Assessing and Improving Agency-Wide Quality Improvement Training

Summary

Impact Statement:

Staff are Customers too! How involving all staff in the identification of barriers to completing department offered QI Training resulted in greater acceptance of, participation in, and an increase in the number of staff completing six required training modules.

Summary:

Kane County Health Department (KCHD) has used SlideRocket to create quality improvement (QI) training modules and tracks staff progress using an internal database, which contains personal staff information and is shared internally within the Community Health Resources (CHR) section. The fiscal year (FY) 2014 QI plan states that staff must complete six required QI modules: aim statements; cause-and-effect diagrams; data collection and analysis; flowcharts; QI 101/Plan, Do, Check, Act (PDCA) cycle; and Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis. In May 2014, only 61.7% of staff had completed all six of the required modules. By using the PDCA tool, the QI and Performance Management (QuIPM) Committee and the CHR section created an aim statement.

Staff were surveyed on May 20, 2014, about barriers of and opportunities from training module completion and use. A cause-and-effect diagram and affinity diagram were then completed on July 16. CHR section staff and the QuIPM Committee were then surveyed about the best possible solution, which would be having the health data and quality coordinator (HDQC) send (via a hyperlink) regular updates to staff with the modules they need to complete, thus addressing the barriers of not knowing which tools need to be completed and where they were.

Within days, the completion percentage increased by 10%, and by September 19, the percentage had reached 77.6%, which did not meet the desired goal. The group still deemed it a success. In the few weeks after the testing phase, the percentage rose to 83.1%. The notification is now a standard monthly process used by the HDQC, who tracks the trainings internally and collectively through the performance management system. Many future plans arose from the project, such as a QI resource library, QuIPM members completing all 13 of the total QI modules, 5-minute reports of QI activities during section meetings, and increased training for QuIPM members.

Organization that conducted the QI initiative:

KCHD

Citation:

Eder, D. Public Health Quality Improvement Exchange. Assessing and Improving Agency-Wide Quality Improvement Training. Wed, 10/11/2017 - 12:18. Available at http://phqix.org/content/assessing-and-improving-agency-wide-quality-improvement-training. Accessed April 19, 2024.

Background and Aim

Planning and Execution Details

QI Implementation:

This solution involved personalized e-mails that listed why staff should complete the training, what module(s) they had to complete, and direct links to access the training. This solution will help deal with the many root causes from the survey and fishbone diagram that indicate confusion about where the modules were and which ones needed to be completed. A personalized e-mail reminder was sent to each staff member who had not completed the six required trainings. The reminder indicated which trainings needed to be completed and provided a hyperlink to their location. The already-created database was the identified mechanism to track completion rates among staff.

Focus activities

Administration:

Quality Improvement and Accreditation Readiness

Workforce development

QI Methods:

PDCA/PDSA Cycle (Plan, Do, Check/Study, Act)

QI Tools:

Affinity Diagram

Brainstorming

Cause and Effect Diagrams

Fishbone Diagram

Prioritization Matrix

Surveys

QI Tool Documentation:

Affinity diagram for potential solutions

Fishbone diagram to determine the root causes of the initiative

Initiative Dates:

5/7/14

Initiative Duration:

Less than 6 months

Methods of evaluation:

To measure the impact of the QI initiative, staff completed handouts after they completed each module, which helps reinforce that staff understand the tool. Completion of modules is also tracked in an already-existing database that contains each staff member's name and the tools he or she has completed. The database determines the percentage of staff who have completed the 6 required modules and the percentage who have completed all 13 modules. The theory was that once the implementation (notification) was sent to staff, the percentage of staff who completed all six modules would increase. Because the trainings and number of QI tools used per month are tracked in the internal performance management system, the team can track tool completion as training increases to see whether particular use of a tool, or group of tools, increases as well.

Supplemental Materials:

Storyboard

Supplemental Files:

Attachment	Size
Storyboard Final.pdf	97.72 KB

Results

Measurable QI Outcomes:

Measurable QI outcomes included the following: • The percentage of staff who completed all 6 required training modules rose from 61.7% in May 2014 to 77.6% by September 19 and to 83.5% a few weeks after. • Completion of all 6 required modules and the 13 total modules is tracked through an internal database and the performance management system. • The group tracks QI tools used by section and individual each month in an internal database and in the performance management system, so the team can measure increased tool use after training modules have been completed.

Other QI Outcomes:

Because of comments about the training modules, a QI resource library was formed during the initiative. It also contains other training methods. The library gives different options to learn about QI, such as YouTube videos on particular tools. Discussions took place regarding how QI tool use is tracked within KCHD. Currently, tools are tallied monthly by section and tracked in a database and as a performance measure. The results of the project were a better, unified method to track QI tool use throughout the month and the benefits of or changes from the tool. To make QI more fun, an agency-wide QI game using paper airplanes and the PDCA cycle occurred on September 15. In terms of the time barrier, the HDQC is working to build the skill set of the QuIPM Committee members so they can train their respective sections. By having created the training tracking database, the HDQC can analyze which trainings have been completed least often and compare that to the number of QI tools conducted at that particular training during the year. This will help focus a training plan that can be built into existing schedules and meetings, thus training staff while addressing the time barrier. Finally, QuIPM Committee members agreed to a 5-minute report on QI during their section and division meetings. This change will hopefully keep QI in the forefront and reinforce its importance, especially to staff who still have yet to complete the six modules.

Lessons Learned, Observations and Insights:

Many of the findings were helpful and instrumental in many of the separate projects and outcomes that came out of the PDCA cycle and in updating the FY2015 QI plan.

Future Plans:

Although the desired goal of 85% was not reached, the team deemed the project a success. Even after September 19, staff have continued to submit training modules, and some staff have completed all 13 modules. The tracking of the 6 required modules and the 13 total modules is a performance measure in KCHD’s performance management system. The process of regularly notifying staff of what modules they have to complete and sending hyperlinks to the modules is now a standard practice performed monthly by the HDQC. During a meeting on September 3, the QI group had discussed that QI members should complete ALL 13 training modules, aside from only the 6 required in the QI plan. Members are currently working on achieving that desired goal.

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Submission Status:

Completed

Comments

Our department has had a

Our department has had a focus on increasing staff training related to Quality Improvement and Accreditation in general. We consider the training as part of our accreditation activities within our workforce development and quality improvement plans. I never thought of using the trainings themselves as a QI project! Interesting! I think compliance from staff regarding any number of activities whether training or participation in wellness activities, is a sign of overall good morale and culture of the agency. So anything to help identify barriers or issues related to compliance is worthwhile.

On another note, I'm curious about what PHAB thinks about the QI projects being conducted. For those in the final stages of accreditation, what feedback have you received, good or bad, about your QI projects? Sometimes we (I know I do) think that QI projects need to be a large project with significant results. However, when I read about some of the projects on this site, I'm realizing it's small projects that can are being done. I was just curious about what PHAB thinks about the array of projects identified by departments. Nice project! Kay

Kay Conley

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Assessing and Improving Agency-Wide Quality Improvement Training

Summary

Background and Aim

Planning and Execution Details

Results

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

Our department has had a

Our QI Council just came up

we at OCCHD are also

Thanks for this submission.

QI Spotlight

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Assessing and Improving Agency-Wide Quality Improvement Training

Summary

Background and Aim

Planning and Execution Details

Results

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

QI Spotlight