North Bay District Health Unit CQI Case Study

“The CQI framework outlines various components of CQI, such as the QI competencies that staff require, the Quality Dimensions that we value at the health unit, the roles and responsibilities of the CQI committee, steps involved in a QI project, and various QI tools and templates. This is a way of bringing everything together to create a systematic approach to CQI and to create the momentum needed to move the culture of CQI forward.”

CASE DETAILS Title Development of a CQI Framework CQI Focus Organizational Innovative, Non-Punitive Culture Culture Strategic Alignment Training and Education

Organizational Human Resources Structure Internal Funding and Resources Multidisciplinary Teams Senior Leadership Middle Management Leadership QI Facilitators Frontline Leaders Characteristics of Data Data Leveraging Data QI Collaboratives External Accreditation/Certification Supports Funding and Resources

MOH, CEO and/or CAO Dr. Jim Chirico, MOH/CEO Interview Participants Name: Danielle Hunter Email: [email protected] Name: Louise Gagné Email: [email protected] Interviewer Kelly Pilato (Brock University) Research Data  Case document  Interview transcripts

 NBPSDHU Dimensions of Quality Demographic Information Number of Staff: ~160 Geographic Location: and Geographic Size: ~17,000 square kilometres Size of Population: ~127,700 Type of Population: Rural and urban Governance Model: The Board of Health consists of 13 members. There are 10 municipal/citizen appointees and 3 provincial appointees. Case Budget Not available Keywords CQI committee, CQI framework, CQI working group, leadership support, QI project, QI training

SUMMARY Problem(s) North Bay Parry Sound District Health Unit (NBPSDHU) did not have an organizational strategy or framework for continuous quality improvement (CQI). Staff had minimal understanding of CQI or quality improvement (QI) tools and processes. It became clear that there was a need to build QI capacity and competency among staff to foster a culture of CQI. Motive(s) External: In 2016, NBPSDHU participated in a research project from the Continuous Quality Improvement (CQI) Locally Driven Collaborative Project (LDCP). The state of quality improvement (QI) at NBPSDHU was assessed with the QI Maturity Tool - Modified Version. The organization’s QI maturity score revealed that staff placed a high value on CQI but there was considerable room for improvement in terms of the culture of CQI, as well as QI capacity and competency among staff.

Internal: NBPSDHU’s leadership team completed an exercise to decide on actionable solutions to the QI Maturity Tool - Modified Ontario Version results. The actions were ranked on a Decision Making Quadrant based on effort (low or high) and impact (low or high). The exercise established the need for a CQI framework as a foundation to build a culture of CQI. Abstract Main Objectives: NBPSDHU aimed to create a CQI framework to build QI capacity and competency among staff and, ultimately, foster a culture of CQI across the organization.

Case Overview: A multidisciplinary CQI working group was formed to develop and implement the CQI framework. The CQI working group conducted an environmental scan to establish six Quality Dimensions for the CQI framework (i.e., responsive, equitable, safe, transparent, effective, efficient). The CQI framework outlines various components of CQI to ensure a systematic approach to CQI across the organization (e.g., roles and responsibilities of the CQI committee, Quality Dimensions, QI competencies that staff require, steps involved in a QI project, evidence-based QI tools and templates). The CQI working group created a QI training plan to increase QI capacity and competency among staff. Select staff have completed IDEAS Foundations of QI training, Adaptive Leadership training, and/or Lean White and Yellow Belt training. An online CQI training module was also developed and has become mandatory for all staff to complete. Senior leaders and managers have been supportive of the development and implementation of the CQI framework and have been engaged through the CQI working group and training opportunities.

Lessons Learned: Some of the critical success factors of the initiative

include leadership engagement and support, the multidisciplinary CQI working group, QI training, and the use of available resources to avoid reinvention of the wheel. The challenge that the initiative faced was slow development of the CQI framework as a result of competing priorities.

Sustainability and Next Steps: The CQI working group will transform into a formal CQI committee to sustain the momentum of the project, and the CQI framework will be finalized and implemented across NBPSDHU. CASE MEMBERS Name and Title Responsibilities

Danielle Hunter, Senior Research CQI working group Chair and Evaluation Analyst Louise Gagné, Manager Planning, CQI working group member Evaluation and Communications Services John Mitchell, Research Assistant CQI working group member

Paul Massicotte, Executive CQI working group member Director Corporate Services Cathy Menzies-Boule, Executive CQI working group member Director Clinical Services Sheri Hueston, Manager CQI working group member Administrative Assistant and Quality Assurance Coordinator Linda Brown, Technical Policy CQI working group member Writer Auburn Larose, Community Health CQI working group member Promoter Catharine Celebre, Nursing CQI working group member Practice Manager MAIN OBJECTIVES  Create a CQI framework to build QI capacity and competency among staff and, ultimately, foster a culture of CQI across the organization CASE OVERVIEW CQI Working Group  A multidisciplinary CQI working group was formed with staff at all levels (i.e., senior leaders, middle managers, front line staff) from across the organization to develop and implement the CQI framework  CQI working group members were invited to join because QI was part of their existing portfolio  Meetings were held approximately every 2 to 3 months to review progress and determine next actions  The CQI working group developed a logic model with a supporting work plan, prioritized outcomes, developed activities for all of the outcomes, and assigned leads and timelines for all of the activities  The progress of the CQI working group was communicated through executive team meetings, BOH quarterly reports, management meetings, a newsletter, and a CQI page on the NBPSDHU intranet

