1. TANEY COUNTY HEALTH DEPARTMENT
CONTINUOUS
QUALITY
IMPROVEMENT
PLAN
Ashwin George Modayil M.H.A, M.P.H.
Robert Niezgoda, M.P.H.
2012
2. Table of Contents
Introduction 3
Terms 9
Vision 13
Quality Improvement Program Structure 14
QI Training
Project Identification Process 15
Goals, objectives and measures with time-framed targets 16
Quality Assurance and the Monitoring QI Plan 17
QI Program Evaluation Process 19
Communication of QI activities 19
Appendix A: PDCA Checklist 21
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3. Introduction
One of the opportunities for improvement that the Taney County Health Department (TCHD)
identified through the Missouri Institute of Community Health’s Accreditation Process in 2005
was a need for a Continuous Quality Improvement (CQI) program. The department was slated
for MICH reaccreditation in early 2008 and Quality Improvement was an arena that needed to
be addressed. The field of quality improvement is an extensive one. Information pertaining to it
is exceedingly vast with a plethora of options tailored to suit the needs of various business
structures. Therefore, it was important to identify and employ the most appropriate CQI
strategy for the department.
What is Continuous Quality Improvement?
Continuous Quality Improvement is the complete process of identifying, describing and
analyzing strengths and weaknesses and then testing, implementing, learning from and revising
solutionsi. It relies on an organizational culture that is proactive and that supports continuous
learning. CQI is firmly grounded in the overall, mission, vision and values of the agency. Most
importantly, it is dependent upon the active inclusion and participation of staff at all levels of
the agency, and stakeholders throughout the processii.
Which CQI strategy?
As was just mentioned, the topic of quality improvement was an extensive one. Therefore, one
of the first challenges was to find a process that would suit the needs of the agency. After an
exhaustive CQI literature review, it was felt that the Plan, Do, Check, Act (PDCA) or the
Deming/Shewhart Cycle would be the most conducive to meet the needs of TCHD. More
accurately, the process is referred to as the FOCUS-PDCA approach. Having originated in the
business industry, the FOCUS-PDCA approach has been tweaked for effective application in a
variety of healthcare institutions – including a public health department.
FOCUS:
Find a process to improve
Organize to improve a process
Clarify what is known
Understand variation
Select a process improvement.
After FOCUS has been achieved, a process improvement plan needs to be implemented. One
such plan is the PDCA cycle – or the Plan Do Check Act cycle.
Planning: Involves creating a timeline of resources, activities, training and target dates. During
this stage a data collection plan needs to be developed, tools for measuring outcomes need to
be identified, and thresholds for identifying when targets have been met need to be stipulated.
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4. Do: This involves the actual implementation of the various interventions as well as data
collection.
Check: This step includes an analysis of the results of the data and an explanation for the
reasons of variations – if any.
Act: Means that one can act on what was learned and then determine what was learned. If the
intervention was successful, then steps to make it a part of standard operating procedure need
to be implemented. If the intervention was not successful, then the various sources of failure
need to be identified. Once these are determined new solutions need to be designed and the
PDCA cycle needs to be repeatediii.
A studyiv showed that repetitive cycles of measuring outcomes followed by implementation of
interventions to improve outcomes could be effectively used to improve quality of care in rural
health clinics.
Why Continuous Quality Improvement?
In addition to increased productivity, improved service quality, enhanced customer
responsiveness and enhanced employee satisfaction, there are several other benefits of
incorporating CQI into the daily workings of the health department. Some of these are v:
Ownership of Process/Program Objectives
CQI can bring about changes in attitudes towards a process/program. Employees can
see how a set of objectives helps to identify a process’s success or indications that a
program is moving in the right direction.
Inclusiveness/Consistency
Implementation of a program on an organizational-wide level promotes a feeling of
inclusiveness in the organization. Employees feel part of a team, have similar
experiences, use the same CQI tools, as well as participate in organizational wide
training.
