Application of Quality and Performance Improvement Concepts



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Health Policy and Management Exercise 2:

Application of Quality and Performance Improvement Concepts:

Examples from a Tuberculosis Control Program


Instructor’s guide version 1.0





HPM Exercise 2: Application of Quality and Performance Improvement Concepts:

Examples from a Tuberculosis Control Program


Estimated Time to Complete This Exercise: 40 Minutes

LEARNING OBJECTIVES


At the completion of these exercises, participants should be able to:

  • Describe the purpose, basic steps, and components of quality improvement

  • Explain how the components of quality improvement fit within the logic model structure

  • Select program inputs, outputs, and outcomes to be assessed as part of quality improvement efforts

ASPH HEALTH POLICY AND MANAGEMENT COMPETENCIES ADDRESSED


D.7. Apply quality and performance improvement concepts to address organizational improvement issues

ASPH INTERDISCIPLINARY/CROSS-CUTTING COMPETENCIES ADDRESSED


K.4. [Program Planning] Explain the contribution of logic models in program development, implementation, and evaluation

K. 5.[Program Planning] Differentiate among goals, measurable objectives, related activities, and expected outcomes for a public health program

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This material was developed by the staff at the Global Tuberculosis Institute (GTBI), one of four Regional Training and Medical Consultation Centers funded by the Centers for Disease Control and Prevention, in collaboration with the Charles P Felton National Tuberculosis Center. It is published for learning purposes only.
Author: Julie Franks, PhD

Charles P Felton National Tuberculosis Center


For further information, please contact:

New Jersey Medical School GTBI

225 Warren Street P.O. Box 1709
Newark, NJ 07101-1709

or by phone at 973-972-0979



Suggested citation: New Jersey Medical School Global Tuberculosis Institute. Incorporating Tuberculosis into Public Health Core Curriculum./ 2009: Health Policy and Management Exercise 2: Application of Quality and Performance Improvement Concepts: Examples from a Tuberculosis Control Program INSTRUCTOR’S GUIDE Version 1.0.

Guide for Instructors



These teaching materials provide an introduction to quality improvement (QI), using logic models to describe program activities and develop related QI steps. After briefly reviewing QI and logic models, students are asked to complete exercises based on a published case study that describes QI efforts within a state-run public health program. The reading material provided includes a paragraph to orient students to the health care services provided by the program

This material is designed for in-class use, with students working in small groups to complete the exercises. After students have completed the steps in Exercise 1 (Complete Logic Model of Program Services), they should come together to discuss their work. As the students share the logic model components they have identified, the instructor may use classroom media to generate a complete logic model based on the students’ findings. Some points for discussion and an answer key of logic model components are included in the teaching materials. Exercise 2 can be completed in the same fashion, with students working in small groups and then coming together as a class to discuss their completed QI logic model. Discussion points and an answer key for Exercise 2 are also included.

Although it is possible for the exercises to be completed individually as a homework assignment, the debate and discussion in small groups may be as valuable as the correct identification of logic model components within the article excerpts provided.

Introduction: Quality Improvement (QI) and Logic Models
QI refers to efforts to continuously monitor and improve program services by systematically assessing relationships among essential program components: problems to be addressed by the program, the program’s organizational context, resources, activities, service outputs, short- and long-term objectives, and goals. QI is built into routine program activities and is undertaken from within an organization, so that administrators, managers, and service providers are engaged in monitoring and improving progress toward program objectives and goals. Because QI is an integral part of program activities, planning for and implementing QI are also integrated into program planning. Many public service programs rely on logic models for program planning. Logic models are particularly useful for focusing QI activities and implementing improvements suggested by QI.
A logic model presents a systematic, graphic representation of the intended links among problems to be addressed, program resources, activities, and outcomes. While the visual scheme of a logic model may vary, it will contain the core components described in the following section.
Logic Model Core Components

Inputs are the enabling and constraining factors that influence a program’s progress toward its goals. The magnitude and characteristics of problems to which the program responds are crucial contextual inputs, as are infrastructure and financial, human, and community resources. In some very basic logic models, the category of inputs may be designated simply as resources. However, the model’s capacity to describe the program is increased if it includes the health burden or specific problem addressed in a program and contextual factors that impact a program’s design and implementation.

