The Kane County Health Department (KCHD) strives to improve the culture of quality with its staff and partnerships in the community. One method of improving competencies and skills is through online training modules on the various quality improvement (QI) tools that the agency uses to improve the work it does. The project that occurred was a Plan-Do-Check-Act (PDCA) project on improving the percentage of staff that had completed six required training modules as outlined in KCHD's Quality Improvement and Performance Management Plan. The project involved the assessment of staff on their knowledge in QI and the barriers to completing the modules, using staff input to determine root causes and implementation strategies, and using the Quality Improvement Committee as staff representing their programs to help determine the strongest strategy to choose for improvement. The project led to the increase in the percentage of staff that had completed the six required modules.
Throughout the PDCA process in identifying the current flow, staff input and engagement, and various other means, the information received led to various opportunities outside of the PDCA itself. Some of these initiatives were an all-staff training on PDCA's using a paper airplane activity, games that were directly tied to understanding QI and the KCHD Quality Improvement and Performance Management Plan, the creation of an internal resource library for those who wanted to learn more outside of the training modules, the use of QI tools outside of the health department's walls with various partners and coalitions, and also a national video in partnership with the Public Health Quality Improvement Exchange (PHQIX) and Kansas State University. The work was also highlighted in a local news site Kane County Connects and the PDCA was published on PHQIX as well. The initiative from the work that came directly from the PDCA and the various projects from "lessons learned" in the PDCA process helped improve the quality improvement culture in Kane County, as well as help educate other agencies in the nation through the national video.
Kane County Health Department
Assessing and Improving Agency-Wide Quality Improvement Training
The Kane County Health Department is an accredited health department that serves a population of over 525,000 residents. It has a main office located in Aurora and Elgin and has a total of 64 staff. Because the health department has only 64 staff serving a large population, the health department has strived to build a culture of quality and to use QI tools to do less with more and better with what resources are available. To do so the health department had created quality improvement training modules on 13 various QI tools and identified 6 required modules as outlined in the KCHD Quality Improvement and Performance Management Plan. Staff progress in completion of the modules are tracked in an internal database, in their performance management system, and to be considered complete one must go through the module and complete and accompanying handout.
In March of 2014 only 61.7% of staff had completed the six required modules and from January 2014 to March 2014 the rate had not increased and remained stagnant. To attempt to increase the percentage of staff that had completed the modules, the agency implemented a Plan-Do-Check-Act (PDCA) project. The community Health Resources (CHR) section, who oversees Quality Improvement, was involved in the process. The 9 members of the Quality Improvement Committee represent the various sections within the organization, so they also were involved in the process. By analyzing the baseline and creating the team, the group determined an Aim Statement: By September 19, 2014, the percentage of staff that have completed all 6 of the required quality improvement training modules will increase from 61.7% to 85%.
The Community Health Resources section tracks the trainings or training modules that staff have completed in a database, but because it has personal names and completion tracking it cannot be shared on the organization’s shared drive. Training modules are available on the shared drive that staff can access at their convenience. There is also no process flow for how staff is notified by managers in regards to completion of trainings within identified timelines.
On 5/20/14 the KCHD staff was surveyed on whether they knew how many training modules they have completed, if they knew where to find the modules, whether there was accountability of completion, and various staff barriers in completing the modules. Using the 5/20 survey as a guide, the QI Committee conducted a Cause and Effect Diagram on 6/4 to analyze potential root causes to completing the modules. The CHR Group then added to the Cause and Effect Diagram during their PDCA meeting on 6/18.
From the analysis of the surveys and Cause and Effect Diagram, the QI Committee then brainstormed potential solutions and created an Affinity Diagram on 7/16/14. The diagram was then analyzed by the CHR section for additional comments. From those potential solutions, the QI Committee and CHR were surveyed on 7/23 to vote on the best possible solution, with their vote representing their respective section.From the Cause and Effect Diagram and survey results, the strategy was determine to build a notification process using the Health Data and Quality Coordinator (HDQC) at the health department. This solution involved personalized emails that listed why they should go through the training, what module(s) they had to complete, and direct links to access the training. The notification was sent out of 08/09 with the deadline to complete the modules by 09/19 (6 weeks).
A personalized email reminder was sent to each staff member that had not completed the six required trainings, which indicated which trainings that needed to be complete and a hyperlink to the location of the trainings. Just by sending the notification there was a large fluctuation of handouts that came in within days of notice. One outcome was that time was a frequently listed barrier, yet compliance increased 10% in the first day or two after notification.
