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8/8/2014
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How Can Local Boards of Health Facilitate Healthcare and Public Health Partnerships to Improve the Health of Communities?
2014 NALBOH Annual Conference
2:45-3:45 p.m.
Jack Moran, PhD Senior Quality Advisor, Public Health Foundation
PHF Mission: We improve the public’s health by strengthening the quality and performance of public health practice
www.phf.org
Today We Will Discuss
How Local Boards of Health can facilitate healthcare and public health partnerships to improve the health of their communities.
Describe a framework being used to build collaborative healthcare and public health partnerships to impact health issues at the community level.
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1. Policy Development
2. Resource Stewardship
What are the driving and restraining forces to developing successful partnerships/collaboration for healthcare and public health to impact the health of a community?
Driving Forces Restraining Forces
Limited Collaboration
F u
What are the driving and restraining forces to developing successful partnerships/collaboration for healthcare and public health to impact the health of a community?
Background of the PHF Project
• IHI/CDC initiative • 8 hospitals • Driver diagram for hospitals • Year-long collaborative
PHF t d PH• PHF represented PH • PHF developed PH driver
diagram • Implemented in 3 pilot sites • Developed one for Oral Health
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Timely and appropriate antibiotic utilization in the acute care setting
Timely and appropriate initiation of antibiotics
A i t d i i t tiD d i id f
•Promptly identify patients who require antibiotics •Obtain cultures prior to starting antibiotics •Do not give antibiotics with overlapping activity or combinations not supported by evidence or guidelines •Determine and verify antibiotic allergies and tailor therapy accordingly •Consider local antibiotic susceptibility patterns in selecting therapy •Start treatment promptly •Specify expected duration of therapy based on evidence and national and hospital guidelines
•Make antibiotics patient is receiving and start dates visible at point of care
•Develop and make available expertise in antibiotic use •Ensure expertise is available at the point of care
Appropriate administration and de-escalation
Decreased incidence of antibiotic-related adverse drug events (ADEs)
Decreased prevalence of antibiotic resistant healthcare- associated pathogens
Decreased incidence of healthcare-associated C. difficile infection
Decreased pharmacy cost for antibiotics
•Monitor, feedback, and make visible data regarding antibiotic utilization, antibiotic resistance, ADEs, C. difficile, cost, and adherence to the organization’s recommended culturing and prescribing practices
Availability of expertise at the point of care
•Give antibiotics at the right dose and interval •Stop or de-escalate therapy promptly based on the culture and sensitivity results •Reconcile and adjust antibiotics at all transitions and changes in patient’s condition •Monitor for toxicity reliably and adjust agent and dose promptly
PHF Convened a Panel of Public Health Experts to:
Identify the primary and secondary drivers of optimal antibiotic utilization in community health settings, as well as unique and shared responsibility for drivers
Identify the elements of a potential change package (i.e., a menu of intervention options)
Actions at various handoff points in patient care system
Potential policy changes
Opportunities for health departments to improve messaging and Opportunities for health departments to improve messaging and education, and answer questions
Aimed at consumers/customers
Home health nurses
INDEPENDENCE Health Department Goals of the Initiative
CenterPoint Medical Center, one of eight hospitals, began collaborating with the Health Department
Reduce the spread of antibiotic resistance
Preserve antibiotics for the future
Decrease demand by the public for inappropriate use
Provide opportunities for collaboration between public health and healthcare
Improve patient care
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Connecticut - Goals of the Initiative
To strengthen or build partnerships between public health (DPH) and the medical provider community across the spectrum of healthcare
To build public health capacity and action in HAI prevention – expand from our surveillance role
To share and complement public health’s strengths with To share and complement public health s strengths with medicine’s strengths
To build the methods and tools of Quality Improvement into public health as well as medical care
To prevent C. difficile and MDROs (MRSA)
Documentation Staff
Family/Visitors
Denial
Lack of follow through
Not reporting/responding to symptoms
Not using PPE properly
High staff turnover & different staff on different units- cut corners
Lack of environmental cleaning with bleach
Improper stool collection/ handling
Home remedies/ food Failure to report
Language Barrier
Inappropriate antibiotic use
Lack of education
Non compliant treatment
Lack of staffing Community Issues
Building DesignLack of PPE
Lack of signage
Lack of communication
Lack of education
Lack of supplies
Lack of administrator support
No timely lab results/ lack od specimen pickupNo commode liner
Maine - Goals of the Initiative
Augusta hospital was first in Maine to report deaths from Clostridium difficile infection (CDI) from virulent strain NAP1
In past 2 years, four of five area nursing homes had reported CDI outbreaks
To reduce CDI, this pilot focused on:
1) reducing transmission
This pilot project used a regional multi-facility “cluster” approach
It involved a hospital, five area nursing homes, and outpatient physicians/medical directors in Augusta
The outcome measure is a decrease in the CDI rate for each facility (# CDI/10,000 patient days) and a reduction of CDI outbreaks
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Driver Diagram Overview
Driver diagrams can be used to plan improvement project activities. They provide a way of systematically laying out aspects of an improvement project so they can be discussed and agreed on.
A driver diagram organizes information on proposed g g p p activities so the relationships between the aim of the improvement project and the changes to be tested and implemented are made clear.
A driver diagram has three columns - Outcome, Primary Drivers and Secondary Drivers.
Exercise 2:
How Can Local Boards of Health Use A Population Heath Driver Diagram To Impact Population Health Issues?
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of Public Health Practice
LEARNING MANAGEMENT NETWORK
The nation’s premier learning management network for professionals helping to protect the public’s health – over 760,000 registered learners and 29,000 courses www.train.org
TECHNICALASSISTANCE & TRAINING
www.phf.org/qiservices hf / t l
ACADEMIC PRACTICE LINKAGES
LEARNING RESOURCE CENTER
Where public health, health care, and allied health professionals find high quality training materials at an affordable price • Comprehensive selection of publications • Many consumer-oriented health education
publications • Stories and webinars on using the Guide to
Community Preventive Services
bookstore.phf.org www.phf.org/communityguide www.phf.org
Public Health Practice • Core Competencies for Public Health
Professionals • Academic Health Department Learning
Community
ANTIBIOTIC STEWARDSHIP PROGRAM
A Public Health and Healthcare Collabora on The Public Health Founda on (PHF) is leading an effort to develop and pilot a driver diagram for public health and healthcare to work together to reduce an bio c resistant infec ons. Collabora on across public health and healthcare is necessary to achieve op mal results in this community health challenge. This program grew out of PHF’s partnership with the Centers for Disease Control and Preven on (CDC) and the Ins tute for Healthcare Improvement (IHI) to develop a framework of key drivers for reducing inappropriate an bio c u liza on in hospitals.
Some drivers of op mal an bio c use fall outside the direct control of public health (e.g., use of an bio cs in livestock food supplies), while others sit squarely within the focus of the public health system. In 2012, PHF led development of a driver diagram illustra ng public health’s role in promo ng op mal an bio c use. Based on input from an interdisciplinary team of experts in quality improvement (QI), infec on control, epidemiology, and public health leadership, the driver diagram outlines primary and secondary drivers of op mal an bio c use to help reduce the spread of an bio c resistant infec ons.
