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.     

Transparent Democratic Foresight Strategies in the California EMF Program

A California Department of Health Services program dealt with possible health effects from Electric and Magnetic Fields (EMF) from power lines. With the advice of stakeholders, and well before any risk determinations were made, transparent policy analyses about the power grid and schools asked the question, "How confident must one be of how big an effect before one would adopt cheap or expensive EMF avoidance measures?" A risk evaluation was carried out with features that promoted transparency. It was formatted to provide a policy-neutral "degree of certainty of causality" to adherents of utilitarian, environmental justice, and libertarian policy frameworks. Though the program had many features advocated by adherents of the precautionary principle, it might be better characterized as following "Transparent Democratic Foresight Strategies," since no single principle justifies the strategies used in this participatory program, and it examined the pros and cons of options but made no recommendations, precautionary or otherwise.     

New approach in the evaluation of a fitness program at a worksite

The most common methods for the economic evaluation of a fitness program at a worksite are cost-effectiveness, cost-benefit, and cost-utility analyses. In this study, we applied a basic microeconomic theory, "neoclassical firm's problems," as the new approach for it. The optimal number of physical-exercise classes that constitute the core of the fitness program are determined using the cubic health production function. The optimal number is defined as the number that maximizes the profit of the program. The optimal number corresponding to any willingness-to-pay amount of the participants for the effectiveness of the program is presented using a graph. For example, if the willingness-to-pay is $800, the optimal number of classes is 23. Our method can be applied to the evaluation of any health care program if the health production function can be estimated.     

Monitoring simultaneously two or more indices of health care. Multivariate quality control procedures

Often the data collected in a health care evaluation program consist of a number of indices, each of which represents a different component of a health care process. The question, "Is the health care process in control," to be answered effectively, must be answered in terms of the effect of the several indices considered jointly rather than in terms of each variable considered separately. This article describes the nature of the problem of monitoring jointly several indices of health care and presents two quality control methods, the control ellipse and Hotelling's T2, which are applicable to the multivariable setting. The discussion focuses on the case of monitoring simultaneously two related indices of health care, and extension of the two techniques to more than two indices is discussed briefly.     

A practical reporting and evaluation system for intervention programs: guiding principles and potential uses.

The continued existence of intervention programs is contingent on the ability to answer basic questions such as "What is your program doing?" and "Why should we fund your program?" This paper outlines basic principles and describes a practical reporting and supplemental evaluation system that can be used by administrators of even the smallest intervention program.     

Issues confronting the new health professionals.

New health practitioners (NHPs) is a generic term referring to mid-level health workers such as physician's assistants and nurse practitioners who perform tasks traditionally within the purview of physicians. In the little over ten years since the first program to train physician assistants was initiated at Duke University, 6,500 physician's assistants (PAs) have completed formal training programs. Similarly, programs to train nurses for extended roles have prepared more than 8,500 nurse practitioners over the same decade. This paper considers the comparative achievements of these two major new health professions during the last decade and identifies eight crucial issues which may influence new health professionals in the ten years which lie ahead: (1) How many NHPs are enough? (2) What impact are NHPs making on distribution? (3) Do we know what clinical difference NHPs make? (4) Are NHPs bringing about cost control in health care? (5) What is the status of the controversy between organized medicine and nursing with regard to NHPs? (6) Are there differences between nurse practitioners and physician's assistants? (7) How are NHPs certified? and (8) Finally, can a better name than "new health practitioners" be found?     

Health technology assessment and public health: a commentary

This article reviews the developments in HTA in four countries, France, The Netherlands, Sweden, and United Kingdom, in relation to public health. It emphasizes that the majority of assessments made are concerned with individual clinical care rather than with the optimization of health. Possible reasons for the neglect of public health issues are that these are inherently more complex than the assessment of individual procedures or drugs. They are usually multisectoral, politically charged, and often considered mundane and "common sense" and, thus, not requiring evaluation (although when evaluations are done they are often counterintuitive). Unless more emphasis is given to the development and evaluation of public health measures, it is unlikely that there will be any major advances in health status. Possible areas for future assessment should include such issues as smoking, drug and other substance misuse, nutrition, and health inequalities. However, it is unlikely that these major areas of concern will be included in the future unless the methods of choice for priorities of development and assessment are changed to include measures that improve health status rather than only clinical services.     