By 9/19/14, the total percentage of staff that had completed the required 6 training modules rose from 61.7% to 83%. Numerous other projects came out from lessons learned throughout the PDCA process, such as an all-staff training, games, a national video, a QI resource library, and the use of QI outside of KCHD's walls with partners. Some staff had completed modules outside of the required 6 that they still needed to completed, which is an added success that wasn’t the direct goal of the project. While not reaching the desired goal by the date of 9/19, the project was still deemed a success. A few weeks after, staff kept completing the modules and the rate rose to over 90%.
The website for the health department is www.kanehealth.com
The innovation for this initiative not only was in the PDCA project itself, but what came out of the results of the process and the actions that took place from the lessons learned. Back in 2009, the health department went through a transition where the number of staff was cut in half and quality improvement was the mechanisms to continue the high level of services and ensure the needs of the community were met. To do so, all levels of staff had to be proficient in the use of QI and QI tools. Back in 2009, QI trainings began occurring through All-Hands (all-staff) meetings. Sections would break apart during these meetings and try out a QI tool on an existing process relative to their program and would report back to the larger group.
As the QI culture grew and the yearly Quality Improvement and Performance Management Plan was created and evolved, training modules were created through SlideRocket as a method in which staff could learn more about a QI tool in their own time and also have a refresher when needed. By having handouts after completion of each module, the Health Data and Quality Coordinator (HDQC) could review the content to ensure the staff was proficient in their understanding of the tool. The completion of tools began being tracked in a training log and as a performance measure, and six tools were identified as being required in the plan. Those tools were QI 101 (which included PDCA), Aim Statements, Cause and Effect Diagrams, Data Collection and Analysis, Flowcharts, and SWOT Analysis. An in-person QI 101 training also occurs for new staff and the completion of the six modules is also built into KCHD’s Workforce Development Plan. In the Quality Improvement and Performance Management Plan each section is required to complete a PDCA each year.
Compliance in the trainings began to stagnate and from January to March of 2014 remained at 61.7%. Throughout the PDCA process and the implementation of the hyperlinked message the rate inevitably rose to over 90% after the PDCA cycle, but the lessons learned through the voice of staff and the QI committee led to the innovative approaches to enhance the QI culture and reach those outside of the health department.
When surveying staff they indicated they weren’t as comfortable in the PDCA process when compared to other tools and the PDCA process seemed complicated. To address this the Assistant Director for Community Health Resources, in conjunction with the KCHD Leadership Team, conducted an All-Hands meeting in which the PDCA process was replicated but by using paper airplanes. Leadership was trained in depth prior to the meeting so they felt proficient to educate staff. In September at the All Hands meeting, the Assistant Director for Community Health Resources conducted a presentation on what a PDCA is. He then had worksheets for each staff that mirrored the creation of a paper airplane to each step of the PDCA. Staff created a paper airplane to what they thought would work well (current process), threw the paper airplane to create a baseline, then would look at potential root causes, make on change, test the change, determine whether to adapt/adopt/abandon, and would track their data through the process. Small airplane toys were given to those who threw the farthest and to those who had the largest improvement.
From the staff survey it was also determined that some staff had different learning styles. Some like hands on activities, some like modules, and some like videos or other ways to learn more about a QI tool. Based on this information a QI resource library was created using Excel which had tabs for each tool and had links to YouTube videos, games, handouts, papers, websites, and other resources that were found. This gave staff another mechanism to learn more about QI and to also address the various learning styles.
Throughout the survey and conversations with the QI Committee, it was determined that some staff may not know about the Quality Improvement and Performance Management Plan and how they fit into the plan. For this reason, games were created when the new QI Plan was revised and if a staff member participated in the game they had a chance to receive a ten dollar gift card. Over the course of a month there was a game each week. The four games were a crossword that directly tied the answers to important sections within the QI plan, a fill in the blank on QI Committee and staff roles, and PHQIX internet scavenger hunt, and a QI word search. While the intention was to be fun and optional, one of the games had an 85% participation rate in the agency. These were a fun way to get staff engaged and more knowledgeable about QI and the QI Plan. It was also reinforced via email that many of the initiatives conducted in QI and the versions of the Quality Improvement and Performance Management Plan can be found easily on the KCHD webpage, which has its own QI page.
By using a wide variety of innovated mechanisms the PDCA project and the projects afterwards were successful. While a tremendous amount of work was done internally, the true goal is to use QI to help improve the work in the community to improve health and to help educate others outside of Kane County to use QI to improve the work in public health. The health department started using QI tools regularly with partners. After a large conference, an emergency, or a drill, SWOT analyses started becoming common practice with partners to improve in case an event were to happen again. Brainstorming and Affinity Diagrams were used to help determine strategies on actions with the health department and partners, partners and initiatives started using the PDCA cycle around areas such as tobacco and diabetes, taking evaluations to drive improvement plans became standard practice, and numerous other activities to ensure accountability and to grow as a public health system from lessons learned.
