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From 2005 to 2008, researchers at the RAND Corporation spurred the use of quality improvement—a data-driven approach to performance often used in industry, the military and health care, but not public health—to boost emergency preparedness among state and local public health agencies.
The researchers published a white paper and articles on the quality improvement approach, developed a pilot collaborative to help five public health agencies use it to prepare for pandemic flu and created a toolkit to encourage other agencies to use quality improvement to improve emergency preparedness.
Researchers reported the following findings in "Using Quality Improvement Methods To Improve Public Health Emergency Preparedness: PREPARE For Pandemic Influenza" (Health Affairs, 27, 2008; online version, July 2008):
Researchers reported the following additional results to the Robert Wood Johnson Foundation (RWJF):
RWJF provided $328,322 through three grants from June 2005 to October 2008. The Office of the Assistant Secretary for Preparedness and Response of the U.S. Department of Health and Human Services also provided funding under two larger contracts with RAND for work on pandemic flu and emergency preparedness.
In the wake of September 11th, the threat of anthrax, pandemic flu and other public health crises, the ability of the U.S. public health system to respond to emerging threats has taken on new importance.
Quality improvement—a data-driven process that identifies desired outcomes, measures performance and promotes best practices—had become important in industry, the military and health care. That approach also can help create adaptable, effective public health organizations, according to researchers at the RAND Corporation, a nonprofit research organization in Santa Monica, Calif. However, it was underused in public health, and agencies lacked widely tested models for applying it.
In 2002, RAND researchers studied nationwide public health preparedness and the ability of local health departments to respond to threats such as epidemics, under a contract with the federal Department of Health and Human Services (DHHS), Office of the Assistant Secretary for Preparedness and Response. The investigators found substantial variation in performance among the agencies: Some responded well, whereas others performed poorly.
The researchers also found that:
The RAND researchers participated in an RWJF meeting on applying the quality improvement approach to public health on November 10, 2004. After talking with staff members from the Institute for Healthcare Improvement (IHI), Cambridge, Mass., at the meeting, the RAND researchers decided to work with them to promote the use of quality improvement methods in public health.
IHI has been the national program office for three RWJF programs:
RWJF has been involved in quality improvement efforts in health care for many years. Funding has covered numerous areas of the health care system, including:
The Public Health Team has built upon these efforts in developing its strategy to improve performance in public health. The team's Strategy Statement on the Foundation's Web site states:
"For the public health system to fulfill its important role in ensuring the safety and health of the public, we must drive fundamental improvements in the quality, performance and impact of public health agencies. We are advancing efforts to help public health agencies improve the services they provide and increase accountability to the communities they serve. We support efforts to establish a national accreditation system for state and local public health agencies. Accreditation will establish agency standards and benchmarks that promote excellence, continuous quality improvement and accountability for the public's health.
"Quality improvement efforts are not limited to public health agencies. We seek to improve the performance within and across the public health system. To that end, we foster collaboration among federal, state and local public health agencies and others integral to the public health system, such as businesses, health care providers, educational institutions, and faith- and community-based organizations. Recognizing the importance of strong leaders to strengthen the system, we are supporting a nationwide leadership program designed to improve cooperation among federal, state and local leaders from the private, public and not-for-profit sectors to work collaboratively to increase preparedness for the challenges of both manmade and natural disasters."
Researchers at the RAND Corporation spurred the use of quality improvement—a data-driven approach to performance often used in industry, the military and health care, but not public health—to boost emergency preparedness among state and local public health agencies, under three grants from RWJF.
During the first grant (ID# 053270; June 2005 to December 2005), RAND researchers worked with staff at the Institute for Healthcare Improvement (IHI) to create a white paper showing how to apply quality improvement in public health. (For information on the paper's contents, see Results and the Appendix.)
To identify best practices, the researchers conducted seven site visits and two telephone interviews with nine exemplary state and local health departments that were known to have made big strides in improving their emergency preparedness, or to be advancing quality improvement and accreditation efforts. They also developed a follow-up plan calling for a pilot learning collaborative to apply quality improvement to emergency preparedness in public health—specifically a global outbreak of influenza or pandemic flu.
The RAND researchers began planning the pilot collaborative—called Promoting Emergency Preparedness and Readiness for Pandemic Influenza, or PREPARE for PI—in 2005, under a contract with the Office of the Assistant Secretary for Preparedness and Response. The collaborative was part of RAND's work on pandemic flu preparedness under a $2-million contract with the federal Department of Health and Human Services (DHHS).
