Achieving Agency-Wide Tobacco Outreach Coordination

Summary

Impact Statement:

Effective tobacco control and prevention outreach is vital to decreasing tobacco use, secondhand smoke exposure, and tobacco-related disease rates. In addition, the loss of significant resources and funding for tobacco control and prevention have made it all the more important to have efficient coordination of these efforts across a jurisdiction. A state health department used multiple PDSA cycles to improve the coordination of messages and activities across tobacco control and prevention programs located within multiple divisions to improve public health system performance, reduce redundancy, improve the effective and efficient use of resources, and ultimately improve population health.

Summary:

Several program areas within 5 of the 15 Minnesota Department of Health (MDH) divisions focus on reducing tobacco use and exposure to secondhand smoke among adults and children. However, this work is not coordinated across divisions, resulting in inefficiencies in outreach efforts, including providing technical assistance, information, and referral; distributing grants/funds; ensuring compliance; distributing materials; collecting and analyzing data; and promoting events. The QI team used the Plan, Do, Study, Act (PDSA) methodology. The Plan stage consisted of defining coordination, identifying project metrics, conducting baseline surveys, and completing a current state analysis of tobacco outreach efforts within MDH. Two improvement theories were developed to focus on building relationships among staff to increase coordination across divisions. The Do phase involved testing a targeted staff directory and tobacco outreach networking events. These two interventions allowed staff to meet and learn about each other’s tobacco outreach work. The project team observed improvements in all metrics related to coordination, including exceeding the project aim, during the Study phase. A key accomplishment during the Act phase was sponsor approval of several recommendations to sustain this work. Five of the eight recommendations have agency-wide implications and reach, including adopting semiannual tobacco outreach events, adding staff photos to the agency directory and in Microsoft Outlook e-mails, inserting collaboration language in all position descriptions, and continuing to monitor the perceived authority to collaborate on the annual organizational survey.

Organization that conducted the QI initiative:

MDH

Citation:

Lenartz, S. Public Health Quality Improvement Exchange. Achieving Agency-Wide Tobacco Outreach Coordination . Thu, 04/02/2015 - 13:41. Available at http://phqix.org/content/achieving-agency-wide-tobacco-outreach-coordination. Accessed April 18, 2024.

Background and Aim

Aim statement:

The project aim was to use QI tools and techniques to improve cross-divisional coordination of tobacco outreach activities by 50% by September 2013.

Need For The QI Initiative:

As stated in the Area for Improvement section, progress in reducing smoking rates among targeted populations and youth has been slowing in recent years. These data, coupled with decreased tobacco funding and the fact that multiple MDH programs address tobacco use, led to the need to complete an inventory of current tobacco services and activities, identify opportunities for collaboration and resource sharing, identify gaps in outreach, and recommend ways in which cross-divisional collaboration can improve efficiency and effectiveness of current operations and reduce inefficiencies. The project was also viewed as an opportunity to use QI tools and processes to solve an organizational issue such as cross-divisional coordination. Three managers, one from each of the following divisions, initiated this project: Environmental Health, Community and Family Health, and the Office of Statewide Health Improvement Initiatives. The sponsors selected for the project included representatives from the following five divisions and offices: • the Environmental Health Division, which has responsibility for the enforcement of the Minnesota Clean Indoor Air Act and the Healthy Home Initiative; • the Community and Family Health Division, which is responsible for MCH efforts on infant mortality reduction, preconception and prenatal health, child and adolescent tobacco use and exposure to secondhand smoke, and Pregnancy Risk Assessment Monitoring System (PRAMS) and Women, Infants, and Children (WIC) program data; • the Health Promotion and Chronic Disease Division, which is responsible for asthma prevention; • the Office of Statewide Health Improvement Initiatives, which is responsible for Minnesota’s tobacco prevention program, and • the MDH Communications Office, which supports program staff in the delivery of selected tobacco-related messaging.

Area for Improvement:

The project’s long-term goal is to maintain or increase Minnesota’s progress toward reducing tobacco use and secondhand smoke exposure state-wide, particularly among some of the most vulnerable residents—infants, children, adolescents, and pregnant women. Recent reports show slower progress being made in reducing teen tobacco use in Minnesota. Results from the 2010 Tobacco Survey indicate more than 50% of high school students are still exposed to secondhand smoke, despite passage of the state’s Freedom to Breathe Act in 2007. Also, 8.5% of WIC households report someone smoking in the household, thereby exposing significant numbers of infants and pregnant women to secondhand smoke. All five of the cooperating divisions address the dangers of tobacco use and secondhand smoke exposure. Programs draw from the same scientific evidence bases to educate and motivate clients, and staff typically work across divisional lines to draw on in-house expertise on reaching targeted audiences with culturally appropriate messages they will heed. However, there was no coordinated, formalized process to ensure a unified outreach or messaging approach. A QI initiative held the potential for avoiding duplication of efforts and achieving economies of scale in outreach activities and message development and delivery, while at the same time accelerating progress toward achieving desired behavior changes. Information from state surveillance and reporting systems (e.g., cancer surveillance, Minnesota Adult Tobacco Survey [2010], Youth Tobacco Survey [2011], PRAMS, vital records) point to the need for increased efforts to reduce smoking prevalence and exposure to secondhand smoke. The slowing of progress can partly be attributed to the loss of significant resources targeting tobacco use and prevention. In 2003, the tobacco settlement funding MDH received for tobacco prevention was absorbed into the legislature’s general fund. In 2009, state funding for youth tobacco prevention was reduced, and in 2010, state funding for the Statewide Health Improvement Program, which targets obesity and tobacco, was cut by approximately two-thirds. Accompanying issues are the challenges inherent in coordinating messages and activities across programs located within multiple divisions. In addition, the loss of significant resources targeting tobacco use prevention and anticipated future reductions as a result of state and federal budget deficits raise the critical question of how MDH can continue to be effective with fewer resources. Overall, the goal is to improve public health system performance, reduce redundancy, improve the effective and efficient use of resources, and ultimately improve population health.