Improved Communication/Teamwork
Regular management meetings involve sharing of information among programs and
services. Staff can offer suggestions on interventions for opportunities in other areas to
assist in needed improvement. This further fosters teamwork.
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5. Stakeholder Perception
Reporting of trended information allows stakeholders to see performance levels on a
routine basis. They can see that the organization sets goals, evaluates data collected and
reviews the impact on organizational programs.
Proactive vs. Reactive
CQI initiatives place the organization in a proactive mode. Under a CQI philosophy,
programs and services are aggressively monitored which assists with detecting problems
in a timely fashion. Analysis of data also helps to distinguish between acceptable and
unacceptable performance levels.
What is required?
The six Key Success Factors (KSFs) for CQI are as followsvi:
Key Success Factor 1: Visionary Leadership.
Key Success Factor 2: Commitment to Customers / Clients.
Key Success Factor 3: Trained Teams.
Key Success Factor 4: Employee Participation.
Key Success Factor 5: Total Quality Management Process (detailed below).
Key Success Factor 6: Alignment of Management Systems.
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6. The CQI Framework:
Fig. 1
VALUES
Adopt
Apply outcomes
Learnings indicators and
standards
M
V
I Train and
S I
support leaders, S
S
staff and I
I
O
stakeholders O
N N
Review,
analyze and Collect data
interpret and
data information
ORG. CULTURE
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7. The Crux of Continuous Quality Improvement
The central idea of CQI lies in the philosophies of scientific method which include hypothesis
generation, experimentation, observation and hypothesis testing. CQI is all about improvement
which can only be brought about by change. The PDCA cycle mentioned earlier is a proven tool
used to help agencies develop tests and implement changes. In other words, the PDCA is a
framework for efficient trial-and-error methodology. The cycle begins with a plan and ends with
an action based on the learning gained from the cycle. Improvement comes from the
application of the knowledge gained and generally, the more complete the appropriate
knowledge, the better the improvements will be when the knowledge is applied to making
changes. Any approach to improvement must be based on building and applying
knowledge.This view leads to a set of fundamental questions, the answers to which form the
basis of improvement:
1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in improvement?
These questions provide the framework for a “trial and learning” approach. The word “trial”
implies that the change is going to be tested.The term “learning” imples that the criteria that
are intended to be studied from the trial have been identified. This approach stresses learning
by testing changes on a small scalevii.
Plan of Action Proposal
Identify a process that needs improvement that is common to all departments
The literature emphasizes that CQI be adopted using a team based approach. This allows for
synergistic problem solving, assumed empowerment and can aid in consensus building. This
approach also forces participants to view how the agency operates as a unified system as
opposed to separate entities that just happen to be a part of the larger “whole.” A team-
based approach infuses a sense of purpose to the issue at hand and can also serve as a
platform for future problem solving initiatives.
Document current operating procedures.
This allows us to understand where we stand at the moment. This information will act as
the basis for formulating future improvement strategies.
Collect Data.
This step calls for data collection using existing standard operating procedures. Once
collected, this data will help us to analyze the effectiveness of the current methods of
operation.
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8. Brainstorm for improvement strategies.
This phase calls for taking a second look at the way things are currently done and to then
question whether any improvements can be made. If this is the case, then an exhaustive list
of how the various processes can be improved needs to be generated.
Meet to hammer out consensus for all proposed strategies.
Since this is a team-based and collaborative effort, buy-in by all employees and stakeholders
is a mandatory precursor for any measure of success. All parties need to cross evaluate each
other’s proposed solutions to ensure that no inter-departmental glitches come about once
the actual trial is rolled out.
Implement the new process / processes
This is where the ‘rubber meets the road’ or where the newly conceptualized process is first
put in action. The data collection structures or templates may also need to be fine-tuned to
reflect any procedural changes and related data collection points.
Collect data
Data collected here needs to be consistent with the type and format of data collected in the
initial data collection phase. This will allow for valid comparisons to be made of the ‘before’
and ‘after’ procedures.
