Changing Systems One Quality Improvement Tool at a Time
By Amanda Cornett, MPHSenior Vice President for Programs, Population Health Improvement Partners*QI Core Co-Lead and Coach, the National Maternal and Child Health Workforce Development Center**Andrea Davis, BASenior Program and Communications Manager, Population Health Improvement Partners*QI Core Program Manager, the National Maternal and Child Health Workforce Development Center**Every day, systems surround and impact the health of women, children and youth, including children and youth with special health care needs (CYSHCN) and their families. Often we are so conditioned to how the system operates that we lose the ability to view it with a critical eye. Quality improvement (QI) methods and tools provide a lens from which to view and transform systems. QI methodologies provide the plan for how to go about improving the systems that surround maternal and child health (MCH) populations, from assessing the current system to identifying and testing changes. QI tools provide the ability to implement each prescribed step in the methodology, or can be used as individual, standalone instruments to solve a specific problem. Below are examples from the National Maternal and Child Health Workforce Development Center (WDC) that capture the essence of using standalone QI tools to move stakeholder groups towards improving systems that serve and improve the health and well-being of MCH populations. Creating a Shared Vision and UnderstandingA key component of improving a system is to create a shared understanding of the system among stakeholders. A process flow diagram provides visible documentation of how a system works. It is used to highlight gaps and variation among current systems or to document the "ideal" system for the future. By engaging with the WDC, state Title V MCH and CYSHCN programs and their partners created process flow diagrams documenting various systems, including care coordination, screening and referral. Hawaii's Title V program used a process flow diagram to visualize and understand developmental screening and surveillance efforts across the state. The team conducted on-site observations with six stakeholder agencies, created process flow diagrams for each agency's process and shared the diagrams at an in-person meeting with 35 stakeholders. Stakeholders reviewed the diagrams; identified duplication and variation across agencies; and identified standard forms, communication techniques, and educational materials needed to standardize the process. Georgia's Title V program used a process flow diagram to create an "ideal" child health referral process. During an in-person meeting, approximately 100 child health program staff members worked in teams to draw their ideal processes. Title V program and WDC staff consolidated the diagrams into one process flow diagram that represented the ideal system. The diagram created a common vision among staff and provided an opportunity to discuss roles, responsibilities and resources needed to successfully implement the new referral process. Identifying PrioritiesIdentifying common priorities can create buy-in and help move a group to act more quickly. An impact matrix provides criteria to prioritize changes based on their: 1) impact on overall goals and 2) difficulty to implement. States that engaged with the WDC found the impact matrix valuable, as it provided focus to overall project objectives and goals and created space for enlightening discussions with partners by providing opportunities for diverse perspectives. Colorado's Title V program used the impact matrix to identify and prioritize over 40 programmatic and cross-agency policy and system changes to improve care coordination for CYSHCN. During an in-person meeting, stakeholders ranked each change and identified the "quick wins" (high impact and easy to implement) and "major projects" (high impact and somewhat difficult/difficult to implement). The team placed the "quick wins" in an action plan and incorporated the "major projects" in the state CYSHCN systems integration plan. Creating Small Rapid Change Maintaining engagement and momentum is challenging. Often, stakeholders agree on a list of changes, but "analysis paralysis" sets in as they try to anticipate all the "what ifs" of each change. The Plan-Do-Study-Act (PDSA) cycle can help build confidence in a change as it allows a group to quickly try the change on a small scale, make observations and take action based on what was learned. One WDC state Title V team used the PDSA cycle to test a data-sharing memorandum of understanding (MOU) with a stakeholder group. The team drafted a MOU and shared it with two stakeholders for feedback. Based on that feedback, the MOU was adapted and shared with three new stakeholders, who provided additional suggestions for improvement. Over the course of a few weeks, the team adapted the MOU and shared the final version with the larger stakeholder group.Another state Title V team aimed to reduce duplication in the referral intake process. After reviewing the intake forms, the team learned that two different forms captured eligibility information. The information was combined into one new form. The team used a PDSA cycle to test the new form with three clients from a pilot site organization. Clients were pleased with less paperwork; however, eligibility staff noted that several additional questions were needed to fully process clients. Based on feedback, the form was modified, and plans were made to test it with five additional clients. Testing the form provided an opportunity for the team to learn on a small scale rather than make the change in a single big step, reducing the chance of failure on a large scale. Using QI tools can help improve the systems of care for MCH populations by establishing a shared vision and understanding among stakeholders, identifying common priorities and creating opportunities to rapidly test changes on a small scale. To learn more about QI, visit the QI Step by Step Guide or Transformation Station on AMCHP's homepage. -------*Population Health Improvement Partners is a national leader in building community and organizational capacity to improve and sustain population health.** National Maternal and Child Health Workforce Development Center offers state and territorial Title V programs training, collaborative learning, coaching and consultation in health transformation.