Qualitative methods in program evaluation

The choice of evaluation methodology is as important as any part of the assessment process. In the past, most selections have been made from among various quantitative strategies and techniques. Recently, program evaluation researchers have begun to discuss some of the limitations of quantitative techniques for addressing some evaluation questions. In response to these limitations--most of which characterize the evaluation of health promotion programs--some have turned to a set of techniques which can complement or, at times, replace quantitative evaluation methods. These methods are collectively called "qualitative" evaluation methods. In this article, we highlight some of the differences between quantitative and qualitative approaches and suggest ways in which both may be used in a given evaluation effort.     

Steps to a HealthierUS Cooperative Agreement Program: foundational elements for program evaluation planning, implementation, and use of findings

The Steps to a HealthierUS Cooperative Agreement Program (Steps Program) enables funded communities to implement chronic disease prevention and health promotion efforts to reduce the burden of diabetes, obesity, asthma, and related risk factors. At both the national and community levels, investment in surveillance and program evaluation is substantial. Public health practitioners engaged in program evaluation planning often identify desired outcomes, related indicators, and data collection methods but may pay only limited attention to an overarching vision for program evaluation among participating sites.     

Developing a process-evaluation plan for assessing health promotion program implementation: a how-to guide

Process evaluation is used to monitor and document program implementation and can aid in understanding the relationship between specific program elements and program outcomes. The scope and implementation of process evaluation has grown in complexity as its importance and utility have become more widely recognized. Several practical frameworks and models are available to practitioners to guide the development of a comprehensive evaluation plan, including process evaluation for collaborative community initiatives. However, frameworks for developing a comprehensive process-evaluation plan for targeted programs are less common. Building from previous frameworks, the authors present a comprehensive and systematic approach for developing a process-evaluation plan to assess the implementation of a targeted health promotion intervention. Suggested elements for process-evaluation plans include fidelity, dose (delivered and received), reach, recruitment, and context. The purpose of this article is to describe and illustrate the steps involved in developing a process evaluation plan for any health promotion program.     

Suggestions for improving the study of health program implementation.

More will be learned about health programs and the implementation of health policy in this country if we pay more attention to issues of program implementation. Of particular use would be more studies which explicitly link program implementation with program outcomes and which recognize the need to combine quantitative and qualitative analysis of program implementation; the use of triangulated methods in focusing on the relationship between program implementation and program outcomes; the incorporation and study of planned variation in the methods of implementing programs; recognition that the process is essentially one of organizational change and innovation, and the incorporation of existing theory and evidence relevant to these issues; and recognition that the ongoing nature of the implementation process requires longitudinal study designs for implementation as well as for outcome assessment. Cronbach [9] has remarked that evaluation research "lights a candle in the darkness, but it never brings dazzling clarity." It may be that more attention to program implementation and better research on the process, such as that suggested in this note, will provide a little more light and will bring if not dazzling , at least modest, improvements in clarity.     

In the world but not of the world: going beyond a dilemma

Is the issue addressed in this volume a question like "What time is it?" or a quest-ion like "What is time?" I argue that it is a quest-ion that requires professional chaplaincy to quest for an answer although it will always have blurred edges that lack succinctness, clarity, and certainty. The challenge posed by the quest-ion means that we must transform the dilemma into a higher synthesis that respects the qualitative aspects inherent in the profession.     

To the class of 2005: Will you be ready for the quality revolution?

