1/25/2012
Early MIECHV Successes
and Challenges:
Tennessee’s Experience with
Continuous Quality Improvement
and Engaging Military Families
Cathy R. Taylor, DrPH, MSN, RN
Michael D. Warren, MD, MPH
Bridget K. McCabe, MD, MPH
Marilyn D. Stephenson, MSN, RN (Moderator)
Part I
Engaging New Stakeholders –
Working with Military Families in
Tennessee (Fort Campbell)
Cathy R. Taylor, DrPH, MSN, RN
Dean, College of Health Sciences and Nursing, Belmont
University
Former Assistant Commissioner, TN Department of
Health
[email protected]
Objectives
1. Describe Tennessee’s opportunities to
engage new stakeholders during the
MIECHV process - Tennessee’s Military
Families
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Ft. Campbell
Ft. Campbell
• Army’s most deployed contingency forces
• 101st Airborne
• 2 Special Operations Command Units
• 86th Combat Support Hospital
• Provides training and mobilization support
for Army National Guard and Reserve units
• Supports active and reserve component
units, Army civilians, Army Families,
retirees and veterans
Ft. Campbell, KY
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Clarksville, TN
• 28.5% Population change 2000-2010
vs. 11.5% TN
• 28% <18 years old vs. 23% TN average
• Per capita income $21,000 vs. $23,000
TN
• Higher than TN averages
•
•
•
•
Adult smoking
Obesity
Excessive drinking
Sexually transmitted infections
Serving Military Families in TN
• Behavioral Health
• WIC
• Existing family planning, home visitation
and care coordination efforts
• Creating new opportunities
• Opening doors
• Partnering with existing programs
• Tailoring interventions to special needs
Part II
Leveraging MIECHV Initiatives to
Enhance Existing Early Childhood
Systems and Engage Stakeholders
in Tennessee
Michael D. Warren, MD, MPH, FAAP
Director, Title V/Maternal & Child Health
Tennessee Department of Health
[email protected]
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Objectives
1. Describe pre-MIECHV home visiting
initiatives in Tennessee
2. Outline challenges and opportunities
associated with MIECHV implementation in
Tennessee
Pre-MIECHV in Tennessee
• CHAD (Child Health and Development)
•
•
•
•
•
Mandated in statute (1979)
Based on Vanderbilt Peabody research model
22 counties in East and Northeast TN
Operated by county health departments
Funded with interdepartmental funds from
Children’s Services (Social Services Block Grant)
Pre-MIECHV in Tennessee
• Healthy Start
•
•
•
•
•
Mandated in statute (1994)
Utilize Healthy Families America model
31 counties throughout TN
Operated by community non-profit agencies
Funded with interdepartmental funds from
Children’s Services (ACF Promoting Safe and
Stable Families Funds)
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Pre-MIECHV in Tennessee
• HUGS (Help Us Grow Successfully)
• Began in 1990’s
• Care coordination program with home visiting
component
• Present in all 95 counties
• Operated by county Health Departments
• Funded by state Medicaid program (TennCare)
Pre-MIECHV in Tennessee
• Nurse Home Visitor Program
•
•
•
•
Mandated in statute (2010)
Utilizes Nurse Family Partnership (NFP) model
Operated by community non-profit agency
Located in Shelby County
Pre-MIECHV in Tennessee
• Statewide interest in evidence-based
programming
• Commitment by state agencies and statewide
home visiting collaborative
• 2010 legislation requiring Department of Health to
annually report on evidence-based practices
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Pre-MIECHV in Tennessee
• Department of Health efforts to collect
continuous quality improvement (CQI) data
for HUGS
• Standard administrative platform used by all 95
county health departmentsallows for uniform data
collection across state
• Data collection began in 2009
• Collaboration with Department QI staff
Pre-MIECHV in Tennessee
• Statewide Home Visiting Collaborative
• Includes program representatives from across state
• Public and private agencies represented
• Strategize how to build more integrated system of
home visiting services
Pre-MIECHV in Tennessee
LEGEND
HUGS
HFA
CHAD
NFP
PAT
Healthy
Start
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Tennessee Population Density
