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Infant Mortality CoIIN Technical Assistance Webinar
Quality Improvement in Public Health Settings October 20, 2014 Lloyd Provost Associates in Process Improvement
[email protected] 1
Quality in Public Health? “Quality
in public health is the degree to which policies, programs, services and research for the population increase desired health outcomes and conditions in which the population can be healthy.”
Consensus Statement on Quality in the Public Health System, U.S. Dept. of Health and Human Services Office of Public Health and Science Office of the Assistant Secretary for Health Public Health Quality Forum
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Summit Pre-work Question about Quality Improvement #15. From your perspective as a leader in your state, please describe on average the exposure that your team/state colleagues have had with the following aspects of quality improvement (QI). (32 states).
Aspects of Quality Improvement 15.a Forming an effective team 15.b Using QI tools to identify and prioritize change concepts 15.c Writing a clear, actionable target goal/aim statement 15.d Distinguishing measurement for improvement from measurement for research/accountability 15.e Creating effective QI measures 15.f Implementing a structured plan to test change 15.g Using small, rapid cycle changes to test improvement ideas
No or minimal exposure
Moderate or high exposure
6%
94%
18%
82%
0%
100%
25%
75%
18% 29%
82% 71%
46%
54%
18% 25%
82% 75%
15.h Identifying whether a change has led to an improvement 15.i Developing a plan to sustain your changes
The Quality Improvement Pioneers
Walter Shewhart W. Edwards Deming
(1900 - 1993)
(1891 – 1967)
Joseph Juran (1904 - 2008) 4
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The Juran Trilogy The Juran Trilogy consists of three types of activities: – Quality Planning, – Quality Control (or Quality Assurance) – Quality Improvement
Quality Planning (usually the role of systems leaders)
Setting aims for improvement Selecting improvement projects Sustaining gains from improvement projects Usually part of a strategic planning process 5
Quality Control Quality Control (QC): “Quality control is the regulatory process through which we measure actual quality performance, compare it with quality goals, and act on the difference” (Juran, 1988)
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Quality Improvement Quality Improvement (QI): The organized creation of beneficial change; the attainment of unprecedented levels of performance.
This article discusses a definition of quality improvement in public health and describes a continuum of quality improvement applications for public health departments. Public Health Management Practice, 2010, 16(1), 5–7 Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 7
Measure of quality
Juran Quality Trilogy
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The Science of Improvement Dr. W. Edwards Deming stressed the importance of studying four areas to become more effective in leading improvement: • Appreciation of a system • Understanding variation • Theory of knowledge • Psychology
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Two Types of Knowledge for Improvement Subject Matter Knowledge
Subject Matter Knowledge: Knowledge basic to the things we do in life. Professional knowledge. e.g. nutrition, developing policies
The Science of Improvement: The interplay of the theories of systems, variation, knowledge, and psychology.
Deming’s System of Profound Knowledge 10
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Knowledge for Improvement Improvement: Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement. Subject Matter Knowledge
e.g. For this program: how do we combine both types of knowledge to develop changes to reduce infant mortality
Improvement
Profound Knowledge 11
The Basis for the Approaches and Methods of Improvement Appreciation of a system
Building Knowledge
Human Side of Change
(Theory of Knowledge)
(Psychology)
Understanding Variation
Based on Deming’s System of Profound Knowledge 12
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System Principles •
A system is an interdependent group of items, people, or processes working together toward a common purpose
• If each part of a system, considered separately, is made to operate as efficiently as possible, then the system as a whole will not operate as effectively as possible [Ackoff (1981)]. • Every system is perfectly designed to achieve the results it gets. 13
The public health system • Public health agencies at state and local levels • Healthcare providers • Public safety agencies • Human service and charity organizations • Education and youth development organizations • Recreation and arts-related organizations • Economic and philanthropic organizations • Environmental agencies and organizations http://www.cdc.gov/nphpsp/essentialservices.html 14
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Functions of Public Health 1. Monitor health status to identify and solve community health problems. 2. Diagnose and investigate health problems and health hazards in the community. 3. Inform, educate, and empower people about health issues. 4. Mobilize community partnerships and action to identify and solve health problems. 5. Develop policies and plans that support individual and community health efforts. 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. 8. Assure competent public and personal health care workforce. 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. 10. Research for new insights and innovative solutions to health problems. http://www.cdc.gov/nphpsp/essentialservices.html 15
Elements of a Process 5. Suppliers 3. Inputs
6. Customers 4. Outputs
“QUALITY” Attributes of the outputs that meet the needs and aspirations of the customers 1. Sequence of steps 2. Thing being passed along
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What are the key processes for Public Health Departments? • Developing of state-level policy • Developing regulations • Organizing and funding specific programs and initiatives to be carried out by other partners • Establishing and disseminating best practice guidelines Structure and Functions of State Public Health Agencies, Leslie M. Beitsch, MD, JD, Robert G. Brooks, MD, Meade Grigg, MS, and Nir Menachemi, PhD, MPH, Am J Public Health. 2006 January; 96(1): 167–172. 17
What Can Go Wrong in a Process? 2. Problems in hand-off between steps 2
1
3
1. Problems in execution within steps
3. Process was not designed to meet the needs 18
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Every system is perfectly designed to achieve the results it gets.