Meet for feedback and see if the stipulated objectives were met.
This is the ‘learning’ phase. Participants need to meet and analyze what worked and what
didn’t. What did work needs to be documented and suggestions for further improvement
needs to be sought. Similarly, strategies that did not result in any significant improvement
also need to be documented for future reference.
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9. Key quality terms:
CQI – Continuous Quality Improvement The ongoing improvement of products, services or
processes through incremental and breakthrough improvements. A philosophy and attitude for
analyzing capabilities and processes and improving them repeatedly to achieve customer
satisfaction
PDCA – Plan Do Check Act
FOCUS
1.) F – Find a process to improve
2.) O– Organize to improve a process
3.) C – Clarify what is known
4.) U – Understand variation
5.) S - Select a process improvement.
Brainstorming: A technique teams use to generate ideas on a particular subject. Each person on
the team is asked to think creatively and write down as many ideas as possible. The ideas are
not discussed or reviewed until after the brainstorming sessionviii.
Baseline measurement: The beginning point, based on an evaluation of output over a period of
time, used to determine the process parameters prior to any improvement effort; the basis
against which change is measuredix.
Benchmarking: A technique in which a company measures its performance against that of best
in class companies, determines how those companies achieved their performance levels and
uses the information to improve its own performance. Subjects that can be benchmarked
include strategies, operations and processes.
Best practice: A superior method or innovative practice that contributes to the improved
performance of an organization, usually recognized as best by other peer organizations
Big QI: This is where top organizational leaders address the quality of the system at a macro
level.
Capability: The total range of inherent variation in a stable process determined by using data
from control charts.
Chart: A tool for organizing, summarizing and depicting data in graphic form
Check sheet: A simple data recording device. The check sheet is custom designed by the user,
which allows him or her to readily interpret the results. The check sheet is one of the “seven
tools of quality” (see listing). Check sheets are often confused with checklists (see listing).
Checklist: A tool for ensuring all important steps or actions in an operation have been taken.
Checklists contain items important or relevant to an issue or situation. Checklists are often
confused with check sheets (see listing).
Common-Cause Variation: Any normal variation inherent in a work process.
Complexity: Unnecessary work; any activity that makes a work process more complicated
without adding value to the resulting product or service.
Compliance: The state of an organization that meets prescribed specifications, contract terms,
regulations or standards.
Consensus: A state in which all the members of a group support an action or decision, even if
some of them don’t fully agree with it.
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10. Constraint: Anything that limits a system from achieving higher performance or throughput;
also, the bottleneck that most severely limits the organization’s ability to achieve higher
performance relative to its purpose or goal.
Cross functional: A term used to describe a process or an activity that crosses the boundary
between functions. A cross functional team consists of individuals from more than one
organizational unit or function.
Employee involvement (EI): An organizational practice whereby employees regularly participate
in making decisions on how their work areas operate, including suggestions for improvement,
planning, goal setting and monitoring performance.
Empowerment: A condition in which employees have the authority to make decisions and take
action in their work areas without prior approval. For example, an operator can stop a
production process if he or she detects a problem, or a customer service representative can
send out a replacement product if a customer calls with a problem.
Facilitator: A specifically trained person who functions as a teacher, coach and moderator for a
group, team or organization.
Failure: The inability of an item, product or service to perform required functions on demand
due to one or more defects.
Feedback: Communication from customers about how delivered products or services compare
with customer expectations.
Five whys: A technique for discovering the root causes of a problem and showing the
relationship of causes by repeatedly asking the question, “Why?”
Focus group: A group, usually of eight to 10 people, that is invited to discuss an existing or
planned product, service or process.
Gap analysis: The comparison of a current condition to the desired state.
Group dynamic: The interaction (behavior) of individuals within a team meeting.
Groupthink: A situation in which critical information is withheld from the team because
individual members censor or restrain themselves, either because they believe their concerns
are not worth discussing or because they are afraid of confrontation
Histogram: A graphic summary of variation in a set of data. The pictorial nature of a histogram
lets people see patterns that are difficult to detect in a simple table of numbers
Improvement: The positive effect of a process change effort.
