Section 6.5 Optimize

Optimization Strategies for Quality ImprovementThis tool suggests ways electronic health records (EHR), health information exchange (HIE), and other forms of HIT can support quality improvement. It addresses recommendations for HIT functionality and people, policy, and process elements that may need to be strengthened to achieve your goals.

Time needed: 8 hoursSuggested other tools: 2.3 Visioning, Goal setting, and Strategic Planning for EHR and HIE

IntroductionImproving the quality of health and health care is a high priority for all. Quality improvement, however, requires a purposeful process focused on activities that are responsive to the needs of the community. Quality data (see Section 4.7 Data Management) are also needed and are not always available in every setting. HHIT that blends quality measures, clinical guidelines, and decision support tools is still relatively new for many local public health (LPH) department EHRs.

How to Use 1. Identify the focus areas for quality improvement in your local community.

2. Determine whether you have standardized data in electronic form that can support quality measurement and reporting in those focus areas.

3. Apply a quality improvement process, such as Plan-Do-Study-Act (PDSA) so that improvements can be planned for, actuated, evaluated, and achieved.

Quality Improvement Focus AreasMost state public health departments spearhead efforts to identify focus areas for LPH departments. Ideally this should be both a bottom-up and top-down process where states identify issues from the Centers for Disease Control and Prevention (CDC) and other federal sources and the LPH departments reflect on the issues they are dealing with on a day-to-day basis at the ground level. The focus areas often include the following public health issues—which EHR, HIE, and other HIT will aid public health nurses in conquering. Check to determine if there are additional or specific focus areas for your state. (In Minnesota, see: www.health.state.mn.us/divs/opi/qi/toolbox/)

Promoting healthy communities, addressing child growth and development, nutrition, healthy aging, pregnancy and birth, tobacco use, preventing unintended pregnancy, and addressing obesity.

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Overcoming health care service gaps or barriers, such as lack of insurance, transportation, mental health providers, and dental services.

Responding to foodborne outbreaks.

Responding to and monitoring instances of communicable disease, such as tuberculosis, sexually transmitted diseases, pertussis, rabies, tick-borne diseases, bed bugs, lice, and others.

Promoting and providing vaccinations.

Improving the cultural competency of services offered.

In addition to the above areas where LPH nurses can have a direct impact, other goals that can be addressed by EHR, HIE, and HIT include:

Adopting evidence-based public health practices

Conducting impact assessments

Preparing for accreditation

Promoting adoption of HIT for data collection that would aid in identifying public health priorities and serve as a hub for communication across LPH departments

Other public health issues can arise in communities, such as the need to address public health nuisances (e.g., lead, water contamination, others) and emergency preparedness. These could also be aided by HIE but go beyond the applications of EHR.

Data and IT Needs for Quality ImprovementOnce you have ascertained the focus areas in your state and for your LPH department, conducting an exercise that assures you can produce the data needed to support your improvement efforts helps you optimize your use of EHR, HIE, and other HIT. Construct a checklist such as the following to identify potential gaps. One example is provided in italics.

Focus Area Data Requirements LPH EHR?

HIO? Other HIT?

Action Needed

DOT for TB Mantoux test results Y Y YChest x-ray results Y YSputum culture results Y Y YLTBI treatment initiated PCPs need to make

available via HIO?Contact list Y EHR needs to support close

contact remindersMaintaining isolation Y Standardized terminologyPCP contact Y YF/U schedule reminders EHR needs F/U reminders

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on dashboard

Implement Quality Improvement ProcessA quality improvement process is a “continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community” (Riley, et al. as cited in: http://www.health.state.mn.us/divs/opi/pm/lphap/qiplan/docs/about.pdf).

Use of EHR, HIE, and other HIT and associated attention to people, policy, and process are not the sole means to achieve quality improvement. Increasingly, however, there is a strong belief and increasing evidence that, together, they can help achieve improvement. The National Committee on Vital and Health Statistics, a federal advisory body to the U.S. Department of Health and Human Services and Congress, observes that “getting usable data into the hands of communities and ensuring that they have the tools and capacities to use them could move the nation a long distance toward realizing the public benefits of the informatics revolution.” (See: http://www.ncvhs.hhs.gov/111213chip.pdf.)

There are a number of ways to construct a quality improvement plan. Most center on a Plan-Do-Study-Act model. The following tool may be helpful to actuate the Plan-Do-Study-Act model:

Plan:

o Identify specific goal(s) from the broad focus areas, as may be directed by your state public health department.

o Describe the strategies you will deploy to achieve the goal.

o List specific resources you will need to carry out the strategies. This toolkit focuses on EHR, HIE, and HIT and associated people, policy, and process resources. You may have other resources you will need, as well.

Do:

o Document baseline data. If you do not have baseline data, collect it. If such collection will take too long, look for benchmark data from other sources (e.g., state level data, other neighboring states). As a last resort, gather anecdotal data or estimates of what stakeholders perceive is the current state of affairs.

o Implement specific strategies using the resources you have defined. This may be as large a project as implementing an EHR—which will require major planning as outlined in this Toolkit. It may be broad-based in scope, such as marshalling primary care providers (PCPs) in the community to sign up and participate in the state’s health information exchange (HIE) organization (HIO). It may require a temporary “fix” such as creation of a local database until your EHR vendor or HIO can add functionality.

Study:

o Document data over short-term milestones as evidence of what you are accomplishing.

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o Evaluate whether the data demonstrate the level of improvement you are seeking. The Plan-Do-Study-Act model is usually considered a cycle because initial plans may not be sufficient to affect the desired level of change and another cycle is required, or because you easily can meet initial goals and could push farther.

Act:

o The Plan-Do-Study-Act Cycle is a technique for rapid improvement. The assumption is that a continuous cycling of planning, doing, and studying will lead to continual refinements in action.

o Action should definitely include taking corrective action where goals are not being met or pushing to the next level when goals are met. However, action should also include celebration of achievements. Ways to celebrate include:

A simple thank you to the staff for their efforts. Acknowledging everyone’s contribution motivates action toward the next level of desired achievement.

Public reporting is a form of celebration, and provides much-needed transparency surrounding how taxpayer dollars are being spent. Public reporting also tends to introduce competitiveness and motivation for further achievement. Public reporting can be the stimulus necessary to garner additional resources.

The following quality improvement plan layout illustrates how the Plan-Do-Study-Act steps may be documented. For any specific goal there may be several improvement strategies, each with its own resource needs. Baseline data will be collected for the overall goal or for each strategy, as applicable. As milestone results are documented, corrective action may initiate another Plan-Do-Study-Act cycle, still with the same goal but potentially a different strategy.

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Quality Improvement Plan

Goal Quality Improvement Strategies

Resources to be Implemented

Baseline Data

Milestone Results Corrective Action as Needed

3 mo 6 mo 9 mo. 12 mo.

Reduce tobacco use

Copyright © 2014 Stratis Health. Updated 03-19-14

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