What is the system that produces infant health? 19
The Basis for the Approaches and Methods of Improvement Appreciation of a system
Building Knowledge
Human Side of Change
(Theory of Knowledge)
(Psychology)
Understanding Variation
Based on Deming’s System of Profound Knowledge 20
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Key Concepts in Theory of Knowledge • There is no substitute for knowledge – subject matter knowledge essential • Management is prediction, any plan is a prediction. • Prediction is based on theory • Apply the Scientific Method using Plan, Do, Study, Act Cycles
Understanding Variation in Data Shewhart’s Theory of Common and Special Causes
….. We used statistical process control techniques to evaluate initial process performance, implement an intervention, and assess process improvements. We found that implementation of these techniques significantly reduced waiting time and improved clients’ satisfaction with the WIC service. 22
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WIC Service Lobby Wait Time: Before and After Improvement
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Psychology – The Human Side of Change “Psychology helps us to understand people, interaction between people and circumstance, interaction between customer and supplier, interaction between teacher and pupil, interaction between a manager and his people and any system of management.” W. Edwards Deming, The New Economics, page 107
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Interaction of the Components of Profound Knowledge • Leveraging the interaction of the four components of profound knowledge leads to improvement • Focusing on appreciation for a system without considering the impact that variation is having on the system will not produce effective ideas for improvement. • Similarly, the interplay of the human side of change and the building of knowledge, as seen in areas of study such as cognitive psychology, is critical for making changes that result in improvement.
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Complete each of the steps in this process Step 1: Pick a number from 3 to 9
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Complete each of the steps in this process Step 1: Pick a number from 3 to 9
Step 2: Multiply your number by 9
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Complete each of the steps in this process Step 1: Pick a number from 3 to 9
Step 2: Multiply your number by 9
Step 3: Add 12 to the number from step 2
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Complete each of the steps in this process NO
Step 1: Pick a number from 3 to 9
Step 3: Add 12 to the number from step 2
Step 2: Multiply your number by 9
Do you have a 2-digit Number?
YES
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Complete each of the steps in this process NO
Step 1: Pick a number from 3 to 9
Step 2: Multiply your number by 9
Step 3: Add 12 to the number from step 2
Do you have a 2-digit Number?
YES
Step 4: Add your 2 digits together
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Complete each of the steps in this process NO
Step 1: Pick a number from 3 to 9
Step 3: Add 12 to the number from step 2
Step 2: Multiply your number by 9
Do you have a 2-digit Number?
YES
Step 4: Add your 2 digits together
Step 5: Divide # from step 4 by 3 to get a 1 digit number
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Complete each of the steps in this process NO
Step 1: Pick a number from 3 to 9
Step 3: Add 12 to the number from step 2
Step 2: Multiply your number by 9
Do you have a 2-digit Number?
YES
Step 4: Add your 2 digits together
Step 5: Divide # from step 4 by 3 to get a 1 digit number
Step 6: Convert your Number to a letter: 1=A 2=B 3=C 4=D 5=E 6=F 7=G 8=H 9 = I
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Complete each of the steps in this process NO
Step 1: Pick a number from 3 to 9
Step 3: Add 12 to the number from step 2
Step 2: Multiply your number by 9
Do you have a 2-digit Number?
YES
Step 4: Add your 2 digits together
Step 6: Convert your Number to a letter:
Step 5: Divide # from step 4 by 3 to get a 1 digit number
1=A 2=B 3=C 4=D 5=E 6=F 7=G 8=H 9 = I
Step 7: Write down the name of a country that begins with your letter
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Complete each of the steps in this process NO
Step 1: Pick a number from 3 to 9
Step 3: Add 12 to the number from step 2
Step 2: Multiply your number by 9
Do you have a 2-digit Number?