[email protected] www.phf.org/An bio cStewardship 202.218.4410
PHF is facilita ng pilot ac vi es that use the Public Health An bio c Stewardship Driver Diagram in collabora ve efforts between the public health and healthcare systems. Current pilot sites include:
Independence Health Department (Independence, Missouri)
Connec cut Department of Public Health
Maine Center for Disease Control and Preven on
Success factors in this work included:
Use of the Public Health An bio c Stewardship Driver Diagram. A driver diagram illustrates primary and secondary drivers of a health challenge; each pilot site used the driver diagram as a reference for selec ng points of interven on.
Use of QI Tools and Methods. The work of all three pilots incorporated QI to ensure that improvement strategies were effec vely targeted and adopted.
Collabora on Between Public Health and Healthcare. Each health department func oned as a resource to its healthcare partners, helping them to meet regulatory requirements and address fiscal needs, convening and facilita ng produc ve discussions, and communica ng about joint ac vi es.
Details on the pilot programs are provided in the a ached case stories. PHF plans to expand the reach of this program by launching addi onal pilot work around the country, and is developing an interven on guide to accompany the Public Health An bio c Stewardship Driver Diagram.
This packet includes: The Public Health An bio c Stewardship Driver Diagram Case stories from state and local pilot sites
Public Health An bio c Stewardship Driver Diagram
Accomplishments of this Work
Expanded partnerships and commitment to con nue them
Educa on on appropriate an bio c use for physicians, pharmacists, nurses, and others
2013 Pilot Ac vi es
Public Health’s Role in Antibiotic Stewardship Driver Diagram SECONDARY DRIVERS
Partnerships, Communication, Reimbursement, & Stewardship
Provide information on which antibiotics are most effective within your community at a certain point in time
Provide information on which diseases are prevalent within a community at a point in time
Develop policies that create incentives for appropriate antibiotic use
Develop appropriate policies for daycare, work, and school on appropriate attendance during illness (staying away and going back)
Surveillance, Analysis, Feedback, Triage, & Leveraging Resources
Leverage existing infrastructure to promote better antibiotic use
Use local resistance data to inform antibiotic choice
Explore ways to gather use and prescribing data
Share Evidence Broadly, Provide Education, Create Urgency, & Empower Alternative Action
Develop intervention plans for segmented target audiences (consumers, providers, insurers, policy makers, etc.)
Change attitudes and perceptions about what constitutes appropriate antibiotic use
Educate health departments and public health professionals
Incorporate antibiotic usage into community assessment and improvement plans
PRIMARY DRIVERS
Decrease demand by the public for inappropriate use
Reduce the spread of antibiotic re- sistance
Decrease adverse events associated with inappropriate antibiotic use
Decrease costs associated with antibiotic use
March 2013 | Version 1.1
Policy, Communication, Education, Incentives, Partnerships, and Facilitation This model was developed collaboratively by public health professionals with expertise in antimicrobial resistance and quality improvement. This work was funded through a collaborative agreement between the Public Health Foundation and the U.S. Centers for Disease Control and Prevention.
Efforts to promote optimal antibiotic use should employ both the public health and healthcare systems. While some drivers of antibiotic resistance fall outside the direct control of public health (e.g., use of antibiotics in livestock food supplies), others highlighted here sit squarely within the focus of public health organizations.
This diagram outlines primary and secondary drivers of optimal antibiotic use. It compliments a driver diagram being piloted in eight hospitals by the Institute for Healthcare Improvement (IHI). PHF is actively seeking comments on the driver diagram from healthcare and public health organizations already engaged in efforts to address antibiotic resistance.
AIM Promote Optimal
Appropriate Antibiotic Use
Story From the Field
In 2012, the Independence Health Department (Independence, Missouri) iden fied
an increase in an bio c resistant infec ons in the community that warranted
improved policies addressing an bio c use in schools and childcare facili es. The
department began par cipa ng in an An bio c Stewardship Program organized by
the Public Health Founda on (PHF). Promo ng op mal an bio c use through both
the public health and healthcare systems, the Public Health An bio c Stewardship
Driver Diagram provided the backbone for this pilot ini a ve. Because of their
excellent working rela onship with Centerpoint Medical Center, the health
department collaborated with the hospital to address an bio c resistant infec ons;
it was a natural next step in their growing partnership.
The public health team in Independence kept the driver diagram nearby to guide ini al brainstorming as they created a series of
logic models to pinpoint opportuni es for interven on. Independence devised a mul pronged approach which focused on two
points of interven on: healthcare providers and childcare providers. PHF’s technical assistance enabled the use of quality
improvement in selec ng interven ons to promote op mal an bio c use as outlined in the driver diagram.
Collabora ng with Healthcare Providers
The Independence team designed resources that can be easily integrated into prac oners’ work with the goals of increasing mul disciplinary communica on, coopera on, and awareness with minimal effort by the providers themselves. These efforts include:
An interdisciplinary repor ng system for alerts and advisories
related to an bio c resistant disease incidence and news.
Quick reference pocket cards to guide physicians about the safest
and most effec ve treatment for common diagnoses at the
moment they write an an bio c prescrip on, if indicated.
An educa onal 3x5” card developed and distributed as part of the
Centers for Disease Control and Preven on (CDC) Get Smart
campaign for pharmacists to give pa ents who receive an bio cs;
the headline “You’ve just had a prescrip on filled, here’s what you
need to know” signals the importance of safe an bio c use.
An educa onal prescrip on pad developed and distributed as part
of the CDC Get Smart ini a ve for providers to give pa ents who
do not receive an bio cs; this prescrip on pad provides
informa on on diagnosis, general instruc ons, and medica ons
that may ease symptoms.
Con nuing Medical Educa on programs for professionals in both healthcare and public health provided in coordina on with
Centerpoint Medical Center.
A grant applica on to the Healthcare Founda on of Kansas City to secure funding for coordina on and expansion of various
elements of the An bio c Stewardship Program.
Story From the Field
Acknowledgements
Special thanks to Deresa Hampton and Shawnna Jackson from the Independence Health Department for providing content
for this story. Funding for this story was provided by the Centers for Disease Control and Preven on under Coopera ve
Agreement Number 5U38HM00051803. The contents of this document are solely the responsibility of PHF and do not
represent the official views of CDC.
Related Resources
Public Health An bio c Stewardship Driver Diagram — The driver diagram used by the Independence Health De
partment to guide their strategies for this program.
PHF provides customized training, facilita on, and workforce development services to public health agencies and
other groups that protect the public’s health. To inquire about technical assistance, please visit PHF at
www.phf.org/TechnicalAssistance or call 2022184415.
Collabora ng with Childcare Providers The Independence team created clear standards that childcare providers can implement when working with families in the
community. Using public recogni on as an incen ve and though ully incorpora ng accessible language for instruc ons and
explana ons, they are ini a ng the following efforts:
The Missouri Department of Health and Senior Services created the Preven on and Control of Communicable
Diseases: Guide for School Administrators, Nurses, Teachers, Child Care Providers, and Parents or Guardians which
includes resources about everything from a “cover your cough campaign” to hand washing reminders, to lessons
about the misuse of an bio cs and an bio c resistant disease. Locally, the Communicable Disease staff in the
Independence Health Department promotes and shares this excellent resource with schools and childcare
providers.
A new Start Right Ra ng System to publicly recognize childcare centers that cooperate with standards as well as
those taking extra steps to ensure that safe an bio c use prac ces and policies are followed.
Basic educa on for childcare providers and parents about the risk of an bio c resistant infec ons with the goal of
reducing inappropriate an bio c use and overall reduc on in the need for an bio cs.
