Rapid Cycle Quality Improvement:
Lessons from a Lead Poisoning
Prevention Program
Deanna Durica, MPH
ddurica@cookcountyhhs.org
Quality Improvement (QI)
• Deliberate and defined improvement process
• Focused on activities that are responsive to community
needs and improving population health
• Continuous and ongoing effort
• Measurable improvements in the efficiency,
effectiveness, performance, accountability, outcomes,
and other indicators of quality in services or processes
• Achieve equity and improve the health of the community
• Plan-Do-Study-Act
(Riley, Moran, Corso, Beitsch, Bialek, and Cofsky. Defining Quality Improvement in Public Health.
Journal of Public Health Management and Practice. January/February 2010).
Why QI?
• Augment teamwork
•
•
•
•
•
•
•
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Boost morale
Cut costs
Enhance customer satisfaction
Get better results
Improve work flow
Increase accountability
Meet accreditation standards
Promote healthier people and communities
Turning Point
performance
management
model
Source: Silos to Systems: Using
Performance Management to Improve
the Public’s Health. Turning Point
Performance Management National
Excellence Collaborative: Seattle WA;
Turning Point National Program, 2003.
1
2
3
4
The PDSA
Cycle for
Learning and
Improvement
Act
• What changes
are to be made?
• Next cycle?
Study
• Complete the
analysis of the data
•Compare data to
predictions
•Summarize
what was
learned
Plan
• Objective
• Questions and
predictions (why)
• Plan to carry out the cycle
(who, what, where, when)
• Plan for data collection
Do
• Carry out the plan
• Document problems
and unexpected
observations
• Begin analysis
of the data
Embracing Quality in Public Health:
A Practitioner’s Quality Improvement Guidebook
Step 1
Step 2
Step 3
Step 4
Step 5
Getting Started
Assemble the Team
Examine the Current Approach
Identify Potential Solutions
Develop an Improvement Theory
Step 6 Test the Theory
Step 7 Study the Results
Step 8 Standardize the Improvement or Develop a New
Theory
Step 9 Establish Future Plans
CCDPH: Context
Cook County Department of Public
Health Jurisdiction
• 125 municipalities
• 30 townships
• unincorporated areas
• 4 CCDPH Districts
• 700 sq miles
• 4 other state certified LHDs
SCC Childhood Lead Poisoning
◦ ~200 reported Elevated Blood
Lead (EBLs) per year
◦ 15 IDPH/CC designated ‘high risk”
communities
CCDPH Lead Poisoning Prevention
Program: Three Units – One Goal
• Prevention Services Unit
– Lead Poisoning Prevention and Healthy Homes
Unit
• Referrals for services, policy and outreach,
coordination of QI, data, some client follow-up,
remediation funding and client applications
• Integrated Health Support Services
– Public health nurses visit families – health and
nutrition information, case management,
developmental screening
• Environmental Health Services
– Lead Inspectors visit families to inspect home and
identify housing-based lead hazards, remediation
coordination with renovators and families
Step 1: Getting Started
• Identify a problem or opportunity
– Hx of issues w/ coordination/cohesion
– Lack of data on program activities
– Little cross-unit knowledge of actions
• Secure sponsorship
– Support of key leadership essential
• Prevention Services (Lead Poisoning)
• Nursing Director/Assistant Director
• Chief Medical Director/ Environmental Health
Step 2: Assemble the Team
• Initial Process - Began in Feb 2011
– Initial meetings – key agency leaders/
managers/selected staff involved in LPP
– Expanded meetings to involve all LPP staff
~20 staff
• Purpose:
–
–
–
–
Instruct on QI /Rapid Cycle methodology
Examine current processes
Identify areas for change
Develop an AIM statement
Lead QI AIM
• We will work together to improve the quality
of the lead case management process in order
to:
– More effectively act to intervene on exposures
(process)
– Identify and prevent sources of lead exposure.
(population)
Step 3: Examine the Current Approach
• Create a process map 
• Collect information to understand the current
approach 
• Identify the root cause 
– Useful Conceptual Tools
•
•
•
•
Affinity Diagram 
Cause and Effect Diagram 
5 Whys 
Brainstorming 
Important - Check for Completeness
• Are ALL the process steps identified clearly?
– Make sure each detailed step is included
• Validate the flowchart with those who carry
out steps in process
• Are the symbols used correctly?