YES
Step 4: Add your 2 digits together
Step 5: Divide # from step 4 by 3 to get a 1 digit number
Step 6: Convert your Number to a letter: 1=A 2=B 3=C 4=D 5=E 6=F 7=G 8=H 9 = I
Step 7: Write down the name of a country that begins with your letter
Step 8: Go to the next Letter: A to B, B to C, C to D, etc. 34
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Complete each of the steps in this process NO
Step 1: Pick a number from 3 to 9
Step 3: Add 12 to the number from step 2
Step 2: Multiply your number by 9
Do you have a 2-digit Number?
YES
Step 4: Add your 2 digits together
Step 8: Go to the next Letter: A to B, B to C, C to D, etc.
Step 6: Convert your Number to a letter:
Step 5: Divide # from step 4 by 3 to get a 1 digit number
1=A 2=B 3=C 4=D 5=E 6=F 7=G 8=H 9 = I
Step 7: Write down the name of a country that begins with your letter
Step 9: Write down the name of an animal (not bird, fish, or insect) that begins with your letter from Step 8 35
Complete each of the steps in this process NO
Step 1: Pick a number from 3 to 9
Step 3: Add 12 to the number from step 2
Step 2: Multiply your number by 9
Do you have a 2-digit Number?
YES
Step 4: Add your 2 digits together
Step 8: Go to the next Letter: A to B, B to C, C to D, etc.
Step 5: Divide # from step 4 by 3 to get a 1 digit number
Step 9: Write down the name of an animal (not bird, fish, or insect) that begins with your letter from Step 8
Step 6: Convert your Number to a letter: 1=A 2=B 3=C 4=D 5=E 6=F 7=G 8=H 9 = I
Step 10: Write down the color of your animal
Step 7: Write down the name of a country that begins with your letter
Output: Color____________ Animal___________
Country__________ 36
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A Gray Elephant in Denmark
“Every system is perfectly designed to achieve exactly the results that it gets” 37
Applying the Science of Improvement Appreciation of a system
Building Knowledge
Human Side of Change
(Theory of Knowledge)
(Psychology)
Understanding Variation
Our “Lens of Profound Knowledge” 38
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Applying the Science:
Key Principles to Guide Improvement work • We can think of all work as a process • A system is an interdependent group of items, people, and processes with a common aim • Every system is perfectly designed to achieve the results it achieves • Improvement requires change, but not every change is an improvement • Variation in data can be due to common and special causes • Improvement in quality can occur with reduction in costs (the Chain Reaction and Business Case for Quality) • People are a key part of systems in organizations – they want to do a good job and take pride in their work 39
The Necessary Ingredients for Improvement • Will to do what it takes to change to a new system • Ideas on which to base the design of the new system • Execution of the ideas
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Some Examples of Building Will for Improvement • Texas changed its Medicaid policy to deny payment for elective deliveries prior to 39 weeks • Georgia prolonged the Medicaid eligibility of postpartum women to increase the accessibility to family planning/reproductive health in order to increase BC use and improve birth spacing. • North Carolina Health Department and Medicaid worked together to make 17P available to all eligible women. They had to work with hospitals and providers to ensure that the medication was available, that the providers would prescribe it In all of the appropriate cases and that there would be a payment mechanism. (http://www.mombaby.org/index.php?c=2&s=58) Ref: Correspondence w. Lauren Smith
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The Necessary Ingredients for Improvement • Will to do what it takes to change to a new system
• Ideas on which to base the design of the new system • Execution of the ideas 42
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Infant Mortality Collaborative Innovation and Improvement Network Framework Domains Engage leadership at the Federal, State, and Local Level across all sectors
Align state & local initiatives, systems & information sharing
Enhance public awareness & family & community engagement
Improve access to and quality of care & services in clinical & public health settings
Improve statelevel data quality, collection & timely & effective use
Address impact of social determinants of health through public health & health care policy & program development.