Using the Public Health An bio c Stewardship Driver Diagram as a guide, the Independence Health Department is off to a
strong start in raising awareness of an bio c resistant infec ons and how to keep them at bay in the community. In the
coming months, they plan to further develop these programs and expand the collabora on between public health and
healthcare systems so that they are sharing more informa on about diagnoses of an bio c resistant infec ons and the rate
of an bio c prescrip on use. In 2014, they will survey physicians and child care centers to measure the impact of these
ini a ves, and work with pharmacies to assess whether there has been a decrease in prescrip ons for an bio cs.
Success Factors
department
for implementa on
Story From the Field
Tackling Healthcare Associated Infec ons through QI
When the staff in the Connec cut Department of Public Health (CDPH) recognized an opportunity to address the significant challenges posed by Clostridium difficile infec on (CDI), they decided to address the problem using a collabora ve approach at regional longterm care (LTC) facili es. Because residents at LTC facili es o en have compromised immune systems due to chronic health issues, they have increased vulnerability to healthcare associated infec ons (HAI), such as CDI. In response to growing CDI prevalence and using the Public Health An bio c Stewardship Driver Diagram as a reference, CDPH proposed the crea on of an interdisciplinary CDI Preven on Collabora ve in LTC facili es to reduce HAI among nursing home residents.
CDPH’s push to incorporate quality improvement (QI) into its work led them to pursue opportuni es to support QI ac vi es, including those related to CDI preven on. In 2012, CDPH received the Public Health Founda on’s (PHF) Future of Public Health Award in recogni on of its promise to generate measurable outcomes benefi ng the future of public health through applied QI. PHF trained CDPH staff to incorporate QI methods into CDI Preven on Collabora ve efforts, and CDPH became part of PHF’s An bio c Stewardship Program. Nurses from 25 LTC facili es in Connec cut received training in QI and best prac ces in reducing CDI during the project kickoff session. Following training, CDPH used monthly tracking and repor ng calls among par cipa ng LTCs to monitor the effec veness of integra ng best prac ces into CDI preven on protocols at the facili es. In addi on to these calls, CDPH asked Qualidigm, a local quality improvement partner, to preform site visits at par cipa ng facili es.
Interdisciplinary Integra on
To improve interdisciplinary CDI preven on protocols, CDPH used QI tools and models such as PlanDoCheckAct (PDCA) cycle, flow charts, and cause and effect diagrams. The team also developed a best prac ces checklist to simplify implementa on of best prac ce protocols in the future and con nued use of QI methods. LTC facili es worked with state surveyors to develop new signage to no fy staff and visitors of CDI cases and proper preven on prac ces. As implementa on proceeded, staff reported improved communica on and morale at the LTC facili es.
Figure 1. Causes of Increased CDI in LTC Facili es
Story From the Field Interdisciplinary Integra on (con nued)
LTC facili es adopted process measures to track implementa on success, including:
Observa ons of staff compliance with new precau on signs about contact with CDI pa ents. Tracking the rate and consistency with which residents with infec ons and their family members receive documenta on and educa onal materials about CDI. Tracking alignment of provider prescribing prac ces with best prac ces in CDI preven on and an bio c stewardship.
CDPH is also tracking incidence of CDI to determine the impact of these efforts on infec on rates in the state’s LTC facili es and will start a campaign to encourage facili es to enroll in the Na onal Healthcare Systems Network.
About the Future of Public Health Awards PHF’s 2012 Future of Public Health Award recognized promising proposed ini a ves in public health that u lize QI to influence posi ve outcomes in CDC’s Winnable Ba les. Award winners received onsite technical assistance to build capacity in QI and advance programs to improve outcomes. To learn more about the program and other PHF services, visit h p://www.phf.org.
Acknowledgements Special thanks to Alessandra Litro, Health Program Assistant II and Richard Melchreit, HAI Program Coordinator at CDPH for providing content for this story. Funding for this story was provided by CDC under Coopera ve Agreement Number 5U38HM00051803. The contents of this document are solely the responsibility of PHF and do not represent the official views of CDC.
Related Resources
CDI Resources for Health Departments h p://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html Future of Public Health Awards h p://www.phf.org/programs/futureaward/Pages/Future_of_Public_Health_Award.aspx Centers for Disease Control and Preven on (CDC) Report, An bio c Resistance Threats, 2013 h p://www.cdc.gov/drugresistance/threatreport2013/
Keys to Success The LTC Preven on Collabora ve benefited from the support and endorsement of CDPH senior leadership and external partners, including two LTC Associa ons, the Connec cut Hospital Associa on, LTC Nursing Associa on, and the Center for Medicare and Medicaid Services Quality Improvement Organiza on. These partners facilitated LTC recruitment for the program, emphasizing that it was a wellorganized, collabora ve ini a ve. CDPH has expanded the LTC Preven on Collabora ve statewide and plans on increasing the number of facili es par cipa ng in the collabora ve.
QI Tools Used
An AIM statement restricts the problem statement to discrete issue on which the improvement team will focus. CDPH used an AIM statement to guide their efforts to analyze exis ng processes and implement process improvement using QI tools. A flowchart visually depicts all the steps and decision points in a process from start to finish. Program par cipants used flowcharts to document processes which helped in analyzing both current and future problems. A cause and effect diagram displays mul ple poten al causes for a problem. CDPH used a cause and effect diagram to categorize ideas into themes for analysis and to show current successes and strengths, which helped to empower par cipants (see Figure 1).
October 2013
Story From the Field
Maine CDC: Working with Healthcare to Address An bio c Resistant Disease
“I am thoroughly convinced that if we do not address an bio c stewardship and the appropriate use of an bio cs, we will con nue to see increasing resistance and the problems of resistant infec ons will grow drama cally over the ensuing years.”
— Stephen D. Sears, MD, MPH State Epidemiologist, Maine CDC
New Strategies to Tackle An bio c Resistant Disease
In 2010, Maine Center for Disease Control and
Preven on (Maine CDC) began an an bio c stewardship
effort in order to reduce the rising rates of mul ple drug
resistant organisms in hospitals. Maine CDC held a two
day cer fica on program for an bio c stewardship that was a ended by a pharmacist and champion physician from every acute
care hospital. Maine CDC also collaborated with the University of New England to study regional differences in an biograms.
During this me, Maine CDC began statewide educa on of nursing facili es regarding infec on preven on and control prac ces.
In 2011 to 2012, four nursing homes in the AugustaWaterville area reported outbreaks of Clostridium difficile infec on (CDI) — an
infec on that is largely the result of taking an bio cs. Maine CDC then joined the Public Health Founda on’s (PHF) An bio c
Stewardship Program, which fosters collabora on between public health and healthcare partners to op mize an bio c use and
reduce an bio c resistant disease. Based on Maine’s surveillance data, Maine CDC concentrated its interven ons on longterm
care facili es (LTCs) — and “hot spots” within LTCs — with the highest rates of CDI. Maine CDC iden fied the AugustaWaterville
area and worked collabora vely with the Northeast Healthcare Quality Founda on (a Quality Improvement Organiza on) to
reduce CDI rates in this region.