BACKGROUND: Graduates are becoming aware of the vast changes occurring in the health care and scientific environments, which will place unprecedented demands on them. A SECOND REVOLUTION: It has been suggested that the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm have alerted healthcare professionals and managers to system defects, enlisted a broad array of stakeholders in the agenda, and accelerated changes in practice needed to eliminate errors and unnecessary deaths. It is now commonplace for comparative data on the effectiveness of hospitals and medical groups to be published in this new age of transparency. Coalitions of employers are now urging the adoption of safer practices in hospitals. In addition, the science of quality improvement has flourished and become robust. COMING CHANGES AND POSSIBILITIES: The changes over the next five years will be breathtaking. Those doctors and hospitals with the best clinical outcomes will benefit from seeing more patients and may even be paid more by Medicare, Medicaid, and insurance companies. Patients will access, via the Web, the latest quality information and make more informed choices about where to seek their care. The environment in which care is provided is also undergoing a major transformation. Hospital buildings themselves are becoming more healing, safer places. Graduates may ask themselves, "Will my residency adequately prepare me to understand and apply the science of quality improvement and evidence-based practice?"     

Awareness of the Food and Drug Administration's Bad Ad Program and Education Regarding Pharmaceutical Advertising: A National Survey of Prescribers in Ambulatory Care Settings

The U.S. Food and Drug Administration's Bad Ad program educates health care professionals about false or misleading advertising and marketing and provides a pathway to report suspect materials. To assess familiarity with this program and the extent of training about pharmaceutical marketing, a sample of 2,008 health care professionals, weighted to be nationally representative, responded to an online survey. Approximately equal numbers of primary care physicians, specialists, physician assistants, and nurse practitioners answered questions concerning Bad Ad program awareness and its usefulness, as well as their likelihood of reporting false or misleading advertising, confidence in identifying such advertising, and training about pharmaceutical marketing. Results showed that fewer than a quarter reported any awareness of the Bad Ad program. Nonetheless, a substantial percentage (43%) thought it seemed useful and 50% reported being at least somewhat likely to report false or misleading advertising in the future. Nurse practitioners and physician assistants expressed more openness to the program and reported receiving more training about pharmaceutical marketing. Bad Ad program awareness is low, but opportunity exists to solicit assistance from health care professionals and to help health care professionals recognize false and misleading advertising. Nurse practitioners and physician assistants are perhaps the most likely contributors to the program.     

Respiratory therapists' attitudes toward recredentialing

Recredentialing, sometimes referred to as recertification, is the process whereby people maintain their professional credentials by retesting or continuing education. The National Board for Respiratory Care has proposed mandatory recredentialing policies for respiratory therapists who receive a professional credential after July 1, 2002. The purpose of this study was to determine respiratory therapists' attitudes toward recredentialing. The author developed a survey instrument that was mailed to a systematic random sample of 1,000 subjects drawn from the active membership of the American Association for Respiratory Care. Data analysis consisted of frequencies, percentages, and measures of central tendency. Group means were compared using the independent groups t-test, with a significance level of p < or = 0.05. Of the surveys, 562 (56.2%) were returned. Of the 15 statements about recredentialing that were rated on a 5-point Likert scale, the respondents were most in agreement with "Proof of continuing education should be sufficient for recredentialing"; "There should be a way to determine whether a respiratory therapist is competent to practice"; and "I don't want to be required to recredential." In response to the multiple-choice question "Who should be in charge of assuring the continuing competency of respiratory therapists, the most frequently selected response was "Employers of respiratory therapists." Most respiratory therapists do not want to be required to recredential. If they are required to recredential, however, they prefer the use of contining education rather than retesting.     