Individual qi: When staff members seek ways to improve their own behaviors and environments
it is referred to as individual qi.
Internal Customer: Anyone in the organization who relies on you for a product or service.
Key performance indicator (KPI): A statistical measure of how well an organization is doing in a
particular area. A KPI could measure a company’s financial performance or how it is holding up
against customer requirements.
Leadership: An essential part of a quality improvement effort. Organization leaders must
establish a vision, communicate that vision to those in the organization and provide the tools
and knowledge necessary to accomplish the vision.
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11. Little qi: When professional staff attack problems in programs or service areas by improving
particular processes, it is termed as (Little qi).
Mean: A measure of central tendency; the arithmetic average of all measurements in a data set.
Mission: An organization’s purpose
Objective: A specific statement of a desired short-term condition or achievement; includes
measurable end results to be accomplished by specific teams or individuals within time limits.
Outputs: Products, materials, services or information provided to customers (internal or
external), from a process.
Pareto chart: A graphical tool for ranking causes from most significant to least significant. It is
based on the Pareto principle, which was first defined by Joseph M. Juran in 1950. The principle,
named after 19th century economist Vilfredo Pareto, suggests most effects come from relatively
few causes; that is, 80% of the effects come from 20% of the possible causes. One of the “seven
tools of quality”.
Problem solving: The act of defining a problem; determining the cause of the problem;
identifying, prioritizing and selecting alternatives for a solution; and implementing a solution.
Process improvement: The application of the plan-do-check-act cycle to processes to produce
positive improvement and better meet the needs and expectations of customers.
Process improvement team: A structured group often made up of cross functional members
who work together to improve a process or processes.
Process map: A type of flowchart depicting the steps in a process and identifying responsibility
for each step and key measures.
Quality assurance/quality control (QA/QC): Two terms that have many interpretations because
of the multiple definitions for the words “assurance” and “control.” For example, “assurance”
can mean the act of giving confidence, the state of being certain or the act of making certain;
“control” can mean an evaluation to indicate needed corrective responses, the act of guiding or
the state of a process in which the variability is attributable to a constant system of chance
causes. One definition of quality assurance is: all the planned and systematic activities
implemented within the quality system that can be demonstrated to provide confidence that a
product or service will fulfill requirements for quality. One definition for quality control is: the
operational techniques and activities used to fulfill requirements for quality. Often, however,
“quality assurance” and “quality control” are used interchangeably, referring to the actions
performed to ensure the quality of a product, service or process.
Quality Circle: A small group of employees organized to solve work-related problems; often
voluntarily; usually not chaired by a department manager.
Quality: a customer's perception of the value of a product or service; organizations, theorists,
and dictionaries define it differently. Well-known definitions include: "conformance to
requirements" (Crosby) "the efficient production of the quality that the market expects"
(Deming) "fitness for use"; "product performance and freedom from deficiencies" (Juran) "the
total composite product and service characteristics of marketing, engineering, manufacturing,
and maintenance through which the product and service in use will meet the expectations of
the customer" (Felgenbaum) "anything that can be improved" (Imal) "meeting or exceeding
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12. customer expectations at a cost that represents value to them" (Harrington) "does not impart
loss to society" (Taguchi) "the totality of features and characteristics of a product or service that
bear on its ability to satisfy a given need" (American Society for Quality Control) "degree of
excellence" (Webster's Third New International Dictionary)
Root cause: A factor that caused a nonconformance and should be permanently eliminated
through process improvement; The prime reason(s) why an incident occurred. Root causes are
often related to deficiencies in management systems.
Run chart: A chart showing a line connecting numerous data points collected from a process
running over time.
