A Pilot Quality Improvement Collaborative to Improve Safety Net Dental Access for Pregnant Women and Young Children.

Objectives To determine acceptability and feasibility of a quality improvement (QI) collaborative in safety net dental practices, and evaluate its effects on financial stability, access, efficiency, and care for pregnant women and young children. Methods Five safety net dental practices participated in a 15-month learning collaborative utilizing business assessments, QI training, early childhood oral health training, and prenatal oral health training. Practices collected monthly data on: net revenue, no-show rates, total encounters, and number of encounters for young children and pregnant women. We analyzed quantitative data using paired t-tests before and after the collaborative and collected supplemental qualitative feedback from clinic staff through focus groups and directed email. Results All mean measures improved, including: higher monthly revenue ($28,380-$33,102, p = 0.37), decreased no-show rate (17.7-14.3%, p = 0.11), higher monthly dental health encounters (283-328, p = 0.08), and higher monthly encounters for young children (8.8-10.5, p = 0.65), and pregnant women (2.8-9.7, p = 0.29). Results varied by practice, with some demonstrating largest increases in encounters for young children and others pregnant women. Focus group participants reported that the collaborative improved access for pregnant women and young children, and that QI methods were often new and difficult. Conclusion for practice Participation by safety net dental practices in a QI collaborative is feasible and acceptable. Individual sites saw greater improvements in different outcomes areas, based on their own structures and needs. Future efforts should focus on specific needs of each dental practice and should offer additional QI training.

Improving Culture, One Quality Improvement Project at a Time.

CONTEXT: A culture of quality improvement (QI) values collaboration, transparency, and staff empowerment. Organizations exhibiting a culture of QI are more likely to engage in QI. OBJECTIVE: We examined whether local health departments' (LHDs') participation in a longitudinal, experiential QI training program changes QI culture. DESIGN: Prior to and following participation in a QI training program, all employees of participating LHDs were asked to complete an 8-item survey assessing components of QI culture on a 5-point scale. INTERVENTION: From 2010 to 2015, multidisciplinary teams from North Carolina LHDs participated in sequential cohorts of a 6-month QI training program, during which the teams completed a QI project. MAIN OUTCOME MEASURE: We dichotomized culture survey responses, with 4 or 5 being "Supportive." We compared adjusted proportions, using linear regression, clustering at LHD, and controlling for cohort. RESULTS: Data from 42 LHDs were included. At baseline, 7.8% responded that their LHD had a supportive culture for all 8 components, compared with 12% at follow-up (P < .001), adjusted for cohort and clustering by LHD. At follow-up, the percentage of employees responding that their LHDs had supportive cultures increased for all components of culture including communication by 4.1% (95% CI: 2.0%-6.2%), problem solving by 2.9% (95% CI: 1.6%-5.5%), team work by 5.2% (95% CI: 2.5%-7.8%), vision by 4.3% (95% CI: 1.1%-7.5%), performance measures by 5.6% (95% CI: 1.6%-9.6%), recognition by 4.7% (95% CI: 1.4%-8.0%), for conflict by 5.5% (95% CI: 1.7%-9.4%), and alignment by 5.8% (95% CI: 2.3%-9.2%). CONCLUSIONS: Engagement with structured QI training programs-and perhaps simply completing QI projects-can cause small, but important changes in organizations' cultures, thus increasing engagement in future QI and improving overall care and services. The article demonstrates that when LHDs participate in a longitudinal, experiential QI training program, their cultures of QI improve. Local health departments participating in similar training programs might experience similar improvements in culture, increasing subsequent participation in QI projects and improving related health outcomes.

Using Quality Improvement Methods to Implement an Early Childhood Oral Health Initiative: A Federally Qualified Health Center Pilot Study.

OBJECTIVES: To assess the use of quality improvement (QI) methods to implement an early childhood oral health program (Baby Oral Health Program-bOHP) in four federally qualified health center (FQHC) dental clinics. STUDY DESIGN: Using a mixed-methods study design, survey responses, administrative data, QI project templates, and focus group measures were collected. Plan-Do-Study-Act (PDSA) cycles as mini-projects to improve the implementation of bOHP were examined. Data analysis included descriptive qualitative reviews and quantitative statistics at baseline, six, and 12 months following the intervention. RESULTS: Twenty-three dental team providers in one urban and three rural clinics participated. Successful QI mini-projects included shortening time period between accepted referral and patient visits, improved documentation of caregiver interview, and efficiency of the infant oral health examination. Lack of change in provider confidence was observed, regardless of years of practice (p=0.93), years of employment (p=0.39), and dental team age (p=0.85). Qualitative reviews highlighted mixed QI results related to training and limited resources invested on follow-up of QI implementation. CONCLUSIONS: A low cost, low resource pilot QI program as part of bOHP implementation showed mixed success, highlighting the critical role of training, staff committment, and leadership support to assure sustainable oral health programs in high-risk populations.

