A Population Health Driver Diagram to Address Neonatal Abstinence Syndrome.

This article describes the process for developing a population health driver diagram to address a priority health issue in East Tennessee: neonatal abstinence syndrome (NAS). Population health driver diagrams are used in quality improvement processes for determining and aligning actions that a community can take to achieve a specified outcome. The Tennessee Department of Health contracted with the University of Tennessee's Department of Public Health to conduct a community participatory process to contribute to a statewide health improvement plan. Colleagues in local public health practice identified NAS as the leading perinatal health issue, and community engagement was achieved by involving community health councils. Qualitative and quantitative data were collected, analyzed, and provided to these councils. A region-wide stakeholders' meeting resulted in the development of a population health driver diagram to address NAS. We describe this process and provide lessons learned that can be valuable in other settings. Population health diagrams have important implications for practice because of their use as a framework for community action, especially in the context of a community health assessment.

Importance of Performance Measurement and MCH Epidemiology Leadership to Quality Improvement Initiatives at the National, State and Local Levels.

Purpose In recognition of the importance of performance measurement and MCH epidemiology leadership to quality improvement (QI) efforts, a plenary session dedicated to this topic was presented at the 2014 CityMatCH Leadership and MCH Epidemiology Conference. This paper summarizes the session and provides two applications of performance measurement to QI in MCH. Description Performance measures addressing processes of care are ubiquitous in the current health system landscape and the MCH community is increasingly applying QI processes, such as Plan-Do-Study-Act (PDSA) cycles, to improve the effectiveness and efficiency of systems impacting MCH populations. QI is maximally effective when well-defined performance measures are used to monitor change. Assessment MCH epidemiologists provide leadership to QI initiatives by identifying population-based outcomes that would benefit from QI, defining and implementing performance measures, assessing and improving data quality and timeliness, reporting variability in measures throughout PDSA cycles, evaluating QI initiative impact, and translating findings to stakeholders. MCH epidemiologists can also ensure that QI initiatives are aligned with MCH priorities at the local, state and federal levels. Two examples of this work, one highlighting use of a contraceptive service performance measure and another describing QI for peripartum hemorrhage prevention, demonstrate MCH epidemiologists' contributions throughout. Challenges remain in applying QI to complex community and systems-level interventions, including those aimed at improving access to quality care. Conclusion MCH epidemiologists provide leadership to QI initiatives by ensuring they are data-informed and supportive of a common MCH agenda, thereby optimizing the potential to improve MCH outcomes.

A Performance Management Initiative for Local Health Department Vector Control Programs.

Local health department (LHD) vector control programs have experienced reductions in funding and capacity. Acknowledging this situation and its potential effect on the ability to respond to vector-borne diseases, the U.S. Centers for Disease Control and Prevention and the Public Health Foundation partnered on a performance management initiative for LHD vector control programs. The initiative involved 14 programs that conducted a performance assessment using the Environmental Public Health Performance Standards. The programs, assisted by quality improvement (QI) experts, used the assessment results to prioritize improvement areas that were addressed with QI projects intended to increase effectiveness and efficiency in the delivery of services such as responding to mosquito complaints and educating the public about vector-borne disease prevention. This article describes the initiative as a process LHD vector control programs may adapt to meet their performance management needs. This study also reviews aggregate performance assessment results and QI projects, which may reveal common aspects of LHD vector control program performance and priority improvement areas. LHD vector control programs interested in performance assessment and improvement may benefit from engaging in an approach similar to this performance management initiative.

Sustaining a quality improvement culture in local health departments applying for accreditation.

CONTEXT: This article focuses on local health departments (LHDs) that are advanced in accreditation and quality improvement (QI) efforts and the barriers and facilitators associated with sustaining improvements and building an organizational culture of QI. OBJECTIVE: To understand the barriers and facilitators associated with building and sustaining progress toward a QI culture in LHDs. DESIGN: Quantitative data from a self-reporting survey and qualitative data from telephone interviews. SETTING: Twenty-two LHDs across the United States responded to the survey. Ten of the 22 LHD respondents participated in telephone interviews. PARTICIPANTS: QI lead staff at LHDs that are advanced in accreditation preparation and QI. MAIN OUTCOME MEASURES: Self-reported LHD survey ratings against indicators for a QI culture, and the identified barriers and facilitators around sustaining QI initiatives. RESULTS: Of the 6 domains of a QI culture measured in the survey, the percentages of respondents that scored themselves highly to at least 1 indicator in each domain are as follows: leadership commitment (100%); employee empowerment (100%); teamwork and collaboration (100%); continuous process improvement (86%); customer focus (72%); and QI infrastructure (64%). Qualitative data from 10 telephone interviews revealed that key barriers to sustaining progress around QI included staff turnover, budget cuts, and major crises or events that arise as priority. Key facilitators included leadership commitment, accreditation, and dedication of resources and staff time to QI. CONCLUSIONS: When engaging in QI, LHDs should consider investing efforts in gaining leadership support and dedicating staff time early in the QI journey to ensure that QI efforts and initiatives are sustained. Local health departments interested in developing a QI culture should also consider pursuing accreditation, as it provides a structured framework for continuous improvement. They should also actively develop QI knowledge and skills among all staff members to minimize the negative impact of staff turnover.

Understanding and controlling variation in public health.

Variation in work processes is a critically important concept and method for creating true and sustainable improvement in public health services and activities. This article describes the concept of variation based on W. Edwards Deming's profound knowledge and defines basic terms such as common cause and special cause variation. Control charts are explained as the primary tool for calculating variation within work processes. The article also provides an example of how variation theory can be applied to create sustainable improvement in public health.

Defining quality improvement in public health.

Many industries commonly use quality improvement (QI) techniques to improve service delivery and process performance. Yet, there has been scarce application of these proven methods to public health settings and the public health field has not developed a set of shared principles or a common definition for quality improvement. This article discusses a definition of quality improvement in public health and describes a continuum of quality improvement applications for public health departments. Quality improvement is a distinct management process and set of tools and techniques that are coordinated to ensure that departments consistently meet the health needs of their communities.

Realizing transformational change through quality improvement in public health.

OBJECTIVE: This article discusses the specific components necessary to achieve transformational change within public health departments as a means for creating sustained performance improvement and better outcomes in the health of the community. DESIGN: This article provides a review of transformation change concepts and application to public health departments. RESULTS: Transformational change for public health departments must be intentionally designed to achieve high performance. While all improvement requires change, not all change results in improvement. CONCLUSION: The successful transformational change effort always occurs from the top-down, while the process improvement occurs from the bottom-up. Transformational change is possible in public health departments when small incremental improvements are linked with large-scale management changes to continually improve public health performance resulting in better population outcomes.

Validation of a method for the determination of narasin in the edible tissues of chickens by liquid chromatography.

Maxiban and Monteban are 2 products marketed by Elanco Animal Health. They contain narasin and are used for the prevention of coccidiosis in chickens. Products used in the European market must be regularly re-registered with new data to support label claims. This study was undertaken as part of such a re-registration effort. A method for the determination of narasin in poultry tissue was previously registered with the authorities; however, a method with more environmentally friendly solvents was desired. The Canadian Food Inspection Agency accomplished this goal and published an improved method. In order to register the method with European authorities as the official Elanco method for determination of narasin, Elanco scientists were required to provide validation data for all edible poultry tissues. This paper shows the validation of the method to detect residues of narasin using solid-phase extraction followed by liquid chromatographic analysis utilizing post-column derivatization.