Scatter diagram: A graphical technique to analyze the relationship between two variables. Two
sets of data are plotted on a graph, with the y-axis being used for the variable to be predicted
and the x-axis being used for the variable to make the prediction. The graph will show possible
relationships (although two variables might appear to be related, they might not be; those who
know most about the variables must make that evaluation). One of the “seven tools of quality”
(see listing).
Seven tools of quality: Tools that help organizations understand their processes to improve
them. The tools are the cause and effect diagram, check sheet, control chart, flowchart,
histogram, Pareto chart and scatter diagram (see individual entries).
Six Sigma: A method that provides organizations tools to improve the capability of their
business processes. This increase in performance and decrease in process variation lead to
defect reduction and improvement in profits, employee morale and quality of products or
services. Six Sigma quality is a term generally used to indicate a process is well controlled (±6 s
from the centerline in a control chart).
Special-Cause Variation: Any violation arising from circumstances that are not a normal part of
the work process
Stakeholder: Any individual, group or organization that will have a significant impact on or will
be significantly impacted by the quality of a specific product or service.
Standard deviation (statistical): A computed measure of variability indicating the spread of the
data set around the mean
Values: The fundamental beliefs that drive organizational behavior and decision making.
Vision: An overarching statement of the way an organization wants to be; an ideal state of being
at a future point.
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13. Vision of quality in the organization:
The phrase ‘Continuous Quality Improvement’ as well as its abbreviated form – CQI have become
common parlance within the Taney County Health Department. Today we can safely say that most
employees have a fairly good idea of what CQI is and how it applies to their various work areas. Little ‘qi’
efforts are almost automatic in some parts of the organization. In fact, some staff members have a
tendency to say “CQI it” when they feel the need to trouble shoot problems within their work areas.
Several work flow process improvements have been initiated and completed without the requirement of
any sort of management intervention. Many of these successes have been presented at the
department’s monthly staff meetings.
However, the big “QI“projects still need support from the CQI Manager. We feel that these system-wide
projects are best conceptualized and executed at the management level with full support of the top
leadership. These larger QI initiatives require the use of some of the more advanced QI concepts and
tools and training towards this end will need to be administered or required.
The Goal of the CQI program is to continuously improve the systematic use of the CQI process with the
process becoming more automatic, more sophisticated, and a routine job responsibility of every staff
member at every level of the organization. The program will also focus on more cycles of the CQI
process in order to facilitate “fine-tuning” of performance and processes. Additionally, the program will
focus on more, larger department-wide systemic Quality Improvement projects that would involve more
of the management team to facilitate organizational improvement.
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14. Quality Improvement Program Structure:
Organization structure, roles and responsibilities
The Taney County Health Department Quality Improvement Manager is responsible for the
development, review and implementation of the CQI program and initiatives for the department with
assistance from the CQI team which consists of the management team and Performance Management
Team. The CQI Team is made up of members of management, staff, and senior leadership. The CQI
Team is then tasked with the implementation of department-wide CQI initiatives or the identification of
program specific projects. Management staff also encourages staff members to identify “qi” projects to
focus on process specific issues. These staff driven “qi” projects are communicated to the CQI Manager
for feedback, further input, technical development, and assistance with the final presentation. The CQI
Manager is also responsible for review of CQI projects, the CQI Program overall, and QI training needs of
management and staff.
Membership
The CQI Team consists of all members of the TCHD Management Team which represents
each division of the organizational chart, including: the director, assistant director, clinical services
division manager, finance and HR division manager, dental division manager, environmental health
supervisor, WIC division manager, community outreach division manager, CQI and IT manager, and
animal control supervisor. Program staff are included in the CQI process through “qi” and “QI” projects
routinely.
Quality improvement Training Process
Quality improvement training is an ongoing process that reflects the philosophy of the TCHD and the CQI
program. Training is incorporated into staff meetings, manager meetings and board meetings routinely.
Each “qi” or “QI” project is reviewed by the CQI manager who provides guidance to the person(s)
involved in the project. This allows for the direct delivery of project specific training to those involved in
the project and helps with the learning process as the CQI project becomes a learning example. Formal
training is also provided to new employees, existing employees, management and the CQI Manager.