Advancing Quality Improvement in Public Health Departments Through a Statewide Training Program.

OBJECTIVES: To examine the effectiveness of an ongoing statewide public health quality improvement training program (PH QI 101) among 4 cohorts of training participants. DESIGN: We conducted a mixed-method evaluation of the PH QI 101 training program that included measures of participants' satisfaction, learning, behavior change, and participants' translation and spread to their organizations what was learned. Data analysis included descriptive quantitative statistics and qualitative reviews. The Mann-Whitney U test was used to examine changes in participants' confidence to conduct a QI project from pre- to posttraining and 6 months posttraining. PARTICIPANTS: Two hundred two staff members from 37 North Carolina local health departments. INTERVENTION: An 8-month experiential learning process in which participants learn to use QI methods by applying them to a specific project. RESULTS: More than 90% of participants reported satisfaction with the program. Median scores on perceived self-confidence to conduct a QI project significantly increased for all training waves. At least 85% of participants reported spreading QI tools to coworkers posttraining. Two-thirds of participants in 3 waves reported that the QI project conducted during the training was at the sustaining results stage. Most participants in 3 of the training waves reported initiating new QI projects at their health department following training. Facilitators to implementation included interest and support from managers and leaders. Lack of interest and competing priorities among other staff were key barriers to implementation. CONCLUSIONS: This program successfully trained 4 waves of public health professionals in QI tools and methods. Leader training and involvement was a key addition to the adapted model. This statewide approach may serve as a model to other states as they seek to achieve national accreditation standards.

Lessons Learned From Measuring Return on Investment in Public Health Quality Improvement Initiatives.

CONTEXT: The Center for Public Health Quality and its partner, North Carolina State University Industrial Extension Service, used 2 existing, yet similar quality improvement (QI) programs to provide technical assistance to conduct return on investment (ROI) and economic impact (EI) analyses so that they could estimate their QI projects' financial impacts. OBJECTIVES: The objectives of this article are to describe the approach and ongoing learning from applying ROI and EI analyses to public health QI projects and analyze the results in order to illustrate ROI potential in public health. DESIGN: We used a before-after study design for all ROI and EI analyses, spanning a 3-year time period. SETTING: The study was conducted as part of 2 existing public health QI training programs that included webinars, face-to-face workshops, on-site facilitation, and longitudinal coaching and mentoring. PARTICIPANTS: The QI training programs included multidisciplinary teams from local and state public health programs in North Carolina. MAIN OUTCOME MEASURE: Return on investment and EI calculations. RESULTS: Numerous adaptations were made over the 3 years of the ROI program to enhance participant's understanding and application. Results show an average EI of $149 000, and a total EI in excess of $5 million for the 35 projects studied. The average ROI per QI project was $8.56 for every $1 invested in the project. CONCLUSIONS: Adapting the ROI approach was important in helping teams successfully conduct their ROI analyses. This study suggests that ROI analyses can be effectively applied in public health settings, and the potential for financial return is substantial.

Translating Clinical Guidelines Into Practice: Challenges and Opportunities in a Dynamic Health Care Environment.

Clinical practice guidelines are evidence-based recommendations with the potential to improve population health, yet they remain inconsistently utilized. In this commentary we discuss barriers and drivers to implementing clinical practice guidelines. We also suggest ways to support their translation into practice.

Measuring What Matters to Children With Medical Complexity and Their Families.

The Collaborative Improvement and Innovation Network to Advance Care for Children with Medical Complexity (CMC CoIIN) was designed with a foundational commitment to partnership with family leaders to codesign and improve systems of care and supports for CMC and their families - this fundamental commitment was essential to the CMC CoIIN's measurement strategy. In this paper, we examine key learnings from partnering with family leaders from interdisciplinary state teams in the CMC CoIIN to identify and define quantitative quality improvement measures to improve care and support for CMC and their families, including quality of life, well-being, and flourishing; unmet health needs; and support systems such as medical home, patient and family engagement, and shared plans of care. Codesigning the CMC CoIIN measurement strategy with family leaders greatly enhanced our measurement approach and provided numerous unique learning opportunities for the CMC CoIIN's project team and state teams.

The potential impact of the Affordable Care Act on population health in North Carolina.

The need to improve population health is critical. This commentary explores how the Patient Protection and Affordable Care Act of 2010 (ACA) can help us improve population health, highlights some of the actions North Carolina has taken in response to the ACA's provisions, and discusses the value of health investments in the future.