Activities include service provision and the necessary steps of program implementation in all its phases. Hiring processes and the establishment of community partnerships are crucial activities in the early phases of program development, as are providing adequate training and supervision of staff. Collecting data to monitor progress in meeting program objectives, disseminating program results, and expanding the funding base are more significant activities in a mature program.
Outputs are the direct products of program activities, such as services delivered or products completed, which provide evidence of service delivery to the target audience as intended. Outputs may also be evidence of program development, such as number of people hired and trained.
Outcomes are specific, measurable changes that are linked to program activities and outputs. Such changes may occur in knowledge, behaviors, or skills of a program’s target population. Outcomes are often measured as short-term or long-term. Short-term results, such as the proportion of a target audience completing prescribed treatment are achieved within a given reporting period, such as quarterly, semiannually, or annually. Long-term outcomes, such as decrease in disease incidence within a target population, manifest over reporting periods or several years of program activities. Outcomes reflect a program’s progress in meeting specific objectives and can provide the impetus for designing or refining QI efforts that will lead to program improvements.
Goals are broad-ranging, fundamental changes linked to program efforts. The goal is realized only after short- and long-term outcomes have taken effect and may be dependent on factors beyond program outcomes or objectives.

The W.K. Kellogg Foundation describes the logic model as a series of “if – then” statements that map the intended road from program efforts to program results.1

Certain conditions create need for program services; program operations require certain resources



IF conditions and resources exist THEN you can accomplish planned activities

IF you accomplish activities, THEN you will deliver products and

Services as planned



IF you deliver products and services as planned, THEN target population will benefit in certain ways

IF target population benefits from program, THEN community- or organizational- level changes may occur


Inputs



(Conditions/

Resources)

Activities

Outputs

Outcomes

Goal




Planned work

Intended results

Adapted from: W.K. Kellogg Foundation, Logic Model Development Guide (Battle Creek, MI, 2004), p.3

QI activities document and assess the intended links between each component of the logic model: how resources are invested in activities; how activities result in outputs; and how outputs promote intended short- and long-term outcomes. Information generated by QI monitoring highlights where the intended links among program components are weak or broken. Whether QI reporting represents these links quantitatively in logs and statistics or qualitatively in narrative descriptions depends on the nature of a program and its specific QI goals. Programs adjust their activities as needed based on QI feedback; thus, QI is effective to the degree that it provides program personnel with timely feedback that can be used to modify or enhance on-going activities.

QI in Action: An Example From the Mississippi State Department of Health Tuberculosis Control Program
The following 2 exercises ask students to use logic models to describe a public health program and its QI efforts. In Exercise 1 they will complete a logic model for the program, and in Exercise 2 explore a model for the program’s QI efforts.
Exercise 1: Complete a Logic Model of Program

This exercise is based on an excerpt from a published article that has been adapted with permission from the publisher. It describes steps the Mississippi State Department of Health (MSDH) took to improve its tuberculosis (TB) control program. Read the background section and program activities description, and identify the specific logic model components of the TB control program’s latent tuberculosis infection (LTBI) treatment efforts.


Background: The Control of TB in the United States and Treatment of LTBI2

To control and ultimately eliminate TB, the first priority of TB control programs throughout the Unites States is to ensure completion of treatment among people who have TB disease. The priority given to patients with TB disease reflects the risks of mortality, on-going transmission of TB, and proliferation of drug-resistant TB associated with noncompletion of treatment for TB disease. Confirmed cases of TB disease must be reported to state or municipal TB control programs, and programs then report cases to the Centers for Disease Control and Prevention’s Division of TB Elimination.

Treatment for LTBI can also play an important role in the elimination of TB. Effective treatment significantly reduces the chance that a person with LTBI will ever develop contagious TB disease, and can, therefore, reduce the infections that would be transmitted through contact with a case of TB disease, infections that could themselves become additional cases of TB disease.

In Mississippi, as in other parts of the Unites States, the state TB control program adopted completion of treatment for LTBI as an important program objective after seeing a steady decline in cases of TB disease in the state in the late 20th century. Because there is no regulatory mandate for treatment of LTBI as there is for treatment of TB disease, many TB control programs are challenged to ensure that patients who are prescribed LTBI regimens successfully complete the course of treatment.
The reasons why many patients do not complete treatment are complex. They may include low motivation to take LTBI medications, since individuals with LTBI are not suffering from symptoms of TB and may never develop TB disease. In addition, the medication may cause side effects. Finally, although the Mississippi TB control program provides LTBI medication without charge for patients without insurance, LTBI patients must go to designated health clinics for monthly appointments throughout the course of treatment, which is of several months’ duration.
LTBI Program Activities

During the early 1980s, Mississippi's TB case rate was the second highest in the nation. In response, the MSDH adopted the ambitious goal of eradicating TB in the state. The MSDH invested human and material resources in a program of directly observed therapy (DOT), in which outreach workers brought medication doses to all patients with infectious TB to ensure that they complete TB treatment.3 The state’s aggressive, consistent TB disease management and control efforts yielded a steady 13-year decline in TB morbidity, the longest continuous, state-wide decline in TB morbidity in the nation.