– Check to see if there is only one output arrow
from an activity box. If there is more than one
arrow, you may need a decision diamond.
Process Map Use – Questions ???
• Who is involved in the process and when?
• What activities are being performed
– When and where is the activity performed?
• How many steps:
– Directly produce the service?
– Are absolutely necessary/are redundant?
– How many decision points are there?
• Are they ways to increase the efficiency of
the process?
• What are opportunities for improvement?
Process Mapping: Value
• All team members were clear about the
current process (at the same time)
• Steps were reflected actual practice vs.
written procedures
• Key steps/trigger points/vulnerabilities were
identified
– Potential areas for improvement/ measurement
• Builds enthusiasm/shared commitment
Process Mapping Result:
Key “Problems” Identified
Issue 1 : Lack of overall
(team) case
management
– ID’ed through
analyzing the steps –
what was there
Issue 2: Lack of
population/prevention
focus
– ID’ed through
analyzing the steps –
what was missing
Solution: Applied
tools to “delve” into
the problem(s) – Root
Cause /Cause Effect
analysis
– Fishbone Diagram
– 5 Whys
Fishbone Diagram
• Why Use It?
– To allow a team to identify, explore and
graphically display underlying causes related
to a problem
• What Does it Do?
– Enable a team to focus on the content of the
problem - not history or personal issues with
problem
– Creates a snapshot of the collective
knowledge and consensus of a team around
a problem.
– Looks at causes, NOT symptoms - results of
the problem
Organize on Fishbone
• Main problem is the head of your fish
• Major causes go on the fish spines
Examples of headers:
People, Plant, Procedures, Policies
Manpower, Machinery, Materials, Methods
Admin, HR, Finance, Operations, Procurement
Lifestyle, Environment, Forms
Identify “sub-causes”
• Technique: Use the 5 whys
• Ask “Why?” up to “5 times” (or until unable to
go lower) related to the problem
– Drill down to root causes
• Identify related causes and roots of those
causes
Selecting an Area for Improvement
• Examine root cause analysis
• Choose the items you want to focus on
– Looks for causes that repeat within the major
categories
– Choose causes that the team can control or
influence
– Best if selected through consensus
– May/should have evidence to support choice
Step Four: Identify Potential Solutions
• Key questions:
– What will the future look like if your problem is
addressed?
– What will your problem look like if your ‘cause’ is
addressed
– How will you make this change?
• For selected solutions Ask “How” (not Why?)
• How will you get there?
• How will you measure progress? that you’ve ‘arrived’?
• What data will you need to collect and how?
• Develop SMART objectives
What did we figure out?
Process map and Fishbone helped us to Identify opportunities
for change:
1.
2.
Problem – There are significant gaps in communication

Problem – Different staff make separate visits to the same
clients about the same issue

3.
Consensus – We need tools to improve communication. Even if that
means more work on the front end, it will help in the long run.
Consensus - We need to figure out a way to visit the client together.
Problem – We know what we should be doing it, but we don’t
know if we’re actually doing it.

Consensus – We need to measure how well we’re doing our jobs to
build value for our program.
How will we know we’ve improved the process? Need
measures… presumes that we have data and
communication (fundamental)
What will we change first?
• Consensus decision 1: Improve communication
through making client data available to all
– How? All case data to be entered into a Unified
Lead Case Summary sheet (ULCS) by each unit.
– PDSA approach – Monthly analysis of the ULCS data
in a Case Conference Meeting.
What else can we change?
• Consensus decision 2: Joint visits for clients
will enhance service provision and increase
client satisfaction.
– How? Established communication protocol for
public health nurses and inspectors so that both
staff can schedule and attend the client visit
together.
– PDSA approach? Monthly checks – # of successful
joint visits vs. # of possible joint visits
And a little more change
(but that’s enough for now)
• Consensus decision 3– we need to measure how well
we’re doing our jobs to build value for our program.
– How? Establish benchmarks based on present
program protocols.
– PDSA approach? Monthly analysis of benchmarks
at our Case Conference meetings. Are we doing
what our protocols say we do?
• But if we need to change anything else, um, maybe,
let’s think about that a little bit…
Benchmarks
Indicator
Benchmark
Unit
Days from STELLAR import to referral
All referrals will be sent within 2 work days
LPPU
% of lead cases >1 month overdue contacted by Each month, 100% of cases 1 – 2 months overdue for LPPU
letter
a follow up blood test will be sent a letter.