Quality improvement in North Carolina's public health departments.

North Carolina has been a leader in the application of quality improvement (QI) to public health practice. Over the past decade, numerous developments have served to accelerate the adoption of QI in North Carolina's local health departments. The outstanding results from the widespread application of QI should help North Carolina to become a healthier state.

Applying Lean principles and Kaizen rapid improvement events in public health practice.

This case study describes a local home health and hospice agency's effort to implement Lean principles and Kaizen methodology as a rapid improvement approach to quality improvement. The agency created a cross-functional team, followed Lean Kaizen methodology, and made significant improvements in scheduling time for home health nurses that resulted in reduced operational costs, improved working conditions, and multiple organizational efficiencies.

Applying the model for improvement in a local health department: quality improvement as an effective approach in navigating the changing landscape of public health practice in Buncombe County, North Carolina.

In local health departments across the nation, problem solving and rapid change occur every day. Often, the results of these changes or problem-solving techniques may not be studied or evaluated fully to determine whether desired results were achieved. In fact, program evaluation, research, and technical assistance at the local level may be reduced or eliminated in many states during a time of rapidly diminishing resources and increasing demand for public health services. In delivering population-level programs, quality improvement (QI) methods may provide a much-needed alternative and more efficient approach than traditional research and evaluation to help answer public health practice questions such as "How do we know when a project or program really works, and, more importantly, how can we do it better?" This article focuses on the Buncombe County Department of Health's (BCDH's) experience utilizing a QI approach called the model for improvement (MFI), incorporating plan-do-study-act cycles and small tests of change, on a specific H1N1 influenza-awareness public health preparedness communication project. In addition, results of the BCDH's participation in QI initiatives and training resulted in success implementing change in other areas of the health department including decreasing wait time and addressing a backlog of prenatal visit appointments from 54 to 15 days, and more than doubling prenatal history efficiency uptake in a 5-week period. These case studies in the BCDH present how the MFI introduced the foundation of a culture of continuous QI within the organization.

Using quality improvement to promote breast-feeding in a local health department.

In 2008, breast-feeding initiation and continuation rates in Beaufort County, North Carolina, were lower than statewide rates. A quality improvement (QI) project was initiated to increase breast-feeding rates by enhancing the overall environment that supports breast-feeding at the Beaufort County Health Department. This case study describes one of the first QI initiatives implemented through the North Carolina Center for Public Health Quality QI training program, conducted in 2009. The aim of this project was to improve the health and wellness of mothers and infants in Beaufort County by promoting breast-feeding among Beaufort County Health Department Women, Infants and Children (WIC) clients. Using QI tools, 4 new approaches to breast-feeding promotion were tested and implemented: creating a nurturing location to breast-feed while at the health department, actively telephoning new mothers to provide breast-feeding support, incentivizing adoption of educational messages by providing a breast-feeding tote bag, and promoting new WIC food packages. These enhancements involved staff in QI planning and implementation and correlated with improved breast-feeding initiation for WIC clients during the year following project completion.

Lessons learned from building a culture and infrastructure for continuous quality improvement at Cabarrus Health Alliance.

This case study describes a local public health agency's multiyear effort to establish an infrastructure and organizational culture for continuous quality improvement, using data from interviews with the agency's senior leaders, managers, and frontline staff. Lessons learned include the importance of setting stretch goals, engaging leaders at all levels of the organization, empowering frontline staff to make changes, providing quality improvement training for staff and leaders, starting with small projects first, spreading quality improvement efforts to involve all parts of the agency, and sustaining momentum by creating a supporting infrastructure for continuous quality improvement and continually initiating new projects.

Standardizing environmental health processes at the Iowa Department of Public Health.

Standardized work is the foundation of continuous improvement. Documenting standard processes is a precursor to problem solving and allows an organization to understand work flow, measure performance, and identify opportunities for improvement. Environmental health is an important function of public health departments but is rarely studied systematically. This article describes documentation of standard processes, identification of improvement opportunities, and lessons learned for environmental health processes at the Iowa Department of Public Health, using a pilot group of 3 local county offices. The approach described in this article can serve as a template for other states to follow in their quality improvement journeys.

Early evaluation results from a statewide quality improvement training program for local public health departments in North Carolina.