Pre-MIECHV in Tennessee
• Over 7,400 families served in FY10
• Services available in all 95 counties
• Few counties serve more than 5.6% of the 0-5
population1
1. Source: Tennessee Commission on Children and Youth, 2011 Resource Map of Expenditures for Tennessee Children.
Tennessee MIECHV Timeline
• Summer 2010: Initial State Plan
• Fall 2010: Statewide Needs Assessment
• Summer 2011: Updated State Plan
• June 8: Updated State Plan
• June 21: Competitive FY11 application
• July 1: FY11 formula application
• July 1, 2011: MIECHV Grantee Startup
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Tennessee MIECHV Programs
• Healthy Families America
•
•
•
•
Davidson County
Maury County
Montgomery County (*focus on military families)
Shelby County
• Nurse Family Partnership
• Campbell County
• Shelby County
• Parents as Teachers
• Hamilton County
• Shelby County
Post-MIECHV in Tennessee
LEGEND
HUGS
MIECHV
HFA
CHAD
NFP
PAT
Healthy
Start
Challenges
• Rapid turnaround (applications/planning)
• Summer 2011 plan/grant submissions
• TN unable to outsource plan development/grant
writing
• Extensive benchmark data collection
• Home visitors concerned about balance between
data collection with service provision
• Different data systemsduplicate data entry
• Multiple models
• Each with different data collection requirements
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Opportunities
• New staff
• Administrator (also ECCS Director)
• Epidemiologist
• Program Director
• Better integration in MCH
• Linkages to other programs (Injury, Family
Planning, CSHCN, ECCS)
• Integrated funding
Tennessee Home Visiting Team
Healthier Beginnings
• Public/Private Partnerships
• Ongoing collaboration with Home Visiting
Collaborative
• Development of uniform intake/referral system
• Efforts with military families
• HFA administered by local non-profit
• Engagement of staff from Fort Campbell
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Early Childhood System
• ECCS is building on the federal investment in
home visiting through:
• Support for statewide home visiting collaborative
• Development of core competencies for Home Visitors
• Support for training related to early childhood
activities (including home visiting)
• Contributing to sustainable resources for all early
childhood professionals like
www.parentsknowkidsgrow.org
• Working to build capacity of 211 to respond to referral
requests for families with young children
Early Childhood System
• Working to build connections among early
childhood professionals around health and
development topics
• Infant Mortality (Safe Sleep)
• Medical Homes (for All Children including Children &
Youth with Special Health Care Needs)
• Infant & Early Childhood Mental Health (Social &
Emotional Development and Challenging Behaviors)
• Developmental Screening and Assessment
What’s Ahead...
• Integrated data system
• Across state-run programs
• Available to community agencies
• Shared benchmarks
• Rollout of core competencies
• Requirement for all state-run programs
• Available to community agencies
• Increased collaboration
• Emphasis on “raising the sea level”
• Attempt to make resources (particularly training)
available broadly
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Part III
Embedding Continuous Quality
Improvement in MIECHV Initiatives –
Lessons Learned from Integration into
a Statewide Home Visiting Program
Bridget K. McCabe, MD, MPH
Director, Quality Improvement
Tennessee Department of Health
[email protected]
Objectives
1. Discuss how Continuous Quality
Improvement (CQI) is being intertwined into
public health initiatives in Tennessee – Home
Visiting
2. Outline prior experiences in CQI that have
shaped the direction of CQI in MIECHV
3. Discuss challenges and opportunities
associated with CQI in Tennessee
What is Continuous Quality
Improvement (CQI)?