Days from referral to first EHS attempt
Days from inspection to report completion
If EBL level is:
≥70 = 1 working day
<70,but ≥45 = 2 working days
<45, but ≥20 (age 0-3) = 5 working days
<45, but ≥20 (age 3-6) and <20, but ≥10 (age 0-3) =
10 working days
<20, but ≥10 (age 3-6) = 15 working days
<10 with pcp request or pregnant woman = 15
working days
10 working days
EHS
EHS
Days from referral to IHSS visit
100% of cases
IHSS
EBL 20-39: home visit within 10 working days
EBL 40-69: home visit within 5 working days
EBL 70 and greater: home visit within 2 working days
% of cases with EBL > 20 with joint EHS and IHSS
visits
% of cases with developmental issues identified
brought for IHSS consultation
100% of cases with EBL > 20 will have a joint EHS and
IHSS visit
100% of cases with developmental issues will be
referred to IHSS for review/follow-up per protocol.
IHSS/EHS
IHSS/EHS
Step 5: Development of an
Improvement Theory
• Predict the relationship between the problem
and the solution
• Use an “If…then…” statement
– If we implement this solution….
– Then this will happen to the problem…
– If we establish a communication protocol, we’ll be
able to provide joint visits to all of our clients.
Step 6: Test the Theory
• What: Ensure that nursing
staff is informed of scheduled
visit date and make a joint
visit
• How: Emails
• To whom: nurses and nursing
supervisors
Document on the UCLS
spreadsheet
• Carry out the plan
• Document problems
and unexpected
observations
• Does our
communication
protocol mean that we
actually make the joint
visits?
Step 7: Study the Results
Primary purpose is to determine if the test – from Step 6
- was successful
– Compare results with the AIM statement/ consensus
decisions
– Do the results match?
Lead Program tools for reflecting on the analysis:
• Monthly Lead Management team and Case Conference
meetings (rapid! – not waiting for a lot of data)
– Evaluate the benchmarks and the actions taken
– Share the data
– Facilitate the discussion
Indicator close-up: Joint Visits
BENCHMARK Data First “Check” –
– 8/2011
Nov 2011
Joint visit % 2012
Joint visit % 2013
43.5%
80%
94%
93%
• 100% of EBL children with levels 20 or greater will receive a
joint home visit
– Data helped us to improve services to clients
– Data helped us to EXPAND services
Step 8: Standardize the Improvement or
Develop a New Theory
Was there an
Improvement?
YES
Implement
changes on a
larger scale
NO
• Develop a
new theory
and test it
Step 9: Establish Future Plans
• Act to sustain your accomplishments
– Change processes
– Change policies
– Communicate the results with customers,
stakeholders
– Continue PDSA cycles and regularly review
performance data
• Plan more improvement projects
Adapt and even… Evolve
• Could see the #s of kids served
• Could see the work load
• Could see our way to new services
The data changed
“We already have too much to do!”
to
“We can do that!”
QI resulted in EXPANDED services
Original indicator:
100% of EBL
children with levels
20 or greater will
receive a joint
home visit
REVISED indicator:
100% of children
meeting the following
criteria will receive a
joint visit:
– Children 0-36 months
at any EBL
– Children 37 months
and older at EBLs of 20
and greater
Process and People
“I don’t want to get
dinged.”
•
•
•
•
“Communication is
so much better!”
Trust building
Facilitation skills
Meeting planning
Shared purpose and explicit roles
and expectations
Questions and Discussion
References
• Hatry HP. Public and private agencies need to manage for results, not
just measure them. Retrieved from
http:www.urban.org/url.cfm?ID=900731&renderforprint=1 on
October 26, 2012.
• Mason M. Quality Improvement Principles Methods and Tools.
• Riley WJ, Moran JW, Corso LC et al. Defining quality improvement in
public health. J Public Health Management Practice, 2010, 16(1), 5-7.
• Tews DS, Heany J, Jones J et al. Embracing Quality in Public Health: A
Practitioner’s Quality Improvement Guidebook. 2nd Edition.
• US Department of Health and Human Services. Consensus statement
on quality in the public health system. Available at
http://www.hhs.gov/ash/initiatives/quality/quality/phqf-consensusstatement.pdf