CONTEXT: Many state and local public health agencies have developed accreditation systems and are utilizing quality improvement (QI) methods and tools to improve the public health infrastructure. Development of strategies to support and build the capacity of the public health workforce to apply QI can help advance these efforts. OBJECTIVE: This article describes the adaptation and creation of a standardized QI training program for local health departments (LHDs), explores the effectiveness of the program in increasing the confidence of the LHD staff to apply QI methods and tools, and discusses lessons learned from the first cohort of the program. METHODS: An existing program designed for health care professionals was pilot tested, adapted, and used in 8 LHDs. A formative evaluation of the new public health QI training program was conducted through a hybrid internal and external evaluation model. Pre/postsurveys were used to measure participant satisfaction and the capacity of LHD staff to conduct QI. RESULTS: Staff from 8 LHDs successfully completed the program and 94% of participants reported that they were satisfied with the overall training program. Seventy percent of participants reported a higher perceived confidence in conducting a QI project, and all participants reported sharing QI tools and methods with their coworkers. CONCLUSION: These findings suggest that QI training programs using methods and tools previously applied in health care and other industries can be successfully adapted to public health. Although additional studies are needed to validate the results, this training model can be used to inform future work in developing a standardized QI training program in public health.

Trends in Diagnosis of Noninvasive Follicular Thyroid Neoplasm With Papillarylike Nuclear Features and Total Thyroidectomies for Patients With Papillary Thyroid Neoplasms.

Importance: Increasing detection of early-stage papillary thyroid neoplasms without improvements in mortality has prompted development of strategies to prevent or mitigate overtreatment. Objective: To determine adoption rates of 2 recent strategies developed to limit overtreatment of low-risk thyroid cancers: (1) a new classification, noninvasive follicular thyroid neoplasm with papillarylike nuclear features (NIFTP), and (2) hemithyroidectomy for selected papillary thyroid carcinomas (PTCs) up to 4 cm in size. Design, Setting, and Participants: This is a cross-sectional analysis of 3368 pathology records of 2 cohorts of patients from 18 hospitals in 6 countries during 2 time periods (2015 and 2019). Participating hospitals were included from the US (n = 12), Canada (n = 2), Denmark (n = 1), South Korea (n = 1), South Africa (n = 1), and India (n = 1). The records of the first 100 patients per institution for each year who underwent thyroid-directed surgery (hemithyroidectomy, total thyroidectomy, or completion thyroidectomy) were reviewed. Main Outcomes and Measures: Frequency of diagnosis of NIFTP, PTCs, and thyroidectomies during the study period. Results: Of the 790 papillary thyroid neoplasms captured in the 2019 cohort, 38 (4.8%) were diagnosed as NIFTP. Diagnosis of NIFTP was observed in the US, South Africa, and India. There was minimal difference in the total proportion of PTCs in the 2015 cohort compared with the 2019 cohort (778 [47.1%] vs 752 [44.5%]; difference, 2.6% [95% CI, -16.9% to 22.1%]). The proportion of PTCs eligible for hemithyroidectomy but treated with total thyroidectomy in the 2 cohorts demonstrated a decreasing trend from 2015 to 2019 (341 of 453 [75.3%] vs 253 of 434 [58.3%]; difference, 17.0% [95% CI, -1.2% to 35.2%]). Conclusions and Relevance: Results of this cohort study showed that the 2 mitigation strategies for preventing overtreatment of early-stage thyroid cancer have had mixed success. The diagnosis of NIFTP has only been applied to a small proportion of thyroid neoplasms compared with expected rates. However, more patients eligible for hemithyroidectomy received it in 2019 compared with 2015, showing some success with this deescalation strategy.

Direct observation of resident-patient encounters in continuity clinic: a controlled study of parent satisfaction and resident perceptions.

CONTEXT: Direct observation (DO) by teaching physicians of medical care provided by resident physicians offers a method to evaluate clinical skills beyond traditional measures that focus solely on medical knowledge assessment. OBJECTIVES: We sought to determine if the presence of the teaching physician observer affects parental satisfaction with care and to assess resident perceptions of DO in a general pediatrics residency clinic. METHODS: A cross-sectional parent survey compared visit satisfaction of parents who experienced a DO with controls in a traditional clinic visit. Additionally, a pre-post survey measured resident perceptions of direct observation before and after implementation of DO in the clinic. FINDINGS: Parents frequently described their overall satisfaction with care as "excellent" after DO and traditional visits (DO 70%, 95% CI, 50-86% and control 80%, CI 66-89%). However, parents in DO visits were less likely to rate their satisfaction with the amount of time spent in the room as excellent (DO 78%, CI 58-91%; Control 95%, CI 85-99%). Most resident physicians were in favor of the DO process (63%) and agreed that DO provides feedback about history-taking (94%), physical examination (94%) and interpersonal skills (91%). CONCLUSIONS: Direct observation by attending physicians does not decrease overall parental satisfaction during clinical encounters. Additionally, residents have a generally favorable opinion of direct observation and believe that it can provide useful feedback.