Root Cause:

A root cause analysis was completed on the issue of the lack of internal and external knowledge of whom to contact for what. Based on this analysis, it was determined that MDH staff do not know individuals outside of their divisions who work on tobacco outreach. Mechanisms to connect staff were needed for coordination and collaboration to occur.

Planning and Execution Details

QI Implementation:

The PDSA methodology was used at every step of the project. Because the issue of lack of coordination was a larger system-level problem without a scope, completing an initial inventory of services and activities across divisions was required (in place of a process map). A collection and analysis of tobacco materials developed and/or distributed was also completed. This analysis resulted in the rejection of the original hypothesis that duplication of tobacco materials existed. Surveys were also used to collect baseline data on several measures related to coordinating tobacco outreach. Survey results highlighted the fact that improvement was needed in all metrics because none of the measures reached the targeted threshold of 60% of staff who agree/strongly agree. Although there was room for improvement on certain issues with partners, the team concluded that the interventions needed to focus internally (based on higher satisfaction levels with coordination among external partners compared with MDH staff). After reviewing the survey findings, the team brainstormed key areas for improvement. A prioritization matrix and an impact/effort plot were used to select one area for improvement—the lack of internal and external knowledge of whom to contact for what. This problem scored the second highest among six opportunities but was thought to be a necessary first step to laying the foundation for future coordination and collaboration. An extensive root cause analysis was completed on this opportunity, which resulted in the consensus that the lack of internal relationship-building mechanisms impeded cross-divisional coordination. The team then developed two improvement theories: (1) If the team develops a mechanism for people to collaborate/meet to foster relationships, then staff will have better knowledge of the expertise and resources available for tobacco-related subject matter; and (2) if the team develops a better staff directory, then it will be easier for staff to find and identify the right people to collaborate with. Two initiatives were then developed and tested to build relationships. A staff directory for the targeted 106 employees (who had received the pre-test survey) was developed. Rapid-cycle testing occurred to continually improve the prototype and reach the 30 entries required for a search function to be operable. The second initiative involved the QI team testing tobacco outreach events for interested staff to gather in person, meet one another, and learn about program areas outside of their division. Because of unforeseen technology limitations, the directory search function could not be operationalized, and the directory initiative was abandoned. However, further research into potential search capabilities for the existing agency-wide directory (or alternate directory) for all staff is included on the post-project action plan. Attendance at the tobacco outreach events exceeded expectations. A follow-up survey sent to those attending indicated that 82% of respondents would like these events to continue. Hosting semiannual tobacco outreach events has consequently been adopted by the Tobacco Prevention and Control Program within the Office of Statewide Health Improvement Initiatives and integrated into its strategic plan.

Focus activities

Population-based Primary Prevention :

Asthma

Chronic disease programs

Tobacco

Other Environmental Health Services:

Indoor air quality

Administration:

Communications

Infrastructure

QI Methods:

Model for Improvement

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

QI Tools:

Affinity Diagram

Brainstorming

Cause and Effect Diagrams

Fishbone Diagram

Prioritization Matrix

Root cause analysis

Surveys

QI Tool Documentation:

Services/activities inventory map

Surveys

Prioritization matrix, step 1

Fishbone diagram

Affinity diagram of root causes

Rapid-cycle testing staff directory

Storyboard

Initiative Dates:

5/2/12 to 10/3/13

Initiative Duration:

Between 12-18 months

Methods of evaluation:

Outcome measures were integrated into a pre- and post-test Vovici (electronic) survey to MDH staff who were identified by the QI team as having tobacco-related responsibilities or interests. The baseline survey achieved a 53% response rate with 56 of 106 targeted staff responding. The post-survey achieved a 36% response rate. The measures included the following: • staff who have coordinated with another division(s) around tobacco efforts in the past year, • staff who believe they have the authority to coordinate with others outside of their division or office, • staff who are satisfied with the level of cross-divisional coordination of tobacco outreach activities, • staff who can identify individuals at MDH with tobacco-related expertise outside of their division, and • staff who believe a process or system is in place to coordinate with others outside of their division on tobacco efforts. Process data collected included the following: • Event 1 participants: 40, target 8; • Event 2 participants: 49, target 15; • directory profiles entered: 32, target 30; and • unique directory users: 41, target 30.