An exciting route that the work took was the national attention it received. In late 2014 the health department was approached by Kansas State University around how the health department does communications and how they use QI. They looked to identify five or six innovators across the county and the Kane County Health Department was chosen as one of the site visits. Faculty and staff came to the health department office in which the work being done around QI was presented to them. Staff recorded the presentations and went back to the university to present to their fellow staff and faculty. The project and work done had led to educating staff and Kansas State students on the benefits of quality improvement and how it is being used in the positive way.
As part of the QI Plan, when a PDCA project is successful it is recommended to be posted on KCHD’s website and also submitted to the PHQIX. The project was submitted and was published, and for the few months after the health department was contacted from various public health agencies to learn more about how they could implement KCHD’s strategies into their organization. The health department was then approached by PHQIX to do a video on QI and the PDCA project. The agency spent two days at the health department office to conduct videos and learn about the work being done, and created a seven minute video that was on the front page of the PHQIX website for a few months. The video helped educate and hopefully motivate those doing similar work. The video was also presented to various groups such as KCHD’s Health Advisory Committee and is a great tool to educate on the importance of the work being done.
By using the PDCA process, quality improvement tools, and innovative approaches the health department was able to create unique opportunities to enhance the work being done in the agency and the partners who serve Kane County residents. By using staff and the QI Committee as the voice of the customer, those who oversee QI at the agency had a better understanding to the needs of the staff and the gaps to address. By communicating and being transparent about the work being done, the health department was able to be recognized through PHQIX and through Kansas State University.
The original goal of the PDCA was to increase the percentage of staff that had completed the six required QI training modules per the Quality Improvement and Performance Management Plan. The Aim Statement was as follows: By September 19, 2014, the percentage of staff that have completed all 6 of the required quality improvement training modules will increase from 61.7% to 85%.
To achieve the goals and objectives there were numerous steps involved. The initiative got the voice of the customer, in this case being internal staff, by initially surveying them on their QI needs and the training modules themselves. That information, along with the input of the QI Committee representing the various sections at the health department, helped determined the root causes to why the percentage of those who had completed the six modules wasn’t increasing. When it came to the best solution the root causes were reviewed and the QI Committee using the knowledge from the survey and their individual section’s input brainstormed solutions, in which an affinity diagram was created, and the solutions were then voted on. The solution that was chosen was the hyperlinked message because it addressed the barriers and issues that came from the voice of the customer and root cause analysis.
The message came in a personalized email reminder was sent to each staff member that had not completed the six required trainings, which indicated which trainings that needed to be complete and a hyperlink to the location of the trainings. Just by sending the notification there was a large fluctuation of handouts that came in within days of notice. One outcome was that time was a frequently listed barrier, yet compliance increased 10% in the first day or two after notification.
By 9/19/14, the total percentage of staff that had completed the required 6 training modules rose from 61.7% to 83%. Numerous other projects came out from lessons learned throughout the PDCA process, such as an all-staff training, games, a national video, a QI resource library, recognition by Kansas State University for a site visit, and the use of QI outside of KCHD's walls with partners. Some staff had completed modules outside of the required 6 that they still needed to completed, which is an added success that wasn’t the direct goal of the project. While not reaching the desired goal by the date of 9/19, the project was still deemed a success. A few weeks after, staff kept completing the modules and the rate rose to over 90%.
With the PDCA process at the health department there is a specific application form and project selection matrix to pick out a project. The criteria for the application form asks specific questions such as the description of the problem, priority level, how does it align with a strategic initiative or support the mission and vision, impact it could have on services, a brief goal statement, who are the stakeholders, short/medium/long term goals, who should be involved, and other various questions. The project selection matrix is a way to determine the best project to choose. Three potential projects are put on the matrix and questions are asks to determine the priority project such as if it has an existing process, has existing data or data could be easily collected, is connected to a strategic initiative or program or grant requirement, is on a manageable scale, has resources available, has ownership and control, has staff interest, and other questions that help prioritize if the project is the best fit. These forms are then submitted to the QI Committee who review and make comments, and if the project is accepted by the committee it is signed and approved for implementation.
The timeframe for the project itself took place from May 7, 2014 through September 19, 2014. The implementation phase itself of the hyperlinked message took place from August 19 to September 19. One key factor with the project is that all health department staff had some level of input and engagement in both the strategy for implementation and the success of the project. The Quality Improvement Committee had a large amount of input because they represented their programs and sections and provided their section’s input in the process itself. The lessons around quality improvement and how it could be used effectively is now being conducted with various stakeholders in the community to improve the work Kane County Health Department does with its partners. PDCA projects are done around tobacco and diabetes initiatives with partners, SWOT analysis and other tools are used in emergency preparedness activities around drills and exercises, numerous quality improvement tools are being used in the Community Health Improvement Plan planning and implementation process, and numerous other examples of how the tools are used to poster collaboration with community stakeholder.