New Strategies to Tackle An bio c Resistant Disease Using PHF’s Public Health An bio c Stewardship Driver Diagram, Maine CDC iden fied drivers for preven ng and trea ng CDI at
Augusta LTCs, which had many of the state’s highest CDI rates. Maine CDC then developed interven ons to strengthen these
drivers within each facility, including:
Establishing standardized protocols for containing CDI outbreaks
Establishing a universal protocol for nursing facili es regarding preven on of C. difficile transmission
Training employees at LTCs to use tracer kits to improve environmental cleaning
Training employees on hand hygiene compliance and observa on
Holding monthly educa onal mee ngs to discuss CDI preven on and treatment protocols
Collec ng facilityspecific data to track CDI trends within and across LTCs
Educa ng physicians on best prac ces for an bio c use for outpa ents, both children and adults
With guidance from PHF’s Senior Quality Advisor Jack Moran, Maine CDC created a Fishbone (or Cause and Effect) Diagram to
iden fy barriers to preven ng transmission and acquisi on of an bio c resistant disease within LTCs. Then Maine CDC worked
with each LTC to pinpoint and correct specific barriers. The LTC infec on preven onists found working closely with Maine CDC
and the Northeast Healthcare Quality Improvement Organiza on (QIO) was essen al to successfully adop ng the new protocols.
Maine CDC was dedicated to building collabora ve rela onships with the LTCs to achieve their common goals. Throughout this
process, the LTCs viewed Maine CDC as a facilitator and guide in infec on preven on — not merely a regulatory enforcer.
Story From the Field
Acknowledgements Special thanks to Peggy Shore and Stephen Sears at Maine Center for Disease Control and Preven on for providing content for
this story. Funding for this story was provided by the Centers for Disease Control and Preven on under Coopera ve
Agreement Number 5U38HM00051803. The contents of this document are solely the responsibility of PHF and do not
represent the official views of CDC.
Related Links and Resources
Public Health An bio c Stewardship Driver Diagram — The driver diagram referenced by Maine CDC used to iden fy
drivers for preven ng CDI. www.phf.org/abxdriverdiagram
PHF provides customized training, facilita on, and workforce development services to public health agencies and other
organiza ons that protect the public’s health. To inquire about technical assistance, please visit PHF at www.phf.org/
TechnicalAssistance or call 2022184415.
PHF’s An bio c Stewardship Program — Informa on about PHF’s An bio c Stewardship Program, which helped support
efforts by Maine CDC to prevent CDI. www.phf.org/an bio cstewardship
Collabora ng with Healthcare Partners Because this challenge exists at the crossroads of public health and healthcare, Maine CDC engages healthcare partners to
op mize the effec veness efforts to reduce CDI at LTCs. In order to reduce an bio c resistant infec ons at LTCs, the health
department has formed partnerships with the following organiza ons:
The Northeast Health Care Quality Founda on, a regional QIO experienced at addressing an bio c resistant infec ons
in healthcare facili es
The University of New England School of Pharmacy (UNESP), which analyzed Maine CDC’s data about rates of an bio c
resistance by organism and by region
The Maine Medical Associa on/Maine Independent Clinical Informa on Service (MICIS), which distributed United
States Centers for Disease Control and Preven on (CDC) Get Smart materials and a Maine CDC physician pocket
reference for prescribing an bio cs and provided onsite educa on to LTC medical directors and other physicians to
improve prescribing prac ces
LTCs in the ci es of Augusta and Waterville, which effec vely adopted new strategies and interven ons to reduce CDI
Expanding the Reach of Collabora on Maine CDC is monitoring CDI trends in LTCs, and will release a report on infec on rates in July 2014. To expand the reach of
its pilot ac vi es, Maine CDC will partner with the Maine Medical Associa on to educate 400 addi onal outpa ent
physicians and LTC directors about prac ces to reduce the spread of CDI. Maine CDC also hopes to bring this collabora ve
approach to addressing an bio c resistant infec ons to many more LTCs in Maine. To do this, Maine CDC is partnering with
the Maine Healthcare Associa on, a provider organiza on serving nursing facili es. The Maine Healthcare Associa on will
host two webinars in which Maine CDC and the QIO will share four tools developed during the pilot with other LTC facili es
throughout Maine.
February 2014
Using the Population Health Driver Diagram to Increase Use of Oral Health Care
To create opportunities for public health and health care collaboration to improve community health,
the Public Health Foundation (PHF) has created a population health driver diagram framework.
Grounded in the belief that public health and health care are more effective when their efforts are
aligned than when they work separately, this approach can be used to tackle challenges at the
crossroads of these two sectors.
A population health driver diagram can be used to help focus and align a community’s efforts to make
progress on a defined community health challenge. The driver diagram consists of a general AIM
statement, goals of the AIM statement, and primary and secondary drivers that specify actions that can
be taken to help achieve the desired goals for improved population health. Population health driver
diagrams serve as a starting point and framework for discussion, and offer flexibility for identifying and
addressing unique community characteristics and needs. They also help to create an atmosphere of
collaboration and cooperation by enabling each participant in these discussions to identify roles already
being played by their organization and others in the community, and determine additional action that
can be taken individually and collectively to positively impact the particular community health challenge.
The Population Health Driver Diagram to Increase Use of Oral Health Care includes an AIM statement,
goals, and primary and secondary drivers. When this driver diagram is being used by a community,
changes may be desirable to any component of the driver diagram. For example, there may be other
drivers that the community identifies and decides to address that are not specified in the driver
diagram, or the AIM statement and goals may need to be refined so that they better relate to the
community. It also is important to note that while the driver diagram articulates many drivers, choosing
a subset of drivers to address may help focus community efforts and achieve desired results. Depending
on the progress a community is making, additional drivers may be addressed over time, existing drivers
may be refined, and other drivers may be added.
This population health driver diagram was developed by PHF with funding from the Office of Disease
Prevention and Health Promotion of the U.S. Department of Health and Human Services. We encourage
you to use this driver diagram to increase use of oral health care in your community. We also encourage
you to and provide us with your feedback.
Please contact Micaela Kirshy, [email protected], (202)218-4410, with questions and feedback.
Population Health Driver Diagram to Increase Use of Oral Health Care
SECONDARY DRIVERS
Educate about available insurance coverage for oral health care
Educate dental and non-dental health professionals about oral health as a population health issue
Engage families and caregivers regarding importance of oral health
Surveillance, Analysis, Feedback
Identify high-risk populations with comorbidities
Identify risk and protective factors at the individual, family, school, and community levels
Identify policies that affect oral health
Track community oral health status
Goals
Increase affordability of oral health care for con- sumers
Increase availability and use of oral health care based on evidence and disease management
Prevent diseases of the mouth
Achieve oral health equity
This work was funded by the Office of Disease Prevention and Health Promotion of the U.S. Department of Health and Human Services
AIM Increase the proportion of children, adolescents, and
adults who use oral health care, education, prevention, and treatment
Diverse Care Settings, Affordability
Provide oral health care in non-traditional settings
Expand use of and insurance coverage for services provided by dental hygienists and other non-DDS/DMD providers, especially for school- based dental sealants
Increase diversity of professionals providing oral health care
Increase and strengthen publicly funded dental coverage
Increase proportion of primary care and public health settings that include an integrated oral health program
Education about Importance
Professional Education, Partnerships, Planning
Align provider incentives to use the prevention and disease management model
Educate dental students in clinic settings with allied-health professionals
Educate primary care providers and team members to provide basic oral health risk assessments, prevention, and education
Increase stakeholder engagement and skill building to ensure capacity and improve oral health outcomes
Require all dental professional education programs to include community service and social responsibility curricula
PRIMARY DRIVERS
3.2 Oral Health Driver Diagram
Cover Note Final.pdf
Final Driver Diagram
1
How Can Local Boards of Health Facilitate Healthcare and Public Health Partnerships to Improve the Health of Communities?
