San Diego County’s public health department has long been committed to quality improvement, with the process of becoming accredited reinforcing the importance of that commitment. As early as 2010, during the PHAB beta test, the Public Health Officer made the number of QI projects a priority performance measure which is shared with the public by inclusion in the county’s operational plan (at least 6 projects a year which bumped up to 8 projects as of FY 2017-2018). However, this is not an easy target to reach and staff needed and requested additional technical support in order to be successful. There were other signs that QI capacity had to be strengthened. The NACCHO self-assessment in 2014 and informal surveys revealed that staff felt intimidated by QI, saw QI as yet another big thing to do and not as a way to enhance or streamline what they are already doing. Staff also said they needed more assistance “in real time” or during the course of their projects, in addition to formal training.
In 2014-2015, the new Performance Improvement Manager launched a “QI on QI” project as a unique strategy of designing a QI technical assistance program with limited resources by adhering to QI principles. This included several solutions:
Staying consistent with QI practices, charters and storyboards have been scored since this project began, using FY 2014-2015 as the baseline. A simple scoring tool was developed to score charters and storyboards that looked at things like the strength of the Aim Statement in the Charter and the clarity of the Theory of Improvement and strength of the Outcomes in the Storyboard. The idea was to determine if there is improvement over time, suggesting that the technical assistance was helping.
Progress is slow but going in the right direction. The scores of the charters increased to 4.2 out of 5. For the storyboards, as a proxy for the final project results, improvement is not as clear-cut with the scores at 3.8 out of 5. This is actually lower than in previous years. These results may reflect that, while staff is growing in terms of their understanding of how to scope a project, as reflected in the charter, the execution of projects is impacted by many factors, including competing demands on staff time. In fact, each year there are several projects that are dropped and thereby not even included in the final results.
Informal surveys and feedback from staff show that they value this “QI on QI” technical assistance, and that the feedback led to good changes to project design. However, staff asked for more and different types of assistance. As a result, the first QI Resource Fair was held in June 2017 and the second in December 2018. The fair features games, exercises, prizes, and a Storyboard showcase as a way to engage and reward staff in QI. Workshops have also been convened with the Public Health Foundation trainers, including one offered in May 2018 specifically designed for new Champions to solicit QI ideas and accelerate QI activity within each of the seven Branches.
County of San Diego Health and Human Services Agency in San Diego, Calif., was awarded national accreditation through PHAB on May 17, 2016.
About the author: Jackie Baker Werth, MPA, PMP, is Performance Improvement Manager at the County of San Diego, Health & Human Services Agency, Public Health Services, in San Diego, Calif. Contact her at [email protected]