Supplemental Materials:

Storyboard

Results

Measurable QI Outcomes:

The QI team exceeded the project aim. Staff who have coordinated with another divisions around tobacco efforts in the past year increased from 36.4% to 64.2%. This was a 76.4% increase (the aim was a 50% increase). Staff who believe they have the authority to coordinate with others outside of their division or office increased from 33.9% to 62.8%. Staff who are satisfied with the level of cross-divisional coordination of tobacco outreach activities increased from 17.9% to 39.6%. Staff who can identify individuals at MDH with tobacco-related expertise outside of their division increased from 39.3% to 53.5%. Staff who believe there is a process or system in place to coordinate with others outside of their division on tobacco efforts increased from 19.7% to 48.9%.

Lessons Learned, Observations and Insights:

Based on a post-project evaluation, team members listed the following key project challenges: • Determining an effective aim statement for a broad issue was difficult. • The topic was very broad. Finding something doable was a challenge. • The scope was too large and undefined at the beginning of the project. • There were technology limitations/challenges for creating the desired directory. Key project successes included the following: • Through the use of a structured QI process, the team took a cultural system-wide issue and not only created an aim statement, but also developed project metrics and achieved improvement in all measures. • Perceptions/opinions changed concerning satisfaction levels with cross-divisional coordination over the course of the grant period. • The interventions garnered support and engagement at all levels of the organization (executive office, manager/supervisors, and program staff). • One team member said, "I believe that this project established a model process, which can be used by others within the department working on outreach." Survey limitations were as follows: • The pre-intervention survey was disseminated to 106 staff, with 56 respondents, resulting in a 53% response rate. • The post-intervention survey was disseminated to 119 staff, with 43 respondents, resulting in a 36% response rate. • The targeted list changed because of staff changes/turnover and because of additions to the list of staff with tobacco-related responsibilities and/or interests. The following lessons were learned (submitted by team members): • Many staff (with whom team members spoke) felt tobacco was not necessarily their “responsibility”; that it was mainly the Tobacco Prevention and Control Program’s role. Working in a structure dictated by programs rather than health outcomes may be one of the reasons for this perception. • Collaboration needs to be modeled and valued by leadership. • Inviting people in person (as opposed to e-mail) to take action is essential. Personal contacts made a difference. • Explaining why this project should be of interest to people was essential. • Leadership involvement in the events added credibility. • There needs to be a simple, convenient method for staff to add their photo to a directory and e-mails. • Collaboration cannot be forced. There needs to be a purpose or goal (clear objective) for collaboration.

Future Plans:

Sustainability plans include eight action items that have been assigned to staff. The Office of Performance Improvement will monitor the status of the following tasks: 1. Explore Intranet directory search options for both the existing all-staff directory and a new type of directory. 2. Implement photo IDs agency-wide on the existing staff directory, with an opt-out feature. 3. Implement photo IDs agency-wide on e-mails, with an opt-out feature. 4. Hold semiannual tobacco outreach events. 5. Insert collaboration language into all (agency-wide) position descriptions. Include a definition of collaboration. 6. Continue to monitor the perceived authority to collaborate across the agency. Monitor the results of this question from the annual employee organizational survey. 7. Clean up outdated tobacco material on the MDH website. 8. Conduct a 12-month follow-up survey in 2014 to monitor the results of this project. Use the same pre-/post-survey.

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Submission Status:

Completed

Comments

This is an interesting read.

This is an interesting read. I think this project is relevant beyond tobacco to any health issue that is being addressed cross-divisionally in an agency. Nice work.

Cindan Gizzi, MPH
Community Assessment Manager
Tacoma-Pierce County Health Dept.
cgizzi@tpchd.org

I like the focus on

I like the focus on coordination of our work across divisions - and using QI to address internal challenges with how we tackle problems. Often these challenges are overlooked in our focus on direct services to clients, but can be the biggest stumbling blocks.

Margy Robinson MPH
HIV Care Services Mgr.
Multnomah County Health Dept.
Portland, OR

This QI project shows the

This QI project shows the importance of having support at all levels when making improvements, from top management to program staff, and the importance of leadership valuing collaboration. I look forward to hearing the results from the 12-month follow-up survey, if you'll share them with us. As Cindan stated, this project is relevant to collaboration between divisions with other health issues.

Great initiative! In the re

Great initiative! In the re coordination process, it might be interesting to see where electronic cigarettes and other nicotine dispensing devices fall in your community and whether those products should also be looked into.

Link to the resource where this submission is also published:

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Achieving Agency-Wide Tobacco Outreach Coordination

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

This is an interesting read.

I like the focus on

This QI project shows the

Great initiative! In the re

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Achieving Agency-Wide Tobacco Outreach Coordination

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

QI Spotlight