1) Focus on underlying organization processes and
systems as causes for successes or failures
2) Use of structured problem solving approaches
3) Use of cross-functional employee teams
4) Employee empowerment to identify problems and
opportunities for improved care
5) Explicit focus on both internal and external customers
(Shortell, SM, et al., 1995)
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Ways to explain CQI through
examples
1) Grocery shopping and the
grocery list
2) Scheduling appointments
via mobile phones
Image: Ambro /FreeDigitalPhotos.Net
3) Organizing charts or
records so that information
is stored in the same place
every time
Ima ge: winnond/FreeDigitalPhotos.Net
An Example of a System
Toothpaste
Dental
Floss
Envelopes
Pencils
Tomatoes
Crackers
Shampoo
Popcorn
Yogurt
Milk
Orange
Juice
Tape
An Improvement to a System
Personal
Hygiene
Items
Office
Supplies
Snacks
Dairy
Items
Produce
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Terminology
“CQI Methodologies”
• PDSA – Plan-Do-Study-Act Cycle
• Lean – Toyota Production System
By measuring it, you say it is important…
• Outcome measure
• Process measure
CQI in the grand scheme of a program
 Grant Funds and Requirements
 Program and Evaluation Technical
Assistance
 Peer Learning Network
P
D
A
S
Evidenced-Based
Home Visiting
HUGS Home Visiting
(Local System of Care)


Evaluation System
Continuous and well integrated with daily work flow
Functions to support:
o Feedback and Improvement Loops (PDSA Cycle)
o Needs Assessment
o Monitoring & Accountability
o Quality Review & Program Clarification
o Stakeholder Engagement
Values & Beliefs


Goals
Actions


P
D
A
S
System of Care
Outcomes
Process Measures
Outcome Measures
o Short
o Intermediate
o Long-term
System Information
Infrastructure Capacity
System Attributes
Adapted from Hodges et al., 2007and Hargreave, 2009
First, define your mission… Then, the
processes that get you to your goals
Objectives drive your outcome and process
measures.
1) Create a Logic Model
2) Create a “Process Map”
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Logic model (The What)
Risk/Need
Identified
Intervention(s)
Risk Reduced
Treatment(s)
Need Met
Outcome
Achieved
Process map (The How)
Screen for
Risk/Need
Directly
Provide
Intervention
OR
Monitor
Success of
Intervention
Outcome
Achieved
Referral
Aligning mission/goals/objectives with actions and
how you measure success.
(Outcome Measures and Process Measures)
Embedding and Integrating CQI
It is a journey with no end…
Enjoy the process of trying
to improve…
Sayings to keep you on the journey:
1) Do the basics well (know your mission).
2) “You eat an elephant one bite at a time.” (African
Proverb)
3) Don’t let the perfect be the enemy of the good.
(Voltaire – 1700’s)
Ima ge: nuttakit / FreeDigitalPhotos.net
Make it part of the process of daily
work…
Double/Triple Duty Tools:
When possible, work with relevant
screening and monitoring tools that serve
the client as well as to evaluate a program
CQI then becomes part of the day’s work…
• Examples:
1) Car seat evaluation (e.g. PRAMS Questionnaire)
2) Developmental screens (e.g. ASQ®)
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Consider population surveillance systems in
your service area (Benchmark)
• Behavioral Risk Factor Surveillance System (BRFSS, CDC)
• Pregnancy Risk Assessment and Monitoring System
(PRAMS, CDC)
• State Vital Records – Birth and Death Files
• State Hospital Discharge Data
• State Birth Defects Registries
• State Newborn Screening Program
Allows you to compare to a larger population.
Question: Are you seeing your target population (i.e. with
more at-risk factors)?
How a Statewide Home Visiting Program’s
Participants Compare to the State Population
(82%)
Benchmarking Opportunities!
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Everyone has a Role/Responsibility
in CQI
(Top down, bottom up, and across.)
Commitment by and professional development of
the entire workforce is required.