Innovation
Potential Strategic Priorities
Periods of Engagement
Enhance access to & quality of care for women before & between pregnancies
Pre-/Interconceptional actions
Promote education, screening, referral & treatment for women with risk conditions including tobacco use, substance abuse & mental health issues Prevention, identification, & management of chronic disease in women of reproductive age Improve family capacity to protect & promote their own health
Reduce infant mortality Detailed aim: To ensure more healthy babies are born as evidenced by a reduction of x% in the rates of: • Prematurity (from x per 1000 births in 20xx to x per 1000 births in 20xx) • infant mortality (from x per 1000 live births in 20xx to x per 1000 live births in 20xx)
Period of Engagement
Prenatal actions (Pregnancy to Birth)
Improve health risk screening and successful service and treatment referrals for all pregnant women Increase access to and quality of prenatal and maternal care Improve family capacity to protect & promote their own health Ensure quality of care for newborns
Neonatal actions (Birth up to 28 Days)
Post-neonatal actions (28 – 365 Days)
Create a perinatal regionalized system of care Improve family capacity to protect & promote their own health Multi-system approach ensuring families engage in safe sleep practices Increased rate of breastfeeding continuation and exclusivity Ensure primary and secondary prevention of fatal injuries
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Potential Actions (Change Concepts)
Strategic Priorities
Partner with professional groups to develop clinical guidelines for well-woman visits
Enhance access to & quality of care for women before & between pregnancies
Ensure access to a medical home for all women that is comprehensive, familycentered, coordinated, and culturally and linguistically appropriate Ensure access to and quality of comprehensive reproductive health & family planning & other health services for all uninsured & underinsured populations
Support mechanisms to facilitate enrollment into Medicaid so providers can directly enroll eligible clients
Pre/Interconceptional actions
Promote education, screening, referral & treatment for women with risk conditions including tobacco use, substance abuse & mental health issues
Ensure access to interconception care for women with prior adverse pregnancy outcomes up to 18-months post partum
Increase access to mental/behavioral health & social support services for women
Prevention, identification, & management of chronic disease in women of reproductive age
Increase # of women screened & monitored for high-risk conditions associated with poor birth outcomes (e.g., hypertension, obesity, gestational diabetes, STIs, etc.)
Provide awareness & training in evidence-based models of tobacco cessation counseling to obstetric & neonatal providers & other public health & social services providers Include males in services, education, and programs to reduce infant mortality Improve family capacity to protect & promote their own health
Expand preconception health education among women & providers Design & implement new health promotion & social marketing campaigns to accelerate use of five key preventive strategies (i.e., immunization, breastfeeding, safe sleep, smoking cessation, & family planning) Innovations
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Period of Engagement
Pre/Interconcepttional actions
Strategic Priorities Enhance access to & quality of care for women before & between pregnancies
Potential Actions to Change System (Change Concepts) Partner with professional groups to develop clinical guidelines for wellwoman visits Ensure access to a medical home for all women that is comprehensive, familycentered, coordinated, and culturally and linguistically appropriate Ensure access to and quality of comprehensive reproductive health & family planning & other health services for all uninsured & underinsured populations Support mechanisms to facilitate enrollment into Medicaid so providers can directly enroll eligible clients 45
The Necessary Ingredients for Improvement • Will to do what it takes to change to a new system • Ideas on which to base the design of the new system
• Execution of the ideas 46
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Execution of Breakthrough Initiatives 1. Setting of statewide priorities and goals connected to infant mortality 2. Developing a rational portfolio of pilot improvement projects to support these goals 3. Deploying resources to the pilot projects 4. Successfully completing each of the individual projects in the portfolio 5. Oversight and learning system for the improvement work 47
Recommendations and Strategies for South Carolina (2013) A: Improve Access to Systems of Care for Women Before, During and After Pregnancy B: Promote Use of Evidence-Based Patient Practices by Health Care Providers and Families C: Promote Health across the Lifespan D: Develop Data Systems to Understand and Inform Efforts E: Eliminate Disparities and Promote Health Equity Healthy Mothers, Healthy Babies, October 2013 South Carolina’s Plan To Reduce Infant Mortality & Premature Births 48
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Improvement Execution Framework
Nolan TW. Execution of Strategic Improvement Initiatives to Produce System-Level Results. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007. (www.IHI.org) 49
A Portfolio of Pilot Projects to Accomplish each Strategic Priority: Strategic Priority 1: Enhance access to & quality of care for women before & between pregnancies Aspect of Strategy
Potential Pilot Project
Partner with Professional Groups
Develop clinical guidelines for well-woman visits
Access to Medical Homes
Comprehensive family-centered care for all women.