To reach the ultimate goal of eradicating TB in Mississippi, the MSDH also offers treatment for LTBI to individuals with LTBI, especially those at high risk of developing TB disease, including young children and people who are HIV-infected.

In 2003, the state’s LTBI treatment program was the subject of MSDH QI efforts.
The MSDH LTBI Treatment Program

All health care providers who conduct screening for LTBI in Mississippi report positive findings to the MSDH and refer patients with positive results to a MSDH health clinic for a full evaluation and initiation of treatment, if appropriate. Treatment is voluntary and only patients who are willing to be treated receive medications.


Prior to the initiation of MSDH QI efforts in 2003, LTBI patients were followed according to an established protocol. During the course of treatment, LTBI patients were dispensed monthly supplies of medication. They were asked to return to their health clinic monthly in order to be evaluated for side effects and adherence to medication, and to receive medication for the coming month. The medication regimen was considered completed when the LTBI patient had received all the prescribed medication. Health clinic personnel were highly proactive in following LTBI patients at high risk of developing TB disease. They went to meet high-risk patients who had missed clinic appointments at their homes and conducted multiple face-to-face educational sessions focusing on the importance of completing the medication regimen. Clinic staff also followed up with LTBI patients who were not identified as high-risk, contacting them if they missed clinic appointments to remind them of the importance of completing LTBI treatment and assess their willingness to continue treatment. However, there were longer delays of a month or more between a missed appointment among these average-risk patients and a follow-up call from the clinic staff.

Before MSDH QI efforts in the LTBI program began, approximately 13% of all identified LTBI patients in the state were overdue for completion of their medication regimen. This percentage varied from 3 to 22% over the 9 MSDH administrative health districts across the state.


Exercise 1: Complete a Logic Model of Program Activities
Step 1: List inputs needed for LTBI treatment services in the first column and program activities related to LTBI services in the second.


Inputs

(Context/Problem and Resources)


Program Activities







Step 2: For each program activity you have listed, identify the resulting outputs. Outputs should be expressed as a quantity, such as numbers of patients receiving a service.


Program Activities

Outputs






Step 3: Identify the LTBI program outcomes and their goal related to LTBI services.


Outcomes

Goal





Answer Key for Exercise I: MSDH TB Control Program LTBI Treatment Services

Step 1: List inputs and resources needed for LTBI treatment services in the first column, and activities related to LTBI services in the second.



Inputs

(Context/Problem & Resources)


Program Activities

Context/Problem

Declining rates of TB disease


Increased programmatic emphasis on LTBI treatment
Persistently low rates of completion for LTBI treatment
Resources

MSDH clinic staff


MSDH clinic facilities
Medications and other supplies
MSDH vehicles for face-to-face interviews

with high-risk patients




Identify and evaluate LTBI cases


Start LTBI cases on treatment

Evaluate each LTBI patient at least every

30 days
Dispense monthly medication supplies to patients, monitor side effects, and provide education
Identify high-risk patients with missed appointments
Meet face-to-face with high-risk patients to identify and address barriers to treatment continuation
Identify average-risk patients with missed appointments
Contact average-risk patients to identify and address barriers to treatment continuation




Step 2: For each program activity you have listed, identify the resulting outputs. Outputs should be expressed as a quantity, such as numbers of patients receiving a service.


Program Activities

Outputs

Identify and evaluate LTBI cases

Start LTBI cases on treatment
Evaluate each LTBI patient at least every 30 days
Dispense monthly medication supplies to patients, monitor side effects, and provide education

Identify high-risk patients with missed appointments


Meet face-to-face with high-risk patients to identify and address barriers to treatment continuation
Identify average-risk patients with missed appointments
Contact average-risk patients to identify and address barriers to treatment continuation

Number of cases identified and evaluated
Number of cases started on treatment
Number of patients evaluated monthly
Number of patients receiving monthly medications and monitoring
Number of high-risk patients who fail to return monthly for medication
Number of high-risk patients located
Number of high-risk patients met with
Number of average-risk patients who fail to return monthly for medication
Number of average-risk patients located and met with



Step 3: Identify the LTBI program outcomes and their goal related to LTBI services.