CQI Framework  NBPSDHU reviewed CQI frameworks from other health units and adapted certain components to their organization  The CQI working group conducted an environmental scan to establish six Quality Dimensions for the CQI framework (i.e., responsive, equitable, safe, transparent, effective, efficient), which align with NBPSDHU’s mission, vision, and values, and are considered fundamental to the development of a culture of CQI

 Once QI project work is underway, each project must demonstrate which quality dimension(s) are being worked towards  The CQI framework outlines various components of CQI to ensure a systematic approach to CQI across the organization (e.g., roles and responsibilities of the CQI committee, Quality Dimensions, QI competencies that staff require, steps involved in a QI project, evidence-based QI tools and templates)

QI Training  The CQI working group created a QI training plan to increase QI capacity and competency among staff  Senior leadership allocated resources to fund QI training opportunities during the development of the framework  The CQI working group and select staff completed Improving and Driving Excellence Across Sectors (IDEAS) Foundations of QI training to provide them with foundational knowledge of CQI prior to creating the CQI framework  Senior leadership and management completed Adaptive Leadership training to provide them with foundational knowledge of CQI and to encourage them to be open to innovation, change, and new ideas  Lean White and Yellow Belt training was run through the Leading Edge Group/OPHA and was delivered to the CQI working group, senior leadership, management, and select staff from each program/service who were slated to become CQI program leads to provide them with an understanding of Lean, process mapping, and QI tools and resources through a public health lens  The CQI working group developed an online CQI training module, which has become mandatory for all staff to complete; the module provides a basic awareness of QI vs. CQI and outlines sources of improvement opportunities across the organization

Leadership  Senior leaders and managers have been supportive of the development and implementation of the CQI framework and have been engaged through the CQI working group and training opportunities KEY ENABLERS  Leadership engagement and support  Multidisciplinary CQI working group  QI training  Use of available resources to avoid reinvention of the wheel RESULTS Outcome(s)  The CQI working group has partially developed the CQI framework  100% of staff are required to complete the online CQI training module  A comprehensive QI training plan has been developed and has allowed several staff members to complete IDEAS training, Adaptive Leadership training, and/or Lean White and Yellow Belt training Impact(s)  Staff who completed Lean White and Yellow Belt training acquired a common understanding of the principles of CQI, which has started to become ingrained into staff meetings LESSONS LEARNED Successes  Senior leaders and managers have been supportive of the development and implementation of the CQI framework and have been engaged in the process; the Decision Making Quadrant exercise likely helped to achieve buy-in from the leadership team  The multidisciplinary nature of the CQI working group has brought staff together from across NBPSDHU with different perspectives and competencies, which is valuable to develop a robust CQI framework  The CQI working group has been critical to the development of the CQI framework and the implementation of the QI training plan  QI training opportunities have allowed select staff to acquire a common language and gain the foundational knowledge required to increase QI capacity and competency across the organization

 The decision to seek out existing resources (e.g., environmental scan for Quality Dimensions, adaptation of CQI frameworks from other health units) saved NBPSDHU valuable time and resources  Staff have provided positive feedback about the online CQI training module Challenges  The development phase of the CQI framework has taken a lot longer than the CQI working group expected due to competing priorities Areas for Improvement  The development phase of the CQI framework has taken a lot longer than the CQI working group expected due to competing priorities, so it would have been helpful to have a staff member dedicated to the project throughout the development and implementation phases  NBPSDHU should have provided QI training opportunities earlier in the project as this might have helped to achieve buy-in from staff  The CQI working group should have focused more attention on consistently communicating their efforts with the rest of the organization  Staff do not have protected time right now to conduct QI projects, so this is something that should be advocated for to senior leadership  The CQI working group did not meet on a regular basis, so it would have been helpful to establish regular meeting times at the outset  The CQI working group Chair took on a lot of the work tasks and should have better distributed the work tasks amongst the working group members to reduce the Chair’s workload and benefit from the expertise of working group members  The CQI working group created the logic model partway through the project, but it would have been better to develop it at the beginning to focus the work of the group at the onset. SUSTAINABILITY AND NEXT STEPS  The CQI working group will transform into a formal CQI committee to sustain the momentum of the project: . The CQI framework will be finalized and implemented across the organization . CQI program leads will support QI projects in their respective program areas, act as liaisons between the QI project members and CQI committee, and help to build capacity for CQI across the organization . A database will be developed to document and monitor QI projects across the organization . CQI committee members will provide support and guidance to all QI project teams . QI projects will be posted on the CQI page on the NBPSDHU intranet with project details (e.g., project lead, synopsis, timelines, successes, challenges, tools, templates) to facilitate knowledge exchange . Additional professional development opportunities will be offered to staff . The Quality Dimensions will be used to categorize QI projects and performance measures will be developed for each of the six dimensions to evaluate the implementation of the CQI framework  QI projects will be integrated into annual operational plans  CQI competencies will be built into onboarding processes and incorporated into job descriptