Three River Thriller - Using Zombies to Teach QI

State: KY Type: Model Practice Year: 2014

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The TRDHD Quality Improvement Team is tasked with continuously monitoring quality improvement projects, as well as teaching new quality improvement techniques. As a local public health department, the overarching issue remains to provide the Ten Essential Public Health services to meets our communities' needs in the most effective and efficient way possible. The TRDHD QI Team planned an all-staff meeting to provide an opportunity to learn a new QI tool, the prioritization matrix. 

The primary goal was for staff to experience the utilization of a new quality improvement tool, the prioritization matrix. Three objectives were identified:

  1. To introduce the prioritization tool that can be utilized in public health practice
  2. To empower staff to be able to independently utilize the prioritization matrix in their respective quality improvement projects
  3. To maintain and foster a continuous quality improvement culture. 
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Three Rivers District Health Department
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Three River Thriller - Using Zombies to Teach QI
Three Rivers District Health Department, located in rural north central Kentucky, serves Carroll, Gallatin, Owen and Pendleton counties. TRDHD has five worksites - a health center in each of the four counties, as well as an additional administrative office. The TRDHD service area is approximately one hour from Louisville, Lexington, and Cincinnati.  The TRDHD Quality Improvement Team is tasked with continuously monitoring quality improvement projects, as well as teaching new quality improvement techniques. As a local public health department, the overarching issue remains to provide the Ten Essential Public Health services to meets our communities' needs in the most effective and efficient way possible. The TRDHD QI Team planned an all-staff meeting to provide an opportunity to learn a new QI tool, the prioritization matrix.  The primary goal was for staff to experience the utilization of a new quality improvement tool, the prioritization matrix. Three objectives were identified: To introduce the prioritization tool that can be utilized in public health practice To empower staff to be able to independently utilize the prioritization matrix in their respective quality improvement projects To maintain and foster a continuous quality improvement culture.  After planning the logistical requirements of an all-day staff meting, the QI Team worked to plan an engaging activity that staff would find entertaining and educating. The team created an impromptu zombie apocalypse to surprise staff, and support the creation of a prioritization matrix that would ultimately choose a weapon to ward off the impending zombies.  The team planned the meeting for three months (May, June and July 2013), by meeting regularly and communicating about the plans. The actual staff meeting was held on July 24, 2013. The staff reported very positive feedback in regards to understanding the prioritization matrix and how to use its criteria to make decisions related to their jobs.  The goal and its objectives have been evaluated and considered met. Several factors led to the success of the project. Since it's inception, the TRDHD QI Team has continuously strived to empower the staff in regards to learning and using QI tools. The team has had competitions specific to QI, presented various skits, and creative presentations to engage staff at all levels in various aspects of quality improvement. Second, TRDHD has strong leadership supported by the District Director, Dr. Georgia Heise. Dr. Heise has also worked to educate the Board of Health about the role of quality improvement in the public health infrastructure. Through an engaged QI team supporting continuous quality improvement with the staff and leadership commitment, a strong quality improvement culture has been established and maintained.  By understanding quality improvement tools such as the prioritization matrix, the staff of TRDHD have the ability to make sound decisions that could affect the delivery of public health services and programs. Ultimately, the utilization of quality improvement tools in public health impacts our communities' health outcomes. 
Three Rivers District Health Department, located in rural north central Kentucky, serves Carroll, Gallatin, Owen and Pendleton counties. TRDHD has five worksites - a health center in each of the four counties, as well as an additional administrative office. The TRDHD service area is approximately one hour from Louisville, Lexington, and Cincinnati. The population served is approximately 48,000. "All One Team, Striving for Excellence, Educating and Empowering with Every Encounter" is the vision statement that drives the operations of our health department. Three Rivers was one of nine local health departments in the first cohort to receive national accreditation from the Public Health Accreditation Board. Generally speaking, the problem coincides with the "this is the way we've always done it," mentality. In the past, prior to quality improvement training, staff have not felt empowered or educated in making recommendations, voicing concerns, or utilizing data to make decisions. By implementing quality improvement trainings, and supporting quality improvement projects, the culture at TRDHD has shifted to be proactive and progressive. TRDHD has 70 full-time and contract staff that participate in agency operations, which represent the target population size. During the staff meeting and zombie apocalypse, 85% of the target audience was reached. Several staff had requested off due to planned vacations or unexpected absences. The entire training was recorded so that staff that had missed the in-person meeting could review the content. At TRDHD, each member of the management team has received training that would be the equivalent to a three hour undergraduate course in quality improvement. Furthermore, all staff continue to receive quality improvement training and time to work on projects related to quality improvement. TRDHD has an active Quality Improvement Team, with representation from each department, as well as the District Director, which meets monthly. In the past, trainings that the QI team plans for all staff to participate in have involved parody songs, fun competitions, and problem solving activities. During the July 2013 all day meeting, the staff had a lunch break. Meanwhile, the TRDHD QI team went to a private area and dressed as zombies. Make-up, fake blood, and ripped clothes attributed to the costumes. Staff were directed back to the training room, and the QI team slowly emerged as zombies, much to the surprise of the staff. The zombies, including Dr. Heise, stayed in character to introduce the prioritization matrix. All staff were engaged and excited about the activity! By capitalizing on the recent popularity of zombies, TRDHD incorporated an innovative way to demonstrate a quality improvement tool. The prioritization matrix was presented to the staff as a method to make decisions. For this example, the staff worked through the tool by creating criteria and weighted scores to determine what tool a human would need to ward off a zombie. Hypothetical weapons considered were shotguns, crossbows, pistols and machetes. The staff narrowed down the options by scoring criteria achieving consensus on the best weapon. Quality improvement in public health practice has evolved tremendously over the past several years. With the formation of the Public Health Accreditation Board and its Standards and Measures, health departments must demonstrate their ability to produce a quality improvement plan and implementation of the plan. The Standards and Measures, specifically Domain 9 which focuses on continuous quality improvement, was one tool used to assist in the development of TRDHD's QI Plan and trainings. Quality improvement tools, such as the prioritization matrix, are widely recognized as proven methods to accurately evaluate, analyze and improve public health processes. The Centers for Disease Control, NACCHO and the Public Health Foundation have all published data and evidence-based articles that encourage the use of quality improvement in public health.Specifically, the Public Health Foundation has recently published the Public Health Quality Improvement Encyclopedia which highlights the prioritization matrix tool. TRDHD adapted the tool, which systematically compares choices by selecting and weighting criteria, to the zombie apocalypse. The District Director, Dr. Georgia Heise, and the QI Team, lead the staff to contrast a prioritization matrix related to killing a zombie. Then, staff worked on a prioritization matrix that could accompany an on-going quality improvement project in their respective department.
The primary goal was for staff to experience the utilization of a new quality improvement tool, the prioritization matrix. Three objectives were identified: a) to introduce the prioritization tool that can be utilized in public health practice, b) to empower staff to be able to independently utilize the prioritization matrix in their respective quality improvement projects, and c) to maintain and foster a continuous quality improvement culture.  The Quality Improvement Team worked to create the agenda for the staff meeting, which included the zombie apocalypse training. The QI Team met three times leading up to the staff meeting, to become comfortable with the matrix and plan the subsequent activity with their own departments: leading their peers through a prioritization matrix directly related to their work. The planning of the staff meeting began in May 2013 and concluding on July 24, 2013, the day of the staff meeting. A survey was distributed to all staff immediately following the meeting to evaluate the effectiveness of the training. The QI Team met to debrief several weeks after the meeting and review data from the survey. It is very difficult to specify a cost associated to quality improvement at TRDHD, as it is incorporated in each employee's day-to-day work. The primary cost associated with the training was attributed to staff time. The training specific to the prioritization matrix lasted two hours. An approximate cost related to staff time, including fringe benefits, is estimated to be $4,000.