Formalized training includes:
1. New employee orientation presentation materials
2. Introductory Presentation for new staff
3. Online courses for all staff through Heartland Centers
4. Advanced training and resources for CQI Team
5. Continuing staff training on QI
6. Other training as needed – position specific training (MCH, Epidemiology, etc.)
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15. Project identification process:
Improvement areas are identified through several methods. The simplest method involves an
intuitive process where employees or managers identify a process, policy, or procedure that is
creating difficulties or is thought to be inefficient. This will result in the initiation of the PDCA
cycle and is likely to result in a “qi” project or may develop into a more involved problem leading
to a “QI” level project. The managers can also initiate a “QI” project after the identification of
an issue through the performance management program (PMP) or the “Pressing Need”
approach. The “Pressing Need” Approach (PNA) is a process whereby a supervisor or manager
identifies priorities in the program area which need to be addressed to further the improvement
of their program or area of responsibility. The most involved process involves system-wide
projects which includes multiple programs or cross-functional team members in the
organization. These projects are long-term and more complicated in their development and
completion. The system-wide “QI” projects are identified by the director, management team, or
Board members through data captured by specific programs, the PMP, identified priorities, or a
possible “crisis” that impacts functioning of the department.
The basis of the TCHD CQI plan is based on the Mission and Vision of the health department to
provide quality and effective programs to members of the community and visitors to the area.
The Mission and Vision are the foundation of the goal of the Strategic Planning process and the
CQI projects are developed to ensure that program delivery is meeting the stated goals and
objectives formulated in the program planning and strategic planning processes. For instance, if
the data collected through the PMP determines that a program area is not functioning at the
appropriately level during anytime during the year, a CQI process is initiated to determine the
reason behind the decreased performance and to implement corrective actions. The CQI
program is therefore, the chosen method which is utilized by management to ensure that the
goals and objectives of the strategic plan are achieved. Additionally, CQI projects may be
expressly identified as a goal within the strategic plan to review and improve a specific function,
program, etc. of the department. This would normally involve a substantial, long-term “QI”
project involving multiple program areas or divisions.
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16. Goals, objectives and measures with time framed targets
The performance measures that the CQI program seeks to achieve includes the following:
i. Ensure that the PDCA cycle is fully recognized and acknowledged in each project
ii. Ensure that the CQI projects become more sophisticated with additional data
elements utilized and more advanced quality improvement concepts and
methodologies implemented
iii. Ensure that additional PDCA cycles are implemented after the initial PDCA
iv. Increase training opportunities for management team and staff
v. Develop and implement quality improvement process
vi. Revise Standard Operating Procedures (SOP) for CQI program at the end of the year
to include new standards and methods developed.
Responsibilities
The CQI manager is responsible for evaluating the CQI program and ensuring that the objectives of the
CQI program are being met through assistance by the TCHD management team. As CQI is a component
of the TCHD culture, the philosophy has always been that management and senior leadership
involvement is crucial to the overall success of the program. Employees will be provided guidance by the
management team, supervisors and CQI manager on specific projects. Training will be provided at staff
meetings periodically through formal training and presentation of ongoing CQI projects.
Time frames associated with CQI Objectives
The following timeline will be managed by the CQI program manager. These timelines will be the basis
for evaluation of the CQI program as well.
Objective Timeframe
Ensure that the PDCA cycle is fully recognized and acknowledged in each Quarterly
project
Ensure that CQI projects become more sophisticated and more advanced QI Annually
concepts and methodologies implemented
Ensure that additional PDCA cycles are implemented after the initial PDCA Conclusion of
each project
Increase training opportunities for management team and staff Quarterly
Develop and implement quality improvement process Annually
Revise Standard Operating Procedures (SOP) for CQI program at the end of the Annually
year to include new standards and methods
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17. Quality Assurance and Monitoring QI Plan
TCHD’s CQI Program is integrated into the Department’s Performance Management Program (PMP)
and Strategic Plan. The Performance Management Program has been designed to showcase critical
program related quantitative data on a monthly basis. During the development phase of the PMP,
managers identified data elements that represented the goals and objectives in programmatic
areas. For example, the number of clients seen on any particular day could be construed as the
most important performance related program data for the WIC, Immunization and Dental programs.
