Using Six Hat Thinking to Improve Childhood Immunization

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Using Six Hat Thinking to Improve Childhood Immunization Rates National Immunization Conference, March 23,

Using Six Hat Thinking to Improve Childhood Immunization Rates National Immunization Conference, March 23, 2005 Barbara Boshard, BSN, MS Quality Improvement Team Leader Section for Communicable Disease Prevention Missouri Department of Health & Senior Services

Session Objectives n Describe the Role of CQI to Improve Immunization Rates n Discuss

Session Objectives n Describe the Role of CQI to Improve Immunization Rates n Discuss the Missouri CQI Model n Share Missouri Tools for Improvement

Missouri’s Immunization Program 2004 $21, 500, 000

Missouri’s Immunization Program 2004 $21, 500, 000

Missouri VFC Program Medicaid Eligible n Un-Insured n American Indian n Alaskan Native n

Missouri VFC Program Medicaid Eligible n Un-Insured n American Indian n Alaskan Native n Less than or Equal to 18 years Old n

Missouri Non-VFC Program n n n n Underinsured Pediatric Clients Hepatitis A/B for Adults

Missouri Non-VFC Program n n n n Underinsured Pediatric Clients Hepatitis A/B for Adults at Risk through STD Clinics Refugees and Immigrants Un- or Underinsured Students (does not include Meningococcal vaccine) Defined Disease Outbreaks Influenza and Adult Td State School Employees

Missouri’s VFC Program n Total VFC Providers = 731 u LPHA = 113 u

Missouri’s VFC Program n Total VFC Providers = 731 u LPHA = 113 u FQHC/RHC = 184 u Other Public = 35 u Private = 399

VFC Site Visits 2004 LPHA n FQHC/RHC n Other Public n Private n Total

VFC Site Visits 2004 LPHA n FQHC/RHC n Other Public n Private n Total n = 97: 113 (86%) n = 132: 184 (72%) n = 11: 35 (31%) n = 165: 399 (41%) n = 390 (53%) n

QI Questions/ PDCA Cycles Six Hat Thinking What do we want? P Blue Hat

QI Questions/ PDCA Cycles Six Hat Thinking What do we want? P Blue Hat Who cares? P AFIX Assessment Red Hat Assessment What are we doing now? P White Hat Assessment Can we do better? P White Hat Assessment Why can’t we? P What changes are needed? P Do it! D Did it work? Black Hat Assessment Green Hat Feedback/ Exchange Info Green Hat Action Plan C/P White Hat Exchange Info Can we do it every time? C/A White Hat Assessment Learn/celebrate? P/A Blue &Yellow Hats Incentives

Principles of CQI Directed by “Customer” Needs n Involves Frontline Staff in Solutions n

Principles of CQI Directed by “Customer” Needs n Involves Frontline Staff in Solutions n Assigns No Blame n Improved Decisions Based on Facts n Improved Results n Continuous Over Time n

The Three Circles of CQI Customer Focus Scientific Outcomes Based

The Three Circles of CQI Customer Focus Scientific Outcomes Based

PDCA Short-term Success Cycles n Plan Do n n Act Check n Plan (Assess)

PDCA Short-term Success Cycles n Plan Do n n Act Check n Plan (Assess) Do (Implement Pilot) Check (Evaluate) Act (Implement Real Change) (Deming, Ishakawa, Shewhart)

Traditional Quality Assurance n Input n Activity n Output = (Example: Number of shots

Traditional Quality Assurance n Input n Activity n Output = (Example: Number of shots given)

Quality Improvement Focus n n n Benefits or changes for participants New Knowledge Increased

Quality Improvement Focus n n n Benefits or changes for participants New Knowledge Increased Skill Changed Attitudes or Values Improved Condition Altered Status

PDCA Cycle One 2003 -2004 n Organized Workgroup n Created Standards, Policies and Procedures

PDCA Cycle One 2003 -2004 n Organized Workgroup n Created Standards, Policies and Procedures n Implemented Manual

Building the Workgroup n Include Key Players n Set Group Norms n Learn about

Building the Workgroup n Include Key Players n Set Group Norms n Learn about CQI n Prioritize n Implement CQI n Use CQI to Improve Immunization Rates in Missouri

Workgroup Priorities n n n Understand & Use CQI Create Specific Standards Use CQI

Workgroup Priorities n n n Understand & Use CQI Create Specific Standards Use CQI to Improve Processes and Customer Service Comply with Grant Build Awareness of Immunization Program in Missouri

CQI & Six Hat Thinking Blue=Pulling It All Together Green=Creating Red=Feeling White=Seeking Information &

CQI & Six Hat Thinking Blue=Pulling It All Together Green=Creating Red=Feeling White=Seeking Information & Data Black=Thinking Logically Yellow=Believing/Supporting

Purpose of Six Hat Thinking* n To Simplify Thinking n To Manage One Thing

Purpose of Six Hat Thinking* n To Simplify Thinking n To Manage One Thing at a Time n To Change if Change is Needed *De. Bono, E, Six Thinking Hats, Little, Brown, & Co. , Boston, 1999.

Beliefs About Six Hat Thinking You Must: n Wear all Hats for Effective Change

Beliefs About Six Hat Thinking You Must: n Wear all Hats for Effective Change n Wear the Right Hat at the Right Time

The Organizer Hat

The Organizer Hat

Blue Hat Question What do we want to accomplish related to immunizations?

Blue Hat Question What do we want to accomplish related to immunizations?

The Fact Hat

The Fact Hat

White Hat Questions n What are we doing now? n How well are we

White Hat Questions n What are we doing now? n How well are we doing it?