Immediately following the staff meeting, a SurveyMonkey link was distributed to staff to collect data regarding the training. The link was distributed in a weekly email that is sent from the District Director, Dr. Georgia Heise. Dr. Heise sends the Management Team meeting minutes, which include topics such as quality improvement. The overwhelming response was extremely positive and many staff commented about the excitement about quality improvement. For the question "My knowledge of quality improvement processes and tools," 55% of staff responded "very beneficial," and 34% of staff reported it to be "somewhat beneficial." For the question "Having time to work through a quality improvement process was," 67% of staff responded "very beneficial,: and 30% of staff reported "somewhat beneficial." The Quality Improvement Coordinator compiled the data and presented the results to the TRDHD QI Team, as well as the TRDHD management team. The primary goal was for staff to experience the utilization of a new quality improvement tool, the prioritization matrix. Three objectives were identified: To introduce the prioritization tool that can be utilized in public health practice, To empower staff to be able to independently utilize the prioritization matrix in their respective quality improvement projects, and To maintain and foster a continuous quality improvement culture.  Upon evaluation, objectives A and B were met according to primary data. Objective C is long-term and will be continuously monitored through staff feedback and future trainings. It was very clear that staff felt very positive about the training, with comments in the survey such as "I enjoyed the zombie apocolypse as a way to introduce a new quality improvement tool!," and "the best part was having a fun activity to give an example of how to do it in the real world. Best staff meeting ever!" While outcome evaluation is continuous, the immediate outcome measured was the utilization by staff of the prioritization matrix in QI projects, was has increased. An intermediate outcome is the participation of employees in continuous QI projects demonstrated by ongoing and completed projects that are reported monthly at team meetings and quarterly staff meetings. The anticipated long-term evaluation result will be a high-functioning culture of quality improvement that utilizes proven tools such as the prioritization matrix. Based on the feedback in the survey, the Quality Improvement Team realizes the importance of maintaining the excitement regarding quality improvement. The zombie apocalypse activity reinforced that when learning is fun, it leaves a lasting positive impression with the staff.
Continuing to provide QI trainings in an exciting way was the biggest lesson learned through the zombie apocalypse and prioritization matrix training. After evaluating the results of the survey, the QI team was surprised by the amount of positive feedback from the staff. Spending time as an agency, specifically focused on quality improvement and on-going training, reinforces TRDHD's vision "All One Team, Striving for Excellence, Educating and Empowering with Every Encounter." The zombie apocalypse training built upon our existing quality improvement culture and motivated the QI Team to provide more trainings to our staff. There was not a cost benefit analysis completed related to the training; cost benefits are calculated in completed quality improvement projects. In terms of sustainability, our staff have utilized the prioritization matrix in a number of successful projects. One example of this is the employees who work in the TRDHD HANDS (Health Access Nurturing Development Services) home visiting program utilized the prioritization matrix to determine items most needed for environmental safety in homes. Upon completing the matrix tool, the HANDS staff partnered with the TRDHD Environmental Health staff, as well as the Kentucky Department for Public Health to secure grant funding through HUD to provide those families in need. To further demonstrate sustainability within TRDHD, the following examples showcase commitment to quality improvement: a) TRDHD's Home Health Agency recently received the HHCAHPS Honors Award as a result of a QI project aimed at reduced re-hospitaliziation rates, b) TRDHD's Clinic team implemented same day scheduling as a result of a QI project which brought no-show rates from 30% to less than 1%, and c) a new policy and training for employee safety including the use of pepper spray. TRDHD will continue to hold quarterly all day staff meetings with at minimum half a day devoted to quality improvement projects and trainings. Furthermore, TRDHD provides technical assistance to several Kentucky local health departments by training staff on quality improvement. The zombie apocalypse training has been replicated at one additional health department as a means to teach the prioritization matrix and was well received.
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