2014 NALBOH Annual Conference
2:45-3:45 p.m.
Jack Moran, PhD Senior Quality Advisor, Public Health Foundation
PHF Mission: We improve the public’s health by strengthening the quality and performance of public health practice
www.phf.org
Today We Will Discuss
How Local Boards of Health can facilitate healthcare and public health partnerships to improve the health of their communities.
Describe a framework being used to build collaborative healthcare and public health partnerships to impact health issues at the community level.
8/8/2014
2
1. Policy Development
2. Resource Stewardship
What are the driving and restraining forces to developing successful partnerships/collaboration for healthcare and public health to impact the health of a community?
Driving Forces Restraining Forces
Limited Collaboration
F u
What are the driving and restraining forces to developing successful partnerships/collaboration for healthcare and public health to impact the health of a community?
Background of the PHF Project
• IHI/CDC initiative • 8 hospitals • Driver diagram for hospitals • Year-long collaborative
PHF t d PH• PHF represented PH • PHF developed PH driver
diagram • Implemented in 3 pilot sites • Developed one for Oral Health
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Timely and appropriate antibiotic utilization in the acute care setting
Timely and appropriate initiation of antibiotics
A i t d i i t tiD d i id f
•Promptly identify patients who require antibiotics •Obtain cultures prior to starting antibiotics •Do not give antibiotics with overlapping activity or combinations not supported by evidence or guidelines •Determine and verify antibiotic allergies and tailor therapy accordingly •Consider local antibiotic susceptibility patterns in selecting therapy •Start treatment promptly •Specify expected duration of therapy based on evidence and national and hospital guidelines
•Make antibiotics patient is receiving and start dates visible at point of care
•Develop and make available expertise in antibiotic use •Ensure expertise is available at the point of care
Appropriate administration and de-escalation
Decreased incidence of antibiotic-related adverse drug events (ADEs)
Decreased prevalence of antibiotic resistant healthcare- associated pathogens
Decreased incidence of healthcare-associated C. difficile infection
Decreased pharmacy cost for antibiotics
•Monitor, feedback, and make visible data regarding antibiotic utilization, antibiotic resistance, ADEs, C. difficile, cost, and adherence to the organization’s recommended culturing and prescribing practices
Availability of expertise at the point of care
•Give antibiotics at the right dose and interval •Stop or de-escalate therapy promptly based on the culture and sensitivity results •Reconcile and adjust antibiotics at all transitions and changes in patient’s condition •Monitor for toxicity reliably and adjust agent and dose promptly
PHF Convened a Panel of Public Health Experts to:
Identify the primary and secondary drivers of optimal antibiotic utilization in community health settings, as well as unique and shared responsibility for drivers
Identify the elements of a potential change package (i.e., a menu of intervention options)
Actions at various handoff points in patient care system
Potential policy changes
Opportunities for health departments to improve messaging and Opportunities for health departments to improve messaging and education, and answer questions
Aimed at consumers/customers
Home health nurses
INDEPENDENCE Health Department Goals of the Initiative
CenterPoint Medical Center, one of eight hospitals, began collaborating with the Health Department
Reduce the spread of antibiotic resistance
Preserve antibiotics for the future
Decrease demand by the public for inappropriate use
Provide opportunities for collaboration between public health and healthcare
Improve patient care
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Connecticut - Goals of the Initiative
To strengthen or build partnerships between public health (DPH) and the medical provider community across the spectrum of healthcare
To build public health capacity and action in HAI prevention – expand from our surveillance role
To share and complement public health’s strengths with To share and complement public health s strengths with medicine’s strengths
To build the methods and tools of Quality Improvement into public health as well as medical care
To prevent C. difficile and MDROs (MRSA)
Documentation Staff
Family/Visitors
Denial
Lack of follow through
Not reporting/responding to symptoms
Not using PPE properly
High staff turnover & different staff on different units- cut corners
Lack of environmental cleaning with bleach
Improper stool collection/ handling
Home remedies/ food Failure to report
Language Barrier
Inappropriate antibiotic use
Lack of education
Non compliant treatment
Lack of staffing Community Issues
Building DesignLack of PPE
Lack of signage
Lack of communication
Lack of education
Lack of supplies
Lack of administrator support
No timely lab results/ lack od specimen pickupNo commode liner
Maine - Goals of the Initiative
Augusta hospital was first in Maine to report deaths from Clostridium difficile infection (CDI) from virulent strain NAP1
In past 2 years, four of five area nursing homes had reported CDI outbreaks
To reduce CDI, this pilot focused on:
1) reducing transmission
This pilot project used a regional multi-facility “cluster” approach
It involved a hospital, five area nursing homes, and outpatient physicians/medical directors in Augusta
The outcome measure is a decrease in the CDI rate for each facility (# CDI/10,000 patient days) and a reduction of CDI outbreaks
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Driver Diagram Overview
Driver diagrams can be used to plan improvement project activities. They provide a way of systematically laying out aspects of an improvement project so they can be discussed and agreed on.
A driver diagram organizes information on proposed g g p p activities so the relationships between the aim of the improvement project and the changes to be tested and implemented are made clear.
A driver diagram has three columns - Outcome, Primary Drivers and Secondary Drivers.
Exercise 2:
How Can Local Boards of Health Use A Population Heath Driver Diagram To Impact Population Health Issues?
8/8/2014
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of Public Health Practice
LEARNING MANAGEMENT NETWORK
The nation’s premier learning management network for professionals helping to protect the public’s health – over 760,000 registered learners and 29,000 courses www.train.org
TECHNICALASSISTANCE & TRAINING
www.phf.org/qiservices hf / t l
ACADEMIC PRACTICE LINKAGES
LEARNING RESOURCE CENTER
Where public health, health care, and allied health professionals find high quality training materials at an affordable price • Comprehensive selection of publications • Many consumer-oriented health education
publications • Stories and webinars on using the Guide to
Community Preventive Services
bookstore.phf.org www.phf.org/communityguide www.phf.org
Public Health Practice • Core Competencies for Public Health
Professionals • Academic Health Department Learning
Community
ANTIBIOTIC STEWARDSHIP PROGRAM
A Public Health and Healthcare Collabora on The Public Health Founda on (PHF) is leading an effort to develop and pilot a driver diagram for public health and healthcare to work together to reduce an bio c resistant infec ons. Collabora on across public health and healthcare is necessary to achieve op mal results in this community health challenge. This program grew out of PHF’s partnership with the Centers for Disease Control and Preven on (CDC) and the Ins tute for Healthcare Improvement (IHI) to develop a framework of key drivers for reducing inappropriate an bio c u liza on in hospitals.
Some drivers of op mal an bio c use fall outside the direct control of public health (e.g., use of an bio cs in livestock food supplies), while others sit squarely within the focus of the public health system. In 2012, PHF led development of a driver diagram illustra ng public health’s role in promo ng op mal an bio c use. Based on input from an interdisciplinary team of experts in quality improvement (QI), infec on control, epidemiology, and public health leadership, the driver diagram outlines primary and secondary drivers of op mal an bio c use to help reduce the spread of an bio c resistant infec ons.