Transition to family practice in Turkey

INTRODUCTION: Turkey's primary health care (PHC) system was established in the beginning of the 1960s and provides preventive and curative basic medical services to the population. This article describes the experience of the Turkish health system, as it tries to adapt to the European health system. It describes the current organization of primary health care and the family medicine model that is in the process of implementation and discusses implications of the transition for family physicians and the challenges faced in meeting the needs for health care staff. In Turkey a trend toward urbanization is evident and more staff positions in rural PHC centers are vacant. Shortages of physicians and an ineffective distribution of doctors are seen as a major problem. Family medicine gained popularity at the beginning of the 1990s, as a specialty with a 3-year postgraduate training program. Medical practitioners who are graduates of a 6-year medical training program and are already working in the PHC system are offered retraining courses. Better working conditions and higher salaries may be important incentives for medical practitioners to sign a contract with the social security institution of Turkey. DISCUSSION: The lack of well-trained primary care staff is an ongoing challenge. Attempts to retrain medical practitioners to act as family physicians show promising results. Shortness of physician and health professionals and lack of time and resources in primary health care are problems to overcome during this process.     

Placentophagia in humans and nonhuman mammals: causes and consequences

Afterbirth ingestion by nonhuman mammalian mothers has a number of benefits: (1) increasing the interaction between the mother and infant; (2) potentiating pregnancy-mediated analgesia in the delivering mother; (3) potentiating maternal brain opioid circuits that facilitate the onset of caretaking behavior; and (4) suppressing postpartum pseudopregnancy. Childbirth is fraught with additional problems for which there are no practical nonhuman animal models: postpartum depression, failure to bond, hostility toward infants. Ingested afterbirth may contain components that ameliorate these problems, but the issue has not been tested empirically. The results of such studies, if positive, will be medically relevant. If negative, speculations and recommendations will persist, as it is not possible to prove the negative. A more challenging anthropological question is "why don't humans engage in placentophagia as a biological imperative?" Is it possible that there is more adaptive advantage in not doing so?     

Effective healthcare teams require effective team members: defining teamwork competencies

Background

Hospital in the home programs have been implemented in several countries and have been shown to be safe substitutions (alternatives) to in-patient hospitalization. These programs may offer a solution to the increasing demands made on tertiary care facilities and to surge capacity. We investigated the acceptance of this type of care provision with nurse practitioners as the designated principal home care providers in a family medicine program in a large Canadian urban setting.

Methods

Patients requiring hospitalization to the family medicine service ward, for any diagnosis, who met selection criteria, were invited to enter the hospital in the home program as an alternative to admission. Participants in the hospital in the home program, their caregivers, and the physicians responsible for their care were surveyed about their perceptions of the program. Nurse practitioners, who provided care, were surveyed and interviewed.

Results

Ten percent (104) of admissions to the ward were screened, and 37 patients participated in 44 home hospital admissions. Twenty nine patient, 17 caregiver and 38 provider surveys were completed. Most patients (88%–100%) and caregivers (92%–100%) reported high satisfaction levels with various aspects of health service delivery. However, a significant proportion in both groups stated that they would select to be treated in-hospital should the need arise again. This was usually due to fears about the safety of the program. Physicians (98%–100%) and nurse practitioners also rated the program highly. The program had virtually no negative impact on the physician workload. However nurse practitioners felt that the program did not utilize their full expertise.

Conclusion

Provision of hospital level care in the home is well received by patients, their caregivers and health care providers. As a new program, investment in patient education about program safety may be necessary to ensure its long term success. A small proportion of hospital admissions were screened for this program. Appropriate dissemination of program information to family physicians should help buy-in and participation. Nurse practitioners' skills may not be optimally utilized in this setting.     

Managed care: quality management differentiates the product

Comprehensive quality management is a goal that requires major corporate commitment to implement and maintain. The best results in a quality management program will be achieved when all components are tied together in a comprehensive program. To do that, a significant investment in personnel and equipment is required. As the benefits of having a program such as the one as described above become more widely known and accepted, more and more managed care insurers and providers will adopt these or similar standards. The question, "How do you know that patients are getting high-quality and sufficient care?" cannot be answered today by insurers who do not have such a program.