These numbers are provided to the PMP coordinator to be entered into the PMP system which
automatically updates associated Dashboard charts and graphs for review by management and the
board monthly. The PMP Dashboard evaluation range identifies “poor”, “moderate” and “optimal”
performance. The represented “dashboard” of “speedometers” provides a quick visual method of
identifying performance within any division. If performance is shown to be suboptimal, CQI cycles
are initiated and executed until performance once again falls within the optimal range. An optimal
value is one that falls between 85% and 100% of the established range for that data element.
Based on the PMP process, the CQI program and initiatives are monitored through the effects that
CQI initiatives have on the overall performance management numbers. The more programs the
department has running optimally, the fewer CQI projects are triggered under this mechanism. As
CQI initiatives are implemented and completed, they are tracked utilizing the CQI monitoring tool.
The CQI monitoring tool allows the collection and analysis of data from each CQI project: whether a
standardized process has been achieved; how many cycles have been completed or if benchmarks
have been achieved to become a Standard Operating Procedure (SOP); what PDCA phase the project
is in; the percentage of project complete; and timeframe for next CQI report. Stated goals and
objectives within each CQI project are utilized to determine the percentage of project completion.
By utilizing this method the CQI Manager is able to quickly monitor progress of each CQI project that
is in progress and what has been achieved.
Because of the continued development of the TCHD CQI Program, additional components and
improvements to the CQI Performance Management Plan are being implemented. Currently, the
management team is in the process of becoming more familiar with the fundamental aspects of the
PMP and CQI system using quantitative data. The implication is that the department is moving
toward a point where quantitative data will be increasingly utilized to measure and reflect program
effectiveness. Challenges still exist when it comes to designing apt data collection mechanisms for
TCHD programs that do not lend themselves as well to quantification. For instance, “How do you
measure communications for the Public Information Division?” is one example among several for
the department. These kinds of problems are where the second CQI mechanism is triggered.
For these more ambiguous problems, the CQI philosophy is drawn upon extensively to help program
managers delve into the most important component of TCHD programs. Once this has been clearly
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18. identified, managers are challenged to design a data collection methodology that can be used within
the Performance Management Program.
Monitoring of the effectiveness and efficiency of the CQI program itself is achieved through a
Quality Assurance (QA) program that takes into account the goals and objectives of the CQI
Program, as well as the timeframes identified.
# Objective Timeframe
1 Ensure that the PDCA cycle is fully recognized and acknowledged in each project Quarterly
2 Ensure that CQI projects become more sophisticated and more advanced QI Annually
concepts and methodologies implemented
3 Ensure that additional PDCA cycles are implemented after the initial PDCA Conclusion of
each project
4 Increase training opportunities for management team and staff Quarterly
5 Develop and implement quality improvement processes Annually
6 Revise Standard Operating Procedures (SOP) for CQI program at the end of the year Annually
to include new standards and methods
The following QA processes will be utilized to monitor the associated Objectives:
# Quality Assurance Tool Utilized By Objective
1 Each project is monitored utilizing the PDCA Checklist (Appendix A). Quarterly the CQI Manager
reviews the completion rate of the PDCA cycle to ensure that each project has fully utilized the
PDCA Cycle to include the necessary PDCA elements. This is represented by the CQI Monitoring tool
percentage complete data element.
2 Annually, the CQI program manager will review the current ongoing and completed CQI initiatives
for opportunities to apply more advanced CQI concepts. This report will be forwarded to the
management team with recommendations for implementation. Once approved, the CQI manager
will provide additional training for the management team and staff on additional CQI
methodologies. The goal will be to increase awareness regarding more complex CQI methods and
to use these methods when appropriate. However, the implementation or utilization of more
complex CQI strategies and concepts on projects will continue to be dependent on the needs of
individual projects.