The Feeling Hat

The Feeling Hat

Red Hat Questions n What is my gut feeling about how our immunization program

Red Hat Questions n What is my gut feeling about how our immunization program works in our office? Who cares?

The Careful & Cautious Hat

The Careful & Cautious Hat

Black Hat Questions n What are the risks if we change how we do

Black Hat Questions n What are the risks if we change how we do business? n What prevents us from doing better?

The Sunny & Positive Hat

The Sunny & Positive Hat

Yellow Hat Questions n Can we do it? Sure we can!

Yellow Hat Questions n Can we do it? Sure we can!

The Creative Hat

The Creative Hat

Green Hat Questions n What changes can we make to do better?

Green Hat Questions n What changes can we make to do better?

The Organizer Hat

The Organizer Hat

Blue Hat Summary Questions n What have we accomplished? n Where do we need

Blue Hat Summary Questions n What have we accomplished? n Where do we need to go now?

CQI = AFIX n Assessment n Feedback n Incentive n e. Xchange of Information

CQI = AFIX n Assessment n Feedback n Incentive n e. Xchange of Information

Remember This Main Concept: + A F + EQUALS CQI I + X

Remember This Main Concept: + A F + EQUALS CQI I + X

What is AFIX? n The single most effective strategy documented by CDC for improving

What is AFIX? n The single most effective strategy documented by CDC for improving immunization rates. n AFIX is a provider-level continuous quality improvement process

Assessment n Assessment of a sample of patient records using CASA (Clinical Assessment Software

Assessment n Assessment of a sample of patient records using CASA (Clinical Assessment Software Application) n Sample 50 Client Records

Feedback of assessment results/reports to clinic staff n Present findings to people who can

Feedback of assessment results/reports to clinic staff n Present findings to people who can make a change n Use CASA reports as a tool to stimulate discussion and as bench marks to measure future change n Offer positive reinforcement and suggestions n

Incentive n Incentive – offering ideas, tools, and other support to help the clinic

Incentive n Incentive – offering ideas, tools, and other support to help the clinic improve rates What would be an incentive for your immunization clinic?

e. Xchange of Information n Collaboratively developing improvement strategies, implementation plans, and ongoing support/follow-up

e. Xchange of Information n Collaboratively developing improvement strategies, implementation plans, and ongoing support/follow-up needs n Clinic specific n Clinic driven

Main Priorities n Create & Implement Specific Standards for CASA/AFIX n To Move Program

Main Priorities n Create & Implement Specific Standards for CASA/AFIX n To Move Program from QA (CASA) to CQI (AFIX)

Performance is Measured n CDC’s National Immunization Survey (NIS)

Performance is Measured n CDC’s National Immunization Survey (NIS)

National Immunization Survey (NIS) Conducted by CDC every 6 months n Random sample by

National Immunization Survey (NIS) Conducted by CDC every 6 months n Random sample by state n Determines immunization status of children n Phone interviews of parents n Confirmed by follow-up with physicians n Includes all children – not only VFC n

Missouri’s NIS Rates Missouri Rates vs National Average 1996 - Mid-Year 2004 Completed 4:

Missouri’s NIS Rates Missouri Rates vs National Average 1996 - Mid-Year 2004 Completed 4: 3: 1: 3: 3 series (full ACIP-recommended series, pre. Varicella)

5 Year Tracking and Trending

5 Year Tracking and Trending

Other CQI Tools Tracking and Trending Providers with 90% and above coverage for 4:

Other CQI Tools Tracking and Trending Providers with 90% and above coverage for 4: 3: 1: 3: 3: 1 n Standardized Action Plans n Ordering History n Vaccine Inventory/Accountability n

VFC Providers 2004 Immunization Rates 90% or Greater 22: 390 = 6%

VFC Providers 2004 Immunization Rates 90% or Greater 22: 390 = 6%

Major Obstacles to CQI n n n n Supporting CQI from Top Down Supporting

Major Obstacles to CQI n n n n Supporting CQI from Top Down Supporting CQI from Within the Group Involving all Levels Determining Adequate Measures Allotting Adequate Time Committing to CQI Process Following-through

The Future – PDCA Cycle 2 Achieve New Level 1 AFIX Standards from CDC

The Future – PDCA Cycle 2 Achieve New Level 1 AFIX Standards from CDC n Address Parking Lot Issues n Restructure to be more Effective n Build Day Care and School Review Systems n Improve Registry n

Provider Action Plan n Identify one thing you can do in your practice setting

Provider Action Plan n Identify one thing you can do in your practice setting to improve your immunization program in 2005. We/I will ___________ [action step(s)] To increase the current immunization rate from _______ (rate) to _______ (rate) by December 31, 2005.

Vision for 2005 and Beyond To provide AFIX for 100% of Missouri’s childhood immunization

Vision for 2005 and Beyond To provide AFIX for 100% of Missouri’s childhood immunization providers each year in order to improve the state’s childhood immunization rates

“Never doubt that a small group of thoughtful, committed people can change the world.

“Never doubt that a small group of thoughtful, committed people can change the world. Indeed it is the only thing that ever has. ” (Eleanor Roosevelt)

Presented by: Barbara Boshard, RN, BSN, MS QI Team Leader Section for Communicable Disease

Presented by: Barbara Boshard, RN, BSN, MS QI Team Leader Section for Communicable Disease Prevention Division of Environmental Health and Communicable Disease Prevention Missouri Department of Health and Senior Services 930 Wildwood Drive, Jefferson City, MO 65102 T: 573 -751 -6439; FAX: 573 -751 -6447 boshab@dhss. mo. gov