[email protected] www.phf.org/An bio cStewardship 202.218.4410
PHF is facilita ng pilot ac vi es that use the Public Health An bio c Stewardship Driver Diagram in collabora ve efforts between the public health and healthcare systems. Current pilot sites include:
Independence Health Department (Independence, Missouri)
Connec cut Department of Public Health
Maine Center for Disease Control and Preven on
Success factors in this work included:
Use of the Public Health An bio c Stewardship Driver Diagram. A driver diagram illustrates primary and secondary drivers of a health challenge; each pilot site used the driver diagram as a reference for selec ng points of interven on.
Use of QI Tools and Methods. The work of all three pilots incorporated QI to ensure that improvement strategies were effec vely targeted and adopted.
Collabora on Between Public Health and Healthcare. Each health department func oned as a resource to its healthcare partners, helping them to meet regulatory requirements and address fiscal needs, convening and facilita ng produc ve discussions, and communica ng about joint ac vi es.
Details on the pilot programs are provided in the a ached case stories. PHF plans to expand the reach of this program by launching addi onal pilot work around the country, and is developing an interven on guide to accompany the Public Health An bio c Stewardship Driver Diagram.
This packet includes: The Public Health An bio c Stewardship Driver Diagram Case stories from state and local pilot sites
Public Health An bio c Stewardship Driver Diagram
Accomplishments of this Work
Expanded partnerships and commitment to con nue them
Educa on on appropriate an bio c use for physicians, pharmacists, nurses, and others
2013 Pilot Ac vi es
Public Health’s Role in Antibiotic Stewardship Driver Diagram SECONDARY DRIVERS
Partnerships, Communication, Reimbursement, & Stewardship
Provide information on which antibiotics are most effective within your community at a certain point in time
Provide information on which diseases are prevalent within a community at a point in time
Develop policies that create incentives for appropriate antibiotic use
Develop appropriate policies for daycare, work, and school on appropriate attendance during illness (staying away and going back)
Surveillance, Analysis, Feedback, Triage, & Leveraging Resources
Leverage existing infrastructure to promote better antibiotic use
Use local resistance data to inform antibiotic choice
Explore ways to gather use and prescribing data
Share Evidence Broadly, Provide Education, Create Urgency, & Empower Alternative Action
Develop intervention plans for segmented target audiences (consumers, providers, insurers, policy makers, etc.)
Change attitudes and perceptions about what constitutes appropriate antibiotic use
Educate health departments and public health professionals
Incorporate antibiotic usage into community assessment and improvement plans
PRIMARY DRIVERS
Decrease demand by the public for inappropriate use
Reduce the spread of antibiotic re- sistance
Decrease adverse events associated with inappropriate antibiotic use
Decrease costs associated with antibiotic use
March 2013 | Version 1.1
Policy, Communication, Education, Incentives, Partnerships, and Facilitation This model was developed collaboratively by public health professionals with expertise in antimicrobial resistance and quality improvement. This work was funded through a collaborative agreement between the Public Health Foundation and the U.S. Centers for Disease Control and Prevention.
Efforts to promote optimal antibiotic use should employ both the public health and healthcare systems. While some drivers of antibiotic resistance fall outside the direct control of public health (e.g., use of antibiotics in livestock food supplies), others highlighted here sit squarely within the focus of public health organizations.
This diagram outlines primary and secondary drivers of optimal antibiotic use. It compliments a driver diagram being piloted in eight hospitals by the Institute for Healthcare Improvement (IHI). PHF is actively seeking comments on the driver diagram from healthcare and public health organizations already engaged in efforts to address antibiotic resistance.
AIM Promote Optimal
Appropriate Antibiotic Use
Story From the Field
In 2012, the Independence Health Department (Independence, Missouri) iden fied
an increase in an bio c resistant infec ons in the community that warranted
improved policies addressing an bio c use in schools and childcare facili es. The
department began par cipa ng in an An bio c Stewardship Program organized by
the Public Health Founda on (PHF). Promo ng op mal an bio c use through both
the public health and healthcare systems, the Public Health An bio c Stewardship
Driver Diagram provided the backbone for this pilot ini a ve. Because of their
excellent working rela onship with Centerpoint Medical Center, the health
department collaborated with the hospital to address an bio c resistant infec ons;
it was a natural next step in their growing partnership.
The public health team in Independence kept the driver diagram nearby to guide ini al brainstorming as they created a series of
logic models to pinpoint opportuni es for interven on. Independence devised a mul pronged approach which focused on two
points of interven on: healthcare providers and childcare providers. PHF’s technical assistance enabled the use of quality
improvement in selec ng interven ons to promote op mal an bio c use as outlined in the driver diagram.
Collabora ng with Healthcare Providers
The Independence team designed resources that can be easily integrated into prac oners’ work with the goals of increasing mul disciplinary communica on, coopera on, and awareness with minimal effort by the providers themselves. These efforts include:
An interdisciplinary repor ng system for alerts and advisories
related to an bio c resistant disease incidence and news.
Quick reference pocket cards to guide physicians about the safest
and most effec ve treatment for common diagnoses at the
moment they write an an bio c prescrip on, if indicated.
An educa onal 3x5” card developed and distributed as part of the
Centers for Disease Control and Preven on (CDC) Get Smart
campaign for pharmacists to give pa ents who receive an bio cs;
the headline “You’ve just had a prescrip on filled, here’s what you
need to know” signals the importance of safe an bio c use.
An educa onal prescrip on pad developed and distributed as part
of the CDC Get Smart ini a ve for providers to give pa ents who
do not receive an bio cs; this prescrip on pad provides
informa on on diagnosis, general instruc ons, and medica ons
that may ease symptoms.
Con nuing Medical Educa on programs for professionals in both healthcare and public health provided in coordina on with
Centerpoint Medical Center.
A grant applica on to the Healthcare Founda on of Kansas City to secure funding for coordina on and expansion of various
elements of the An bio c Stewardship Program.
Story From the Field
Acknowledgements
Special thanks to Deresa Hampton and Shawnna Jackson from the Independence Health Department for providing content
for this story. Funding for this story was provided by the Centers for Disease Control and Preven on under Coopera ve
Agreement Number 5U38HM00051803. The contents of this document are solely the responsibility of PHF and do not
represent the official views of CDC.
Related Resources
Public Health An bio c Stewardship Driver Diagram — The driver diagram used by the Independence Health De
partment to guide their strategies for this program.
PHF provides customized training, facilita on, and workforce development services to public health agencies and
other groups that protect the public’s health. To inquire about technical assistance, please visit PHF at
www.phf.org/TechnicalAssistance or call 2022184415.
Collabora ng with Childcare Providers The Independence team created clear standards that childcare providers can implement when working with families in the
community. Using public recogni on as an incen ve and though ully incorpora ng accessible language for instruc ons and
explana ons, they are ini a ng the following efforts:
The Missouri Department of Health and Senior Services created the Preven on and Control of Communicable
Diseases: Guide for School Administrators, Nurses, Teachers, Child Care Providers, and Parents or Guardians which
includes resources about everything from a “cover your cough campaign” to hand washing reminders, to lessons
about the misuse of an bio cs and an bio c resistant disease. Locally, the Communicable Disease staff in the
Independence Health Department promotes and shares this excellent resource with schools and childcare
providers.
A new Start Right Ra ng System to publicly recognize childcare centers that cooperate with standards as well as
those taking extra steps to ensure that safe an bio c use prac ces and policies are followed.
Basic educa on for childcare providers and parents about the risk of an bio c resistant infec ons with the goal of
reducing inappropriate an bio c use and overall reduc on in the need for an bio cs.