Another added benefit of the project is that there wasn’t a high cost associate with the work itself. SlideRocket and SurveyMonkey have been existing tools that the health department has already used and SlideRocket is part of an existing budget item. The largest cost was just the commitment of staff hours to take the survey or the modules themselves, with the hope that the increased understanding will lead to an increased use of tools in the future, which will hopefully help streamline some of their work which will save time and inevitably save money. With the QI games and activities the health department had bought a few 10 dollar gift cards and some toy airplanes to make learning about quality improvement more fun. The health department used one of their volunteers to help build the QI resource library and send out the original hyperlinked message so there was no cost associate with those activities.
The objective was that by September 19, 2014, the percentage of staff that have completed all 6 of the required quality improvement training modules will increase from 61.7% to 85%. By September 19th the percentage was at 83%, but rose to over 90% shortly after the implementation phase had ended.
There are various ways in which data was collected before, during, and after the process. Each staff is tracked in the number of trainings modules they have completed through a QI training module database. This includes every possible module not just the six required ones. The six required modules are tracked in the QI training module log, as a performance measure in the Kane County Health Department Performance Management System (tracked monthly), and in the Kane County Health Department Workforce Development Plan.
When staff were surveyed throughout the project data was collected and analyzed via SurveyMonkey. This data was used in determining the needs and barriers of the customer, in this case being health department staff. Throughout the entire project the data was collected and analyzed in the QI training module database to identify trends or increases in percentages during the implementation phase. As a result of the findings at the end of the project, the health department has now implemented a hyperlinked message as part of its normal process. The percentage of completion is still being tracked in the module database, the Performance Management System, and the Workforce Development Plan, and there is also a performance measure for the percentage of staff that have completed every training module available at the health department. Results are reviewed regularly by the Health Data and Quality Coordinator and the Assistant Director for Community Health Resources to prioritize particular tools where an in-person training or different training method may be most beneficial, or whether a quality improvement tool needs to be implemented to analyze the particular performance measure around QI training compliance.
There were many lessons learned throughout the PDCA that led to various alterations in the processes that exist at the health department, as well as new initiatives and projects. The largest lessons learned in the PDCA itself with the training modules is that there was some confusion to where the training modules were located and the issue of time to do them, and by streamlining the process through a hyperlinked email it led to success in raising the percentage of staff completing the QI training modules themselves. The simple task of making the process easier for the staff helped create a success strategy in the implementation of the initiative.
Throughout surveying staff and work with the QI Committee, many lessons were learned. The idea that not all people learn the same way helped lead to the QI resource library, the four QI games that were created, and evaluating how training occurs at Kane County Health Department. The notion that not everyone is as comfortable in PDCAs as was once thought is what led to the PDCA paper airplane activity at the all-staff meeting at the agency, which also helped address the challenge of dealing with different learning styles as well.
The success of the project helped increase how the agency works with its partners and how the lessons learned could help others outside of Kane County. QI tools have become standard practice in many activities and initiatives with partners in how we can all work together towards a common goal and improve upon an existing process or partnership. Presenting to Kansas State University and creating a video through the Public Health Quality Improvement Exchange is a way that Kane County Health Department can share its success to build a stronger public health system and hopefully motivate others in similar fields to adopt some of the successful practices that had occurred.
Although a cost-benefit analysis was not done during the PDCA project the use of quality improvement and how in improves a practice has many potential for cost-benefit analyses in the future. By using existing tools in place such as SlideRocket, SurveyMonkey, the existing QI database, and staff input, cost was limited to implement the project itself. Having the training requirements built into job descriptions, the QI Plan, the Workforce Development plan, the Performance Management System, and other mechanisms can help ensure the sustainability of the work being done.
Throughout this process and work around QI the health department has had a large stakeholder commitment to the practice and the work being done. Many of the initiatives have been discuss with the health department’s governing entity, partners, and the community. The video created was highlighted at a Health Advisory Committee meeting and is now part of new staff orientation. Previous initiatives around tobacco, which had received a model practice in 2014, have built a funding mechanism where agencies can apply to conduct a PDCA in conjunction with the health department. The use of QI tools are tracked in a monthly log with the various programs at the health department, and include the work being done with partners. By building a strong framework for success, sustainability and buy in should be able to be maintained well into the future.
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