• Leadership must be in support of empowering
all levels of staff to make improvement
changes
• Field staff must feel supported in order to
engage in the process of CQI
Workforce Training – Remote Experiential
Learning
• Embedded into work schedule
• Protected time to learn and work through
QI projects
• Short duration but frequent (1 hour every
few weeks)
• Remote to cover large geographical area
• Engage groups to tackle small QI projects
• Technical support from State Agency
(Handout with Curriculum Overview Provided)
http://www.ihi.org/knowledge/Pages/Tools/PlanDoStudyActWorksheet.aspx
Sample Tool: PDSA Worksheet from Institute for Healthcare Improvement
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Embracing Quality in
Local Public Health:
Michigan’s Quality
Improvement
Guidebook
http://accreditation.localhealth.net/MLC2%20website/Michigans_QI_Guidebook.pdf
The Public Health
Memory JoggerTM II
Quick Reference for
Quality Improvement
techniques
http://www.phf.org/resourcestools/Pages/P
ublic_Health_Memory_Jogger_II.aspx
The Public Health
Quality Improvement
Handbook
Public Health Foundation
(PHF) in collaboration with
American Society for Quality
(ASQ)
http://www.phf.org/resourcestools/Pages/P
ublicHealthQIHandbook.aspx
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Example Experiential Learning:
Documentation Committee
• Gathered front line staff/leadership for about 12 months
• Meeting every 3 weeks
Achievements:
1. Revised Documentation Record to streamline
documentation
2. Revised ASQ schedule to reduce burden while still
adhering to best practice (surveillance and screening)
3. Developed a medical verification form and guidelines for
use to reduce burden of contacting medical providers
Summary Exercise for CQI Initiatives
Some Lessons Learned
• Invest in a core team that will support CQI training and
use throughout your organization (SUSTAINABILITY)
•
Dedicated support to translate the data collected into
information that can drive decisions and CQI (strong
analytical skills)
Current efforts in TN – lead epidemiology/biostatistician
position learning the ropes of QI; working with TN QI group
and with HRSA’s technical expertise
• Start small… “Low Hanging Fruit”
Effort
•
Return on Investment
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Challenges and Opportunities
TN’s Biggest Challenges:
•
•
•
Rapid deployment
CQI staffing resources are stretched thin
Legacy statewide IT system – IT resources stretched thin
TN’s Biggest Opportunities:
•
Only state with border to border public health IT system
•
Hybrid system – mostly centralized
•
•
•
Connects to other public health programs: WIC; Family Planning; etc.
Rural Regions – under state agency authority
Metro Regions – contracted under state agency
Thank you
Dru Potash
Gary Self
Kathy Shearon
Michael Crieghton
Ernest Miser
Ellen Omohundro
John Hutcheson
Susannah Craig
Lacy Lesmeister
Maternal and Child Health Team at the
Tennessee Department of Health
¿Questions?
Other resources on the WWW
•
Association of State and Territorial Health Officers
(ASTHO)
•
http://www.astho.org/Programs/Accreditation-and-Performance/QualityImprovement/
•
National Association of City and County Health Officials
(NACCHO)
•
National Network of Public Health Institutes (NNPHI) –
Multi-State Learning Collaborative
•
Public Health Foundation (PHF)
•
Institute for Healthcare Improvement (IHI)
•
•
•
•
http://naccho.org/toolbox/
http://www.nnphi.org/program-areas/accreditation-and-performanceimprovement
http://www.phf.org/Pages/default.aspx
http://www.ihi.org/Pages/default.aspx
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References
•
Plan-Do-Study-Act (PDSA) Worksheet for Testing Change. Retrieved February 25,
2009 from the Institute for Healthcare Improvement Web site:
http://www.ihi.org/knowledge/Pages/Tools/PlanDoStudyActWorksheet.aspx
•
Tews DS, Sherry MK, Butler JA, Martin A. Embracing Quality in Local Public
Health: Michigan’s Quality Improvement Guidebook; 2008.
http://accreditation.localhealth.net/MLC-2%20website/Michigans_QI_Guidebook.pdf
•
Michael Brassard (Author), Diane Ritter (Author), Francine Oddo (Editor), Janet
MacCausland (Illustrator), Michele Kierstead (Illustrator), Deborah Crovo (Illustrator).
The Public Health Memory Jogger II: A Pocket Guide of Tools for Continuous
Improvement and Effective Planning; Goal/QPC; 1st edition (March 31, 2007); 165
pages
http://www.phf.org/resourcestools/Pages/Public_Health_Memory_Jogger_II.aspx
•
Public Health Quality Improvement Handbook. Bialek R, Moran JW and Duffy GL
(editors). Public Health Foundation. 2008.
http://www.phf.org/resourcestools/Pages/PublicHealthQIHandbook.aspx
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