Medicaid Enrollment
Develop and support mechanisms so providers can enroll eligible clients
Women with prior adverse pregnancy outcomes
Ensure access to interconception care up to 18-months post partum
Uninsured population
Develop access for comprehensive health services
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Roadmap for Pilot Team Improvement Improvement Will Ideas
Execution
Key Reference 51
Fundamental Questions for Improvement • What are we trying to accomplish? Aim Statement • How will we know that a change is an improvement? • What changes can we make that will result in an improvement? Source: Improvement Guide, p 3, 4 52
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Role of a Pilot Team’s Aim Statement • Answers and clarifies “What are we trying to accomplish? for the QI Project. • Creates a shared language to communicate about the project. • Provides a basis for developing the rest of the project (measures and changes). • Many different formats are useful for the statement. 53
Examples of Project Aim Statements for CoIIN Tennessee Decrease unintended pregnancies to 44.4% by 2020 (10%) Decrease rate of sudden unexpected infant deaths by 10% by 2020. Decrease percentage of preterm birth to 9.9% by 2020 (10%) Decrease percentage of women who smoke during pregnancy to 14.7% by 2020 (10%) 54
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Measurement for Improvement Model for Improvement What are we trying to accomplish?
Focus
How will we know that a change is an improvement? What change can we make that will result in improvement?
Act Act
Plan Plan
Study
Do Do
Aim
Measures Ideas
From: Associates in Process Improvement 55
Measurement Guidelines for QI Projects • A few key measures that clarify a team’s aim and make it tangible should be reported each month. • Be careful about over-doing process measures, keep focus on outcomes. • Make use of available data systems for measurement. • Integrate measurement into the daily routine. • Plot data on the key measures each week or month during the pilot project. 56
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Executing Improvement through Repeated Use of the Plan, Do, Study, Act Cycles Model for Improvement
Changes That Result in Improvement
What are we trying to accomplish?
How will we know that a
change is an improvement?
What change can we make that will result in improvement?
A P S D
Act - What changes are to be made? - Next cycle?
A P
Do
Study
S D
Hunches Theories Ideas
Plan - Objective - Questions and predictions (Why?) - Plan to carry out the cycle (who, what, where, when) - Plan for Data collection
- Complete the analysis of the data - Compare data to predictions - Summarize what was learned
- Carry out the plan - Document problems and unexpected observations - Begin analysis of the data
Source: Improvement Guide, p 10 57
Three principles to guide PDSA’s to test a change: Principle 1: Test on a small scale and build knowledge sequentially Principle 2: Collect data over time Principle 3: Include a wide range of conditions in the sequence of tests The Improvement Guide, p. 145
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Need for Testing in QI Projects Another state (following action by Texas) also changed its Medicaid policy to deny payment for elective deliveries prior to 39 weeks. But after implementation, they found out that they hadn’t reprogramed their claims systems to kick out the births that were going to be denied Ref: Correspondence w. Lauren Smith 59
Multiple Cycles to Accomplishment Improvement Home Visiting Aim: increase the % of mothers served by the program who were eligible for and received an Edinburgh Depression Screening Leslie McAllister and Tom Hinds Dept. of Children & Families, WI
A P S D
80% of Eligible Mothers Receive depression screening Cycle 6: Early documentation of client enrollment date
Cycle 5: Creating incentives for completing screens/assessments
Cycle 4: Changing assessment documentation flow
Currently about 52% of Eligible Mothers
A P S D
Cycle 3: Screening timeline tools used by home Visitors/supervisors to plan and monitor completion
Cycle 2: Integrating screening/data review into supervision sessions Cycle 1: Training on where to document depression screening in SPHERE 60
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Aim
Roadmap for Successful Pilot Quality Improvement Projects to Accomplish the State Plan
Measures Ideas
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Some QI References •
• •
• •
The public health quality improvement handbook, Ron Bialek, Grace L. Duffy, and John W. Moran. American Society for Quality, Quality Press, Milwaukee, 2009. Public Health Management Practice, 2010, 16(1), 5–7, 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nolan TW. Execution of Strategic Improvement Initiatives to Produce System-Level Results. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007. (www.IHI.org) The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996. A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996. 62
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On-line Model for Improvement • To review the Model for Improvement or share with colleagues, visit the IHI’s website • http://www.ihi.org/IHI/Topics/Improvement/Im provementMethods/HowToImprove/
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