Using the Public Health An bio c Stewardship Driver Diagram as a guide, the Independence Health Department is off to a
strong start in raising awareness of an bio c resistant infec ons and how to keep them at bay in the community. In the
coming months, they plan to further develop these programs and expand the collabora on between public health and
healthcare systems so that they are sharing more informa on about diagnoses of an bio c resistant infec ons and the rate
of an bio c prescrip on use. In 2014, they will survey physicians and child care centers to measure the impact of these
ini a ves, and work with pharmacies to assess whether there has been a decrease in prescrip ons for an bio cs.
Success Factors
department
for implementa on
Story From the Field
Tackling Healthcare Associated Infec ons through QI
When the staff in the Connec cut Department of Public Health (CDPH) recognized an opportunity to address the significant challenges posed by Clostridium difficile infec on (CDI), they decided to address the problem using a collabora ve approach at regional longterm care (LTC) facili es. Because residents at LTC facili es o en have compromised immune systems due to chronic health issues, they have increased vulnerability to healthcare associated infec ons (HAI), such as CDI. In response to growing CDI prevalence and using the Public Health An bio c Stewardship Driver Diagram as a reference, CDPH proposed the crea on of an interdisciplinary CDI Preven on Collabora ve in LTC facili es to reduce HAI among nursing home residents.
CDPH’s push to incorporate quality improvement (QI) into its work led them to pursue opportuni es to support QI ac vi es, including those related to CDI preven on. In 2012, CDPH received the Public Health Founda on’s (PHF) Future of Public Health Award in recogni on of its promise to generate measurable outcomes benefi ng the future of public health through applied QI. PHF trained CDPH staff to incorporate QI methods into CDI Preven on Collabora ve efforts, and CDPH became part of PHF’s An bio c Stewardship Program. Nurses from 25 LTC facili es in Connec cut received training in QI and best prac ces in reducing CDI during the project kickoff session. Following training, CDPH used monthly tracking and repor ng calls among par cipa ng LTCs to monitor the effec veness of integra ng best prac ces into CDI preven on protocols at the facili es. In addi on to these calls, CDPH asked Qualidigm, a local quality improvement partner, to preform site visits at par cipa ng facili es.
Interdisciplinary Integra on
To improve interdisciplinary CDI preven on protocols, CDPH used QI tools and models such as PlanDoCheckAct (PDCA) cycle, flow charts, and cause and effect diagrams. The team also developed a best prac ces checklist to simplify implementa on of best prac ce protocols in the future and con nued use of QI methods. LTC facili es worked with state surveyors to develop new signage to no fy staff and visitors of CDI cases and proper preven on prac ces. As implementa on proceeded, staff reported improved communica on and morale at the LTC facili es.
Figure 1. Causes of Increased CDI in LTC Facili es
Story From the Field Interdisciplinary Integra on (con nued)
LTC facili es adopted process measures to track implementa on success, including:
Observa ons of staff compliance with new precau on signs about contact with CDI pa ents. Tracking the rate and consistency with which residents with infec ons and their family members receive documenta on and educa onal materials about CDI. Tracking alignment of provider prescribing prac ces with best prac ces in CDI preven on and an bio c stewardship.
CDPH is also tracking incidence of CDI to determine the impact of these efforts on infec on rates in the state’s LTC facili es and will start a campaign to encourage facili es to enroll in the Na onal Healthcare Systems Network.
About the Future of Public Health Awards PHF’s 2012 Future of Public Health Award recognized promising proposed ini a ves in public health that u lize QI to influence posi ve outcomes in CDC’s Winnable Ba les. Award winners received onsite technical assistance to build capacity in QI and advance programs to improve outcomes. To learn more about the program and other PHF services, visit h p://www.phf.org.
Acknowledgements Special thanks to Alessandra Litro, Health Program Assistant II and Richard Melchreit, HAI Program Coordinator at CDPH for providing content for this story. Funding for this story was provided by CDC under Coopera ve Agreement Number 5U38HM00051803. The contents of this document are solely the responsibility of PHF and do not represent the official views of CDC.
Related Resources
CDI Resources for Health Departments h p://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html Future of Public Health Awards h p://www.phf.org/programs/futureaward/Pages/Future_of_Public_Health_Award.aspx Centers for Disease Control and Preven on (CDC) Report, An bio c Resistance Threats, 2013 h p://www.cdc.gov/drugresistance/threatreport2013/
Keys to Success The LTC Preven on Collabora ve benefited from the support and endorsement of CDPH senior leadership and external partners, including two LTC Associa ons, the Connec cut Hospital Associa on, LTC Nursing Associa on, and the Center for Medicare and Medicaid Services Quality Improvement Organiza on. These partners facilitated LTC recruitment for the program, emphasizing that it was a wellorganized, collabora ve ini a ve. CDPH has expanded the LTC Preven on Collabora ve statewide and plans on increasing the number of facili es par cipa ng in the collabora ve.
QI Tools Used
An AIM statement restricts the problem statement to discrete issue on which the improvement team will focus. CDPH used an AIM statement to guide their efforts to analyze exis ng processes and implement process improvement using QI tools. A flowchart visually depicts all the steps and decision points in a process from start to finish. Program par cipants used flowcharts to document processes which helped in analyzing both current and future problems. A cause and effect diagram displays mul ple poten al causes for a problem. CDPH used a cause and effect diagram to categorize ideas into themes for analysis and to show current successes and strengths, which helped to empower par cipants (see Figure 1).
October 2013
Story From the Field
Maine CDC: Working with Healthcare to Address An bio c Resistant Disease
“I am thoroughly convinced that if we do not address an bio c stewardship and the appropriate use of an bio cs, we will con nue to see increasing resistance and the problems of resistant infec ons will grow drama cally over the ensuing years.”
— Stephen D. Sears, MD, MPH State Epidemiologist, Maine CDC
New Strategies to Tackle An bio c Resistant Disease
In 2010, Maine Center for Disease Control and
Preven on (Maine CDC) began an an bio c stewardship
effort in order to reduce the rising rates of mul ple drug
resistant organisms in hospitals. Maine CDC held a two
day cer fica on program for an bio c stewardship that was a ended by a pharmacist and champion physician from every acute
care hospital. Maine CDC also collaborated with the University of New England to study regional differences in an biograms.
During this me, Maine CDC began statewide educa on of nursing facili es regarding infec on preven on and control prac ces.
In 2011 to 2012, four nursing homes in the AugustaWaterville area reported outbreaks of Clostridium difficile infec on (CDI) — an
infec on that is largely the result of taking an bio cs. Maine CDC then joined the Public Health Founda on’s (PHF) An bio c
Stewardship Program, which fosters collabora on between public health and healthcare partners to op mize an bio c use and
reduce an bio c resistant disease. Based on Maine’s surveillance data, Maine CDC concentrated its interven ons on longterm
care facili es (LTCs) — and “hot spots” within LTCs — with the highest rates of CDI. Maine CDC iden fied the AugustaWaterville
area and worked collabora vely with the Northeast Healthcare Quality Founda on (a Quality Improvement Organiza on) to
reduce CDI rates in this region.
