Wanted: QI professionals to improve community health status
QI skills needed to analyze data, focus efforts
Who in the hospital has the skills to assess and contribute to community health improvement? Several health care quality experts say members of hospital quality improvement, utilization review, and outcomes management departments hold the key. Their expertise is ideal for unlocking the potential of community health improvement programs.
QI professionals, however, must be willing to adapt and change the way they go about their business to play a key role, they stress.
"There is a movement to create accountability around the health and well-being in communities, and people with experience in outcomes measurement are going to become a significant asset. They're needed, and they have to be ready to roll up their sleeves and jump in," says Tyler Norris, a Boulder, CO-based consultant.
Ann Bailey, MBA, program manager of community health improvement at the Veterans Healthcare Administration in Washington, DC, says all hospital quality professionals are well-suited for community health initiatives because of their grounding in continuous quality improvement (CQI) principles.
"Community health improvement we see as CQI applied at the community level," Bailey says. "It's really a CQI process. You start with what are the health issues, what data about the health status of the community is available, and also what are the needs that the community identifies through focus groups and surveys?" It's then a matter of prioritizing those needs and developing action teams to deal with them, she says.
Bailey says quality professionals have the potential to be instrumental in:
* helping determine community needs and goals;
* selecting indicators of community health;
* collecting and tracking community data;
* introducing interventions.
"Let's say one [community] need was reducing teen pregnancy or violence. A team would follow that and set up a monitoring cycle. They'd look at the data, decide what the intervention would be, and make necessary changes," Bailey says.
She adds that the CQI expertise found in quality departments can be applied in gathering data for community health indicators and helping decide what the indicators should be. "There are data out there at a high level, so from the statistical expertise side, the quality department can offer the expertise," she says. "And there aren't a whole lot of good methods of evaluating. A lot of organizations haven't thought about evaluation until the end. So we advocate using a CQI approach to do that, to use tools for consensus building such as charts and the cause-and-effect diagrams, so you can chart the root causes of a health issue."
Sometimes, even when data are readily available, politics decides how money is spent. "What if your biggest problem in a community is heart disease, but everyone's focused on violence? There are tools, facilitation skills, and so forth that you get from the CQI level," Bailey says. "It's taking CQI out to the community. So the data isn't so much of a problem; what's a problem is that sometimes there's not an agreement on how to track it."
So far, however, not many institutions are applying Bailey's thinking. "From a standpoint of thinking of it as a CQI process, we don't see a lot of that," Bailey says.
Marian Knapp, who for three years was project leader of the Boston-based Community-Wide Health Improvement Learning Collaborative, agrees. "There is some discussion about [using quality tools in community health], but my own impression is that a lot of people aren't doing it."
Knapp, whose project was a joint enterprise between the Institute for Healthcare Improvement in Boston and a small not-for-profit organization called GOAL-QPC in Methuen, MA, says she brought together nine teams from the United States and Canada, and each picked an important topic to its community, such as post-neonatal death or falls in the elderly. "The teams worked for two years, struggling and working with experts to actually figure out whether or not the principles of continuous improvement might be applicable to community health, and the answer is yes.
"I'm convinced that these methods are the missing link, because what it does is provide a framework for people to actually take action in a simple format that anyone can learn," Knapp says.
Community health priorities variable
But Knapp, like other community health professionals, cautions that outcomes measurement and other QI tools cannot be goals in and of themselves, and must be subservient to the community's goals. "Outcomes measurement is critical if you know what you're trying to get done," Knapp says. "It doesn't do any good to have the outcomes measured if you don't have goals. What quality improvement says is you have to define a very clear aim about what you want to have done. In one of our communities, we wanted to reduce post-neonatal death [infants two to 12 months]. We then looked at what outcomes measure we needed to track to know that we were reducing it. So the measurement came second, not first. You've got to decide what you want to do, and then get the data that's available."
Knapp cautions that while good, solid, scientifically based outcomes measures are important, an organization cannot spend forever getting them. If it does, it will never get started on the solution. "We had some teams that spent six to nine months trying to collect data, whereas if they had just spent a week in the emergency room seeing what's coming in, they would know what the issues are," Knapp says.
One has to be flexible when dealing with community health issues, as well, because the community's priorities often change weekly, Knapp says. A CQI approach cannot be so rigid that it cannot accommodate such changes. Knapp says the top 10 issues in a community will stay the same, but they will be ranked differently at different times. So it would be useless to spend too much time coming up with a scientifically based measure to name the top indicator.
Acceptance by community needed
How should QA/UR professionals prepare for this trend, if they're not already? For one, they need to bone up on population-based statistics. "Community health improvement is a dynamic process where you assess what the health needs and goals are, look for collaborative partners, and address them from a systematic standpoint," says Patsy Matheny, MPA, MSW, director of community health improvement at U.S. Health Corporation in Columbus, OH. "And for that you use both quantitative and qualitative population-based statistics. If you carry out those assessments and identify what would bring better quality of life and health to the community, that's key to how you pick indicators."
When reaching out to the community, however, the community must understand what must be done and why. Too often, health care quality gets mired in complicated formulas and flowcharts, Norris says. "You cannot use quality language in a community setting because the terms don't make sense at a grass-roots level," he says.
"The purpose isn't to create QI but to create results," Norris says. And for that, he says QI people need to work on their communication skills to translate complicated data into everyday language that makes issues relevant to the community.
Knapp agrees. "If people start talking about the details of standard deviation, you're going to lose 90% of the people affected by the problems," she says.
Nonetheless, many quality experts believe it can be done. "Clearly there is an opportunity for quality people to use their skills in a new way to partner with other people" in community health, says Jamie Novell, executive vice president of Crozer Keystone Health System in Media, PA.
"Quality people have some skills and tools that would be useful in community health, and they have the opportunity to go out and proactively involve themselves, and most people also have some experience in tracking information that is, in some cases, difficult to find," Novell says. *
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