The newly introduced national public health accreditation and its focus on continuous Quality Improvement (QI) has cast a new spotlight on the need for the adoption of Lean in Public Health Departments (PHD). However, as Dilley and her colleagues observed in their study of Quality Improvement Interventions in Public Health Systems, the adoption of Lean and other QI methods has not made enough progress towards increasing efficiencies that lead to better health outcomes.
Continuous improvement in public health has potential for optimizing quality gains in disease surveillance, public health emergency response, health promotion, policy advocacy, and research that lead to actual improvements in health outcomes. But, current QI efforts may not be directly linked to specific improvements in health outcomes. We attribute the lag in public health QI efforts to three factors:
1. The lack of process data in public health: Unlike healthcare or manufacturing where most steps in the major value streams have process data, public health seldom maintains such data. In healthcare, data is maintained on patient wait-times, length of stay, time to admission, time to referral, etc. These data points can be monitored and any deviation from the set threshold may prompt a QI project or a kaizen event. Without consistent process data records, it’s quite a challenge to assess performance and show the need for QI in public health.
2. The lack of evidence-based quality improvement solutions in public health: The long history of collecting process data and analyzing the effects of corrective measures have earned manufacturing and to some extent healthcare evidence-based QI solutions. In healthcare, studies such as the one done by Purdue Healthcare Advisors “Rural hospitals learn ‘lean healthcare’ to the benefits of both patients and providers,” provided evidence-based QI solutions to reduce wait times during patient admission. Public health, on the other hand, relies on untested solutions. For example, one PHD tried to merge three application forms to resolve applicants’ frustrations with the lengthy process of filling and submitting forms for business licenses to the environmental health unit. But there was/is no evidence indicating that merging the application forms would result in an improved user experience or improvements in population health status. After two to three years, applicants may be dissatisfied with the new merged form and another QI project may be needed.
3. The lack of standards upon which to base quality: Whereas the Joint Commission and other quality monitoring bodies provide standards of quality in their fields, public health has not had standards that guide quality until the advent of public health accreditation. It may be that QI will only gain momentum when the adherence to accreditation standards takes broader hold. This is especially important because QI can only be relevant and successful if there is a standard upon which quality can be basedand that those standards can be linked into improved health outcomes.
As Taiichi Ohno said: “without standards, there can be no kaizen.” The PHAB standards are the most comprehensive set of standards we have so far. They have a very high potential to be linked into an improved health outcome.
So, the question is: What does the linking of accreditation standards to health outcomes mean for PHD? Most lean and QI projects aimed at improving compliance with accreditation standards will contribute to improved health outcomes. As such, we recommend that the initial Public health departments’ QI efforts be based on improving compliance with accreditation standards. Lean specialists working with local and state PHDs should conduct baseline assessments of the extent to which the PHDs complied with accreditation standards, then develop a QI plan to improve areas where non-compliance was identified. (For example, if a PHD was not maintaining regular communication with disease surveillance partners, a kaizen event should be held to improve the communication process in the plan.)
As state and local public health departments around the country go through cycles of adherence to accreditation standards, process data will begin to emerge within each department and across departments. It will emerge on the number of disease investigations that are conducted according to the set protocols. Once this data is available, performance targets can be set and when performance results fall short of the targets, QI projects can be initiated. As more and more departments conduct QI activities, the standardization that accreditation enforces will also allow for and encourage best-practices and evidence-based solutions to emerge.
What is stopping you from taking the next step towards accreditation to improve the health of your community and the quality of your services?