New Strategies to Tackle An bio c Resistant Disease Using PHF’s Public Health An bio c Stewardship Driver Diagram, Maine CDC iden fied drivers for preven ng and trea ng CDI at
Augusta LTCs, which had many of the state’s highest CDI rates. Maine CDC then developed interven ons to strengthen these
drivers within each facility, including:
Establishing standardized protocols for containing CDI outbreaks
Establishing a universal protocol for nursing facili es regarding preven on of C. difficile transmission
Training employees at LTCs to use tracer kits to improve environmental cleaning
Training employees on hand hygiene compliance and observa on
Holding monthly educa onal mee ngs to discuss CDI preven on and treatment protocols
Collec ng facilityspecific data to track CDI trends within and across LTCs
Educa ng physicians on best prac ces for an bio c use for outpa ents, both children and adults
With guidance from PHF’s Senior Quality Advisor Jack Moran, Maine CDC created a Fishbone (or Cause and Effect) Diagram to
iden fy barriers to preven ng transmission and acquisi on of an bio c resistant disease within LTCs. Then Maine CDC worked
with each LTC to pinpoint and correct specific barriers. The LTC infec on preven onists found working closely with Maine CDC
and the Northeast Healthcare Quality Improvement Organiza on (QIO) was essen al to successfully adop ng the new protocols.
Maine CDC was dedicated to building collabora ve rela onships with the LTCs to achieve their common goals. Throughout this
process, the LTCs viewed Maine CDC as a facilitator and guide in infec on preven on — not merely a regulatory enforcer.
Story From the Field
Acknowledgements Special thanks to Peggy Shore and Stephen Sears at Maine Center for Disease Control and Preven on for providing content for
this story. Funding for this story was provided by the Centers for Disease Control and Preven on under Coopera ve
Agreement Number 5U38HM00051803. The contents of this document are solely the responsibility of PHF and do not
represent the official views of CDC.
Related Links and Resources
Public Health An bio c Stewardship Driver Diagram — The driver diagram referenced by Maine CDC used to iden fy
drivers for preven ng CDI. www.phf.org/abxdriverdiagram
PHF provides customized training, facilita on, and workforce development services to public health agencies and other
organiza ons that protect the public’s health. To inquire about technical assistance, please visit PHF at www.phf.org/
TechnicalAssistance or call 2022184415.
PHF’s An bio c Stewardship Program — Informa on about PHF’s An bio c Stewardship Program, which helped support
efforts by Maine CDC to prevent CDI. www.phf.org/an bio cstewardship
Collabora ng with Healthcare Partners Because this challenge exists at the crossroads of public health and healthcare, Maine CDC engages healthcare partners to
op mize the effec veness efforts to reduce CDI at LTCs. In order to reduce an bio c resistant infec ons at LTCs, the health
department has formed partnerships with the following organiza ons:
The Northeast Health Care Quality Founda on, a regional QIO experienced at addressing an bio c resistant infec ons
in healthcare facili es
The University of New England School of Pharmacy (UNESP), which analyzed Maine CDC’s data about rates of an bio c
resistance by organism and by region
The Maine Medical Associa on/Maine Independent Clinical Informa on Service (MICIS), which distributed United
States Centers for Disease Control and Preven on (CDC) Get Smart materials and a Maine CDC physician pocket
reference for prescribing an bio cs and provided onsite educa on to LTC medical directors and other physicians to
improve prescribing prac ces
LTCs in the ci es of Augusta and Waterville, which effec vely adopted new strategies and interven ons to reduce CDI
Expanding the Reach of Collabora on Maine CDC is monitoring CDI trends in LTCs, and will release a report on infec on rates in July 2014. To expand the reach of
its pilot ac vi es, Maine CDC will partner with the Maine Medical Associa on to educate 400 addi onal outpa ent
physicians and LTC directors about prac ces to reduce the spread of CDI. Maine CDC also hopes to bring this collabora ve
approach to addressing an bio c resistant infec ons to many more LTCs in Maine. To do this, Maine CDC is partnering with
the Maine Healthcare Associa on, a provider organiza on serving nursing facili es. The Maine Healthcare Associa on will
host two webinars in which Maine CDC and the QIO will share four tools developed during the pilot with other LTC facili es
throughout Maine.
February 2014
Using the Population Health Driver Diagram to Increase Use of Oral Health Care
To create opportunities for public health and health care collaboration to improve community health,
the Public Health Foundation (PHF) has created a population health driver diagram framework.
Grounded in the belief that public health and health care are more effective when their efforts are
aligned than when they work separately, this approach can be used to tackle challenges at the
crossroads of these two sectors.
A population health driver diagram can be used to help focus and align a community’s efforts to make
progress on a defined community health challenge. The driver diagram consists of a general AIM
statement, goals of the AIM statement, and primary and secondary drivers that specify actions that can
be taken to help achieve the desired goals for improved population health. Population health driver
diagrams serve as a starting point and framework for discussion, and offer flexibility for identifying and
addressing unique community characteristics and needs. They also help to create an atmosphere of
collaboration and cooperation by enabling each participant in these discussions to identify roles already
being played by their organization and others in the community, and determine additional action that
can be taken individually and collectively to positively impact the particular community health challenge.
The Population Health Driver Diagram to Increase Use of Oral Health Care includes an AIM statement,
goals, and primary and secondary drivers. When this driver diagram is being used by a community,
changes may be desirable to any component of the driver diagram. For example, there may be other
drivers that the community identifies and decides to address that are not specified in the driver
diagram, or the AIM statement and goals may need to be refined so that they better relate to the
community. It also is important to note that while the driver diagram articulates many drivers, choosing
a subset of drivers to address may help focus community efforts and achieve desired results. Depending
on the progress a community is making, additional drivers may be addressed over time, existing drivers
may be refined, and other drivers may be added.
This population health driver diagram was developed by PHF with funding from the Office of Disease
Prevention and Health Promotion of the U.S. Department of Health and Human Services. We encourage
you to use this driver diagram to increase use of oral health care in your community. We also encourage
you to and provide us with your feedback.
Please contact Micaela Kirshy, [email protected], (202)218-4410, with questions and feedback.
Population Health Driver Diagram to Increase Use of Oral Health Care
SECONDARY DRIVERS
Educate about available insurance coverage for oral health care
Educate dental and non-dental health professionals about oral health as a population health issue
Engage families and caregivers regarding importance of oral health
Surveillance, Analysis, Feedback
Identify high-risk populations with comorbidities
Identify risk and protective factors at the individual, family, school, and community levels
Identify policies that affect oral health
Track community oral health status
Goals
Increase affordability of oral health care for con- sumers
Increase availability and use of oral health care based on evidence and disease management
Prevent diseases of the mouth
Achieve oral health equity
This work was funded by the Office of Disease Prevention and Health Promotion of the U.S. Department of Health and Human Services
AIM Increase the proportion of children, adolescents, and
adults who use oral health care, education, prevention, and treatment
Diverse Care Settings, Affordability
Provide oral health care in non-traditional settings
Expand use of and insurance coverage for services provided by dental hygienists and other non-DDS/DMD providers, especially for school- based dental sealants
Increase diversity of professionals providing oral health care
Increase and strengthen publicly funded dental coverage
Increase proportion of primary care and public health settings that include an integrated oral health program
Education about Importance
Professional Education, Partnerships, Planning
Align provider incentives to use the prevention and disease management model
Educate dental students in clinic settings with allied-health professionals
Educate primary care providers and team members to provide basic oral health risk assessments, prevention, and education
Increase stakeholder engagement and skill building to ensure capacity and improve oral health outcomes
Require all dental professional education programs to include community service and social responsibility curricula
PRIMARY DRIVERS
3.2 Oral Health Driver Diagram
Cover Note Final.pdf
Final Driver Diagram