershi
ps
Work
force
Enfo
rce
Evalu
ate
Educ
ate
Moni
tor
Link
0
Diag
nose
Percent
80
Office of Local Liaison
Colorado DPHE
Importance & Intent for QI (Survey)
100
90
90
84
80
74
70
72
68
70
6868
68
60
54
50
50
48
54
52
40
40
37
20
1
Rese
arch
Polic
y
ners
hips
Part
kforc
e
Wor
Very important
Proportion being met
QI in next 12 months
Enfo
rce
uate
Eval
Educ
ate
itor
Mon
Link
nose
0
Diag
Percent
64
Office of Local Liaison
Colorado DPHE
Workforce Proficiency (SON Survey)
80
72
70
68
68
60
54
46
45
54
50
48
41
40
31
40
37
30
25
22
20
Proportion being met
2
Rese
arch
Polic
y
Partn
ersh
ips
Work
force
Enfo
rce
Eval
uate
Educ
ate
Mon
itor
Link
0
Diag
nose
Percent
50
Office of Local Liaison
Colorado DPHE
Proficiency
X
X
X
X
X
Link
Enforce
Partnershi
p
Policy
Educate
Research
X
X
Evaluation
X
X
X
X
Workforce
< 50% of model (locally)
< 50% of model (state)
Rated most important
> 50% intend QI in 1 year
Greatest discrepancy:
importance vs. model
Indicators < 50% (locally)
Indicators < 50% (state)
< 30% of local work force
highly proficient
Diagnosis
Monitor
NPHPS Priority Matrix
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Merger: QI Collaborative & the Capacity
Building Steering Committee (2003).
• Articulated a new group identity (mission, vision and new
name: PH-PIC).
• Analyzed and distributed the NPHPS Colorado results and
other assessment data.
• Created a BT-focused training opportunity in Feb 2004 to
learn QI/PI process and use the NPHPS data.
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
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
Number:
149
101 (68)
98 (97)
48 (32)
34 (23)
1.2
2.2 hrs
3.1 hrs.
37
23
Merger: QI Collaborative & the Capacity
Building Steering Committee (2003).
• Articulated a new group identity (mission, vision and new
name: PH-PIC).
• Analyzed and distributed the NPHPS Colorado results and
other assessment data.
• Created a BT-focused training opportunity in Feb 2004 to
learn QI/PI process and use the NPHPS data.
• Presented PH-PIC methods, activities & the “Primer on PHPI” at CPHA (September 2004).
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
Act
Plan
Study
Do
Example of a Basic Plan
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)
Repeated Use of the Cycle
DATA

Act Plan
Study Do

Hunches, theories, ideas


Changes
that result in
improvement
Denver Public Health Department: 6/24/04
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
Number:
11
11 (100)
-0
-1
NA
4.1 hrs.
---
Merger: QI Collaborative & the Capacity
Building Steering Committee (2003).
• Articulated a new group identity (mission, vision and new
name: PH-PIC).
• Analyzed and distributed the NPHPS Colorado results and
other assessment data.
• Created a BT-focused training opportunity in Feb 2004 to
learn QI/PI process and use the NPHPS data.
• Presented PH-PIC methods, activities & the “Primer on PHPI” at CPHA (September 2004).
• Created the “Colorado Public Health Performance
Improvement Plan”.
http://www.cdphe.state.co.us/as/ollhom.asp
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?
Outline
• Current efforts
• Learning communities
• Regional Health Information Organization
(RHIO)
What might we accomplish today?
•
•
•
•
•
•
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
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 508-517)
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 508-517)
EVALUATION LEARNING COMMUNITY
CPHA Abstract
Draft – June 3, 2005
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.
MONITORING LEARNING COMMUNITY
•
•
Initiating work around cataloguing
available data sources and identifying
data gaps.
Adjunct work by Colorado Health
Information Exchange
Colorado Health Information Exchange
2 Complementary Initiatives
Goal: Create a local health information infrastructure
for clinicians to access patient information
across individual health care institutions
Build upon what exists
• Denver Health (DH)
• 150,000 residents (25% of population)
• Kaiser Permanente of Colorado (KPC)
• 3rd 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
PROJECT
(10/2004)
Steering
Committee
Working groups:
COHIE
Learning
Laboratory
•
•
•
•
•
Technical
Clinical
Evaluation
Legal
Organizational
Community Advisory Council
VISION
Colorado Regional Health Information Organization
(10/2009)
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
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
Larimer
Clinical Data Contributor TBD ?
Payor # 1 – RMHP ???
Boulder
Weld
RxHub ???
COHIE:
Rural small MD access ?
Exempla
“Community” patient index
CHCN - Health Center?
Mesa County
The Children’s
Hospital
common (standard) messaging
Vendor independent (neutral)
Kaiser Permanente
Colorado Care
Collaborative (RMD)
Denver Health
MedSouth IPA
Rose Medical Group
University Hospital
El Paso County
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
COLORADO TEAM - VISUAL MODEL
National Public Health Leadership Institute
Draft V1.1, June 20, 2005
And then
tools/methods
and measures
will evolve to
support/revise
the…
Conceptual
Framework
• 10 Essential Services
If the conceptual
work is successful,
we should focus
on….
• Clear PH message
Performance
Improvement
Leadership
Development
• Accountability targets
• Unified measurement process
• Systems thinking
• Change management
Then partners
will agree to
emphasize…
And if true
leaders emerge,
we should
generate ….
State/Local
Partnerships
• Respectful relations
• Inclusive planning