Outcomes

Goal

Short-term outcome

Patients continue LTBI treatment


Long-term outcome

Patients complete LTBI treatment




Patients treated for LTBI do not develop TB disease
Decrease in reported cases of TB
Eradicate TB in Mississippi


Points for Discussion of Exercise I

  • In the case of TB control in Mississippi, inputs include both the declining rate of TB disease in the state, which freed up program resources that could then be dedicated to treatment of LTBI; and persistently low rates of completion of LTBI treatment, which created the need for activities to improve treatment completion.





  • As the LTBI program is described here, it did not define outputs or outcome targets, so that the program did not have a built-in mechanism for tracking performance. Without this mechanism, the MSDH could not easily judge if progress were being made toward the state’s goal of eradicating TB.


Complete Logic Model of Program Services

Inputs

Program Activities

Outputs

Outcomes

Goal

Context/Problem

Declining rates of TB disease


Increased programmatic emphasis on LTBI treatment
Persistently low rates of completion for LTBI treatment
Resources

MSDH clinic staff


MSDH clinic facilities
Medications and other supplies
MSDH vehicles for face-to-face interviews with high-risk patients

Identify and evaluate LTBI cases
Start LTBI cases on treatment
Evaluate each LTBI patient at least every 30 days
Dispense monthly medication supplies to patients, monitor side effects, and provide education
Identify high-risk patients with missed appointments
Meet face-to-face with high-risk patients in order to identify and address barriers to treatment continuation
Identify average-risk patients with missed appointments
Contact average-risk patients to identify and address barriers to treatment continuation


Number of cases identified and evaluated
Number of cases started on treatment

Number of patients evaluated monthly

Number of patients receiving monthly medications and monitoring
Number of high-risk patients who fail to return monthly for medication
Number of high-risk patients located
Number of high-risk patients met with
Number of average-risk patients who fail to return monthly for medication
# of average-risk patients located and met with


Short-term outcome

Patients continue LTBI treatment


Long-term outcome

Patients complete LTBI treatment




Patients treated for

LTBI do not develop

TB disease
Decrease in reported

cases of TB


Eradicate TB in Mississippi


Exercise 2
Planning and Implementing QI
In the same way that logic models describe program components, they can be used to map QI efforts. Because QI efforts are integrated into program activities, some components of a QI logic model will mirror related program logic model components. For instance, the ultimate goal of QI and the program goal may be identical. In the case of the MSDH’s efforts to improve completion of treatment for LTBI through QI, the QI goal and the program goal are identical: the eradication of TB in Mississippi. Similarly, QI outcomes may be closely related to program outcomes.
For this exercise, read the 2nd excerpt below that describes the MSDH’s efforts in LTBI QI, and list the specific QI activities, outputs, and short- and long-term outcomes.

Development of QI Efforts

In October 2002, a new administration took office in the MSDH and gave high priority to performance accountability and QI. The MSDH LTBI program was one of several disease-control programs targeted for performance accountability and QI interventions. The MSDH administrative and disease surveillance staff came together with representatives from county-level clinic staff in a multidisciplinary QI team.

The QI team members developed specific, achievable state-level objectives, including the short-term objective of achieving a 5% noncompletion rate for all LTBI patients who started treatment. The objectives were derived from an analysis of missed appointments and treatment completion among LTBI patients at each clinic over the 4-month period preceding the start of QI efforts. The team established an evaluation database to document missed LTBI treatment appointments at every MSDH clinic in an on-going manner and to compile monthly data from all clinics. The team also developed quality control charts to depict missed appointments and numbers of patients who had completed treatment at individual clinics, within each state health district, and in the state overall. A schedule was drawn up according to which clinics would receive monthly feedback on LTBI program performance. Monthly feedback allowed clinic staff to quickly identify the need to respond to missed appointments and to assess the effectiveness of their efforts to reach missing patients. Clinics were also able to track their performance over time and compare it with other clinics and health districts in the state.
Results of QI Efforts

Monthly reviews of data began in February 2003 and continued for 6 months through July 2003. The mean LTBI medication completion rate increased and the standard deviation of completion rates among health districts decreased during the study period. This pattern held over all administrative health districts with minor exceptions.



Exercise 2: Complete a Logic Model for QI Efforts

Step 1: List inputs and resources needed for QI efforts in the first column and related activities in the second.

Inputs

Context/Problem and Resources


QI Activities







Step 2: For each activity you have listed, identify the resulting QI outputs.


QI Activities

Outputs







Step 3: Identify QI outcomes and their goal related to QI efforts.

Outcomes

Goal







Answer Key for Exercise 2: MSDH QI Efforts
Step 1: List inputs and resources needed for QI efforts in the first column and related activities in the second.