Although IHI had extensive experience with quality improvement collaboratives, it relied on a model targeted to chronic care and clinical practice rather than public health. RAND researchers therefore began working with staff at the Center for Health Care Quality at Cincinnati Children's Hospital and Medical Center, which had participated in learning collaboratives in public health.
Because PREPARE for PI was the first quality improvement collaborative in emergency preparedness, and one of only a few in public health, the researchers realized that they needed more time to develop a framework and performance measures and to educate participants. RWJF therefore provided funding to extend the time period for the collaborative (Grant ID# 058603; November 2006 to June 2007).
The Collaborative Framework
To develop a framework for the collaborative's work, RAND researchers convened a team of experts in emergency preparedness and quality improvement from RAND and Cincinnati Children's Hospital and Medical Center. The resulting framework included four components:
The planners agreed to apply this framework to five activities designed to reduce mortality, morbidity and social disruption in the event of a flu pandemic:
The Quality Improvement Process
Three- or four-person teams from five health departments—two state and three local—agreed to participate in the collaborative to improve their pandemic flu preparedness, from May 2006 to February 2007. The departments were:
The teams attended three 1.5-day learning sessions (May and September 2006 in Washington, and February 2007 in Santa Monica, Calif.). The teams also submitted monthly progress reports to RAND and participated in conference calls with project staff and other experts.
During the learning sessions, the teams chose which of the five key activities they would focus on and created goals and performance measures for each activity. The teams then used small, rapid-cycle tests to implement changes in preparedness at their agencies. RAND researchers evaluated the results through an online survey, interviews with team members and the monthly team reports. (See Findings for more information.)
To encourage other public health departments to integrate quality improvement into their work, RWJF then funded RAND to create and disseminate results and tools from the learning collaborative (Grant ID# 062347; August 2007 to December 2008). To develop a toolkit, project staff convened an advisory board of experts in public health and the use of quality improvement and also solicited input from a RAND advisory board.
The Office of the Assistant Secretary for Preparedness and Response at DHHS provided funding to enable project staff to search the Web for best practices in emergency preparedness for use in the toolkit. This effort was part of RAND's work on pandemic flu preparedness under a $2-million contract with DHHS.
Project staff produced a white paper, articles, a toolkit and a webinar (online seminar) on using quality improvement in public health preparedness and disseminated these products through the Web and at national conferences and other events. See Results and the Bibliography for details.
RAND researchers reported the following findings from studying the collaborative in "Using Quality Improvement Methods To Improve Public Health Emergency Preparedness: PREPARE For Pandemic Influenza" (Health Affairs, July 2008, online issue):
Researchers reported the following additional results to RWJF:
As of May 2009, RAND is continuing to promote the use of quality improvement methods and tools in public health and emergency preparedness. For example, the organization is working with the Centers for Disease Control and Prevention to develop accountability measures for state and local public health emergency preparedness.
The project has had a significant impact on the way RAND disseminates its work on emergency preparedness, according to the project co-directors. For example, the organization is now creating more user-friendly CD-based toolkits and other products for use by the public health community and also is offering more webinars to such practitioners.
Using quality improvement methods to improve public health emergency preparedness
RAND Corporation (Arlington, VA)
Contact: Nicole Lurie, M.D., M.S.P.H.
(703) 413-1100 ext. 5127
RAND Corporation (Santa Monica, CA)
Contact: Debra Lotstein, M.D., M.P.H.
(310) 393-0411, ext. 6076
Findings and Recommendations in Quality Improvement in Public Health: A Way Forward (2006)
Factors Contributing to the Quality Improvement Gap Between Public Health and Other Fields
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Lotstein D, Seid M, Ricci K, Leuschner K, Margolis P and Lurie N. "Using Quality Improvement Methods To Improve Public Health Emergency Preparedness: PREPARE For Pandemic Influenza," Health Affairs, 27(5); Web Exclusive: w328–w339, July 2008. Abstract available online.
Seid M, Lotstein D, Williams VL, Nelson C, Leuschner KJ, Diamant A, Stern S, Wasserman J and Lurie N. "Quality Improvement in Public Health Emergency Preparedness," Annual Review of Public Health, 28: 19–31, 2007. Abstract available online.
Seid M, Lotstein D, Nelson C and Lurie N. Quality Improvement in Public Health: A Way Forward. Arlington, VA: RAND, 2006.
"Quality Improvement Strategies for Public Health Emergency Preparedness," held November 19, 2008. Available online.
Report prepared by: Lori De Milto
Reviewed by: Sandra Hackman
Reviewed by: Molly McKaughan
Program Officer: Susan B. Hassmiller
Program Officer: Terry L. Bazzarre
Program Officer: Abbey K. Cofsky
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