3 The CQI monitoring tool will be used to track the progress of each project. After the project is
complete a determination will be used as to whether additional CQI cycles are necessary to improve
processes further. The goal will be to ensure that additional cycles are implemented until an optimal
Standard Operating Procedure is identified and monitoring is established to ensure optimal
performance is maintained.
4 Training will be provided to the management team, staff and board members on a regular basis. For
quality assurance purposes, the CQI Manager will work to provide one training each quarter with
documentation on the training and outcomes. An annual report will be submitted to the
management team.
5 The benchmark standards established by PHAB and the Public Health Foundation will be utilized to
measure and critique the CQI Program. A quality improvement review will be implemented annually
to identify areas of improvement within the CQI Program and Projects. This QI review will be based
on the Quality Assurance data, training program outcomes, CQI Monitoring tool, or other identified
priorities by the CQI Manager in coordination with the Management team and Board. These QI
Processes will also be in alignment with the TCHD strategic plan and priorities.
6 After completion of the annual reports and QI processes, the CQI Manager will submit
recommendations and revisions to the management team for the Continuous Quality Improvement
Plan SOPs to include new standards, concepts, and methodologies.
18
19. CQI Program Evaluation Process
The CQI annual report will focus on reporting the accomplishments of the CQI Program, the completed
projects for the year, the lessons learned, training provided, new processes implemented and activities
which may need to be implemented during the coming year. The process to assess the effectiveness of
the quality improvement plan and activities may include:
1. Review of the process and the progress toward achieving goals and objectives
2. Efficiencies and effectiveness obtained and lessons learned
3. Customer/stakeholder satisfaction with services and programs
4. Description of how reports on progress were used to revise and update the quality
improvement plan
Communication of quality improvement activities
Communication of quality improvement activities in the Taney County Health Department will be
completed through presentations provided during monthly staff meetings, management team meetings,
and board meetings. In depth CQI Training is conducted on various topics. However, during each staff
meeting, CQI presentations from various programs focusing on accomplishments and lessons learned
are provided. During staff meetings and board meetings, CQI projects that address administrative or
substantial programmatic outcomes are presented. These presentations allow management and board
members to discuss CQI initiatives, ask questions, and learn from the CQI presentations and projects.
19
20. References:
i
Casey Family Programs and National Child Welfare Resource Center for Organizational Improvement. “Using
Continuous Quality Improvement to Improve Child Welfare Practice – A Framework for Implementation.” [Online]
14 August, 2007 http://muskie.usm.maine.edu/helpkids/rcpdfs/CQIFramework.pdf
ii
Ibid
iii
Center to Advance Palliative Care. “Continuous Quality Improvement” [Online] 14 August, 2007
<http://64.85.16.230/educate/content/development/cqi.html>
iv
Salman, Ghassan F. “Continuous Quality Improvement in Rural Health Clinics.” [Online] 14 August, 2007 <
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1490210>
v
Crawford, Shirley and Colangelo, Michael. “Methods in Implementing an Effective CQI Program in a Social
Services Setting.” [Online] 11 December, 2007
<http://www.cwla.org/programs/trieschman/2003toolsfiles/2003toolswkshopD2slides.ppt>
vi
Melum, Mara Minerva. “How to Make CQI Work For You – Continuous Quality Improvement of Healthcare.”
[Online] 7 December, 2007 < http://findarticles.com/p/articles/mi_m0843/is_n6_v17/ai_11647230>
vii
Slavin, Lee and Bennett, Leo. “Continuous Quality Improvement: What Every Healthcare Manager Needs to
Know” [Online] 15 September, 2007 < http://www.case.edu/med/epidbio/mphp439/CQI.htm>
viii
(Quality Improvement Course, 2007)
ix
Ibid
20