Inputs

(Context/Problem & Resources


QI Activities

Persistently low rates of LTBI treatment completion in TB control program

(The article points out that in 2002, 13% of patients did not complete LTBI treatment, with the percentage of noncompletion in state health districts ranging from 3 to 22%)

New MSDH administration
MSDH leadership committed to QI efforts
Performance accountability and quality improvement principles
Multidisciplinary QI team
MSDH evaluation database


Announce priority given to performance accountability and QI
Select targets for QI
Establish multidisciplinary QI team
Set specific, achievable objectives
Use statistical analysis and quality control charts in ongoing improvement evaluation process
Provide concise and timely feedback to TB program



Step 2: For each activity you have listed, identify the resulting QI outputs.


QI Activities

Outputs

Announce priority given to performance accountability and QI
Select targets for QI

Establish multidisciplinary QI team

Set specific, achievable objectives

Use quality control charts in ongoing improvement evaluation process


Provide concise and timely feedback to TB program


Awareness of MSDH performance accountability and QI efforts
QI targets selected, including LTBI program activities
Multidisciplinary QI team established
Specific, achievable objectives set and distributed
Quality control charts used by all LTBI clinics

Concise and timely feedback provided by TB program to LTBI clinic staff





Step 3: Identify QI outcomes and their goal related to QI efforts.


Outcomes

Goal

Improve clinic follow-up with patients receiving LTBI treatment
Increase to 95% the proportion of LTBI patients placed on treatment who complete a recommended treatment regimen


Decrease the reported incidence of TB
Eradicate TB in Mississippi


Points for Discussion of Exercise 2:

  • The MSDH leadership’s commitment to QI was an important contextual factor that enabled QI efforts to go forward.

  • Key activities included communicating information about QI plans as they developed. Such sharing of information resulted in valuable output: attainable QI objectives.

  • QI outcomes were closely linked to program outcomes. The essential difference was that QI outcomes were measurable (progress toward a reduction in the rate of noncompletion of treatment) and were divided into reasonable short- and long-term outcomes. Thus the QI efforts allowed the TB program to continuously assess how well it achieved its long-term outcome of treatment completion. Over time, this information will also allow the program to track the relationship between achieving this long-term outcome and its progress toward the goal of eradicating TB in Mississippi.

Complete Logic Model of QI Efforts


Inputs

(Conditions and Resources)

Activities

Outputs


Outcomes

Goal

Persistently low rates of LTBI treatment completion in TB control program

(The article points out that in 2002, 13% of patients did not complete LTBI treatment, with the percentage of noncompletion

in state health districts ranging from 3 to 22%)
New MSDH administration
MSDH leadership committed to QI efforts
Performance accountability and quality improvement principles
Multidisciplinary QI team
MSDH evaluation database


Announce priority given to performance accountability and QI
Select targets for QI

Establish multidisciplinary QI team

Set specific, achievable objectives

Use quality control charts in ongoing improvement evaluation process


Provide concise and timely feedback to TB program


Awareness of MSDH performance accountability and QI efforts
QI targets selected, including LTBI program activities
Multidisciplinary QI team established
Specific, achievable objectives set and distributed
Quality control charts used by all LTBI clinics

Concise and timely feedback provided by TB program to LTBI clinic staff



Improve clinic follow-up with patients receiving LTBI treatment
Increase to 95% the proportion of LTBI patients placed on treatment who complete a recommended treatment regimen


Decrease the reported incidence of TB
Eradicate TB in Mississippi

References
  1. W.K. Kellogg Foundation. Logic Model Development Guide. Battle Creek, MI: W.K. Kellogg Foundation; 2004.





  1. Fos PJ, Lee JE, Sung JH, Zuniga MA, Amy BW. The role of quality improvement in disease management: a statewide tuberculosis control success story. J Public Health Pract. 2005;11:222-227.



  1. Holcombe JM. Not by D.O.T. Alone. http://www.msdh.state.ms.us/msdhsite/_static/14,485,125.html. Accessed November 10, 2009.



1 W.K. Kellogg Foundation. Logic Model Development Guide.

2 Fos PJ, Lee JE, Sung JH, Zuniga MA, Amy BW. The role of quality improvement in disease management: a statewide tuberculosis control success story. J Public Health Manag Pract. 2005;11:222-227. Excerpted and adapted with permission from the publisher.

3 See J. Michael Holcombe, MPPA, CPM, Mississippi State TB Controller. ‘Not by D.O.T. Alone’.

Date last modified: November 19, 2009




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