1. Feasibility of using a Quality
Improvement Approach within APHA?
AN APHA-ISC/SC PERSPECTIVE
O R I E N TAT I O N F A C I L I TAT E D B Y P R I T I I R A N I
F E B R U A RY 2 8 , 2 0 1 2

2. Acknowledgements
2
 Model for Improvement was developed by the
p p y
Associate in Process Improvement and is used by
the Institute for Healthcare Improvement
 New York State Health Department for their support
For APHA-ISC/SC 2/28/12

3. Eureka?
3
 Describe the key
elements of Quality
Improvement Framework
p
 Identify at least two
opportunities to apply
quality improvement
 Have key information to
decide
d id on th fthe feasibility
ibilit
of using the methods
within APHA
For APHA-ISC/SC 2/28/12

4. Call For Action
4
 APHA membership has declined 12% from
2007 to 2011.
 Similar decline seen in professional
associations across the US due to shrinking
budgets and g
g growing unemployment.
g p y
 APHA wants to increase membership and
better serve members’ needs.
 As liaison to units, ISC can help APHA better
understand what needs to be done to better
serve members and bring in new members.
For APHA-ISC/SC 2/28/12

5. ISC and APHA Units
5
 ISC/SC is the liaison to APHA units: Section, SPIGS,
Forums, Caucuses
 2011 Action Report/2012 Workplan has been re-
structured to be consistent with a quality
improvement framework
 Q lit improvement framework?
Quality i tf k?
For APHA-ISC/SC 2/28/12

6. 6
Model for Improvement
Two Parts
Part 1 – Three Critical Questions
1. What are we trying to
accomplish?
li h?
2. How will we know that the
change is an improvement?
3. What changes can we make
that will result in an
improvement
Part 2 – Plan-Do-Study-Act Cycle
a a o S udy c Cyc e
For APHA-ISC/SC 2/28/12

7. Have you used a similar framework in
p
personal or professional life?
p
7
1. What was the project?
p j
2. What is similar?
3. What is different?
4. What are the critical elements?
5. What helped move it along to achieve objective?
p g j
6. What were the barriers?
For APHA-ISC/SC 2/28/12

8. What we will need to get started
8
 Select a strategic p j
g project with significant impact?
g p
 Identified group who will test the interventions or
changes?
 Potential to identify and collect process and outcome
measures? Can some of these be tracked daily,
weekly or monthly?
kl thl ?
 Identify interventions that be used that are known to
have worked?
 Some aspect of project can be completed in 12
months?
For APHA-ISC/SC 2/28/12

9. Measurement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What h
Wh t change can we make that will
k th t ill
result in improvement?
Act Plan
The Improvement Guide
Study Do
Langley, Nolan, Nolan, Norman,
Provost 1996
For APHA-ISC/SC 9 2/28/12

10. Adapting the Framework for the ISC/SC
10
What will we need?
What are we doing?
What is the timeline?
Can you picture what it will look like if most of the
sections/spigs/APHA adopted a quality improvement
approach?
For APHA-ISC/SC 2/28/12

11. What is the ISC/SC trying to accomplish?
11
Examples
 Increase membership engagement in _#__
sections/spigs by ___%.
 Number of identified strategies objectives
improved and/or reached increased by 15%.
IIncrease membership numbers i APHA b ___
b hi b in by
%.
For APHA-ISC/SC 2/28/12

12. Measurement Assumptions
p
 The purpose of measurement in quality
improvement is for learning not judgment
 All measures have limitations, but the limitations do
not negate their value
g
 Seek usefulness, not perfection
 Measures are one voice of the system. Hearing the
y g
voice of the system gives us information on how to
act within the system
 Measures tell a story; goals in your aim statement
give a reference point
For APHA-ISC/SC 12 2/28/12

13. Identify a Balanced “Family” of Measures
y y
Outcome = Voice of the customer/student:
 How is the system performing?
 What is the result?
 How is the learning of the student affected?
Process = Voice of the workings of the system:
 Are the parts/steps in the system performing as planned?
 Are key changes being implemented in the system?
Balancing = Looking at a system from different dimensions
 What happened to the system as we improved the outcome and
process measures?
 Are we improving some parts of the system at the expense of
others?
For APHA-ISC/SC 13 2/28/12

14. How will we know that the change is an
improvement? -
14
Membership engagement examples Engagement ● Equity ● Outcomes
 % of members actively involved in leadership, committees,
projects
 % of members who read emails, newsletters over a finite
period of time (e.g. before and after a planned event)
 % of members by region, field, membership level
region field level,
ethnic/racial, geographic level, who participate
 % of strategic projects with clear focus, process and
outcome measures change ideas
measures,
 Project objectives movement, or lack thereof
 Section/SPIG/Project leaders/APHA staff satisfaction levels
For APHA-ISC/SC 2/28/12

15. How will we know that the change is an
improvement? Part 2
p
15
Membership Recruitment measures’ examples
p p
 Percentage of membership change
 Number of PDSAs identified
 Number of PDSAs tested
 Proportion of member implementing PDSAs
p p g
 Section/SPIG/Project leaders/APHA staff satisfaction
levels
For APHA-ISC/SC 2/28/12

16. What changes can ISC make that will result in
an improvement
16
Examples
p
 Develop or work with a few sections/spigs to write
examples of clearly focused strategic projects.
 Test out metrics by using identified interventions
 Develop spreadsheet or dashboards if possible
For APHA-ISC/SC 2/28/12

17. The PDSA Cycle
•State objective of cycle
•What modifications to
What
make? •Make predictions
•What is the next cycle? •Develop a plan to carry
out
Act
A t Plan
Pl
Study Do •Carry out the test
C t th t t
•Complete analysis •Document problems
•Compare to prediction and unexpected
outcomes
•Summarize learning
•Begin data analysis
Learning & Improvement
For APHA-ISC/SC 17 2/28/12

18. Learning to Implementing:
Repeated use of th PDSA C l
R t d f the Cycle
Changes that
result in
improvement
A P
S D
Implementation of
I l t ti f
change
Wide scale
Wide-scale tests of
A P change
S D Follow-up
tests
Very small
Hunches scale test
Theories
Ideas
For APHA-ISC/SC 18 2/28/12

19. What resources does the ISC/SC need?
19
1. Training and opportunity for application
 Personal
 Group
2.
2 Defined roles someone who will:
roles…someone
 facilitate access with leaders to allow for smooth operations;
 encourage/remind teams to be persistent;
 identify measures and best practice
3. Conference call with small group of knowledgeable
leaders to identify measures and change ideas
4. 3-5 teams who are willing to test the framework until
the September of 2012…Open Space Priorities?
For APHA-ISC/SC 2/28/12

20. Is it feasible to use a “rapid” collaborative Quality
Improvement (QI) Approach within APHA?
20
Traditional Rapid QI
Project selection All Strategic – Important, Actionable
Purpose Definition Problem – what should be Problem – what should be
improved based on causative improved stated in
factors – strategies – time-
g q
quantitative terms – causative
limited factors – strategies – time-
limited
Population Varies: organization, county, Test sample
state
Measures Identification Goals and objectives Outcomes – Process –
“Balancing”/Unintended
consequences
Measures Collection
easu es Co ect o Months
o t s O go g,
Ongoing, at least monthly
east o t y
Periodicity
Intervention Best practice, evidence-based Best practice, evidence-based
broken into action-sized chunks
Post-Intervention Theoretically should be adapted Adapted
Cycle length Months to years Days-Weeks-Months
For APHA-ISC/SC 2/28/12

21. Is it feasible to use a “rapid” Quality
Improvement (QI) Approach within APHA?
p ( ) pp
21
Strengths
 Expertise among membership
 Value collaboration, dissent, discussion
 Committed leaders
 Significant student membership
 Offers opportunity to apply QI methods
Challenges
 Many chiefs
 Changing volunteer leadership
 APHA staff not trained in QI methods
 Majority of APHA members do not have QI training
 Discipline/Focus
p
For APHA-ISC/SC 2/28/12

22. Next Steps?
22
After decision on feasibility, options available:
Five Phases: (1) Learning; (2) Pilot-1; (3) Pilot-2; (4) Implementation; (5)
Spread
1.
1 Seek out training
a. Apply Improvement framework at personal level
b. Apply Improvement framework as a ISC/SC group
c. Study great examples of application
d.
d Continue orientation at June meeting
2. Identify persons for roles
3. Recruit advisors
4.
4 Identify focus metrics change ideas
focus, metrics,
5. Recruit sections/SPIGS to test
6. Test and Study
7. Regroup in September
For APHA-ISC/SC 2/28/12

23. Selected Resources
23
 Institute for Healthcare Improvement – Model for
p
Improvement:
http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx
 Ne York State Department of Health application of
New
Model for Improvement:
http://www.health.ny.gov/statistics/chac/improvement/index.htm
 Proposed 2012 APHA Policy Paper on quality
improvement and performance management to be
posted at: http://www.apha.org/advocacy/policy/
For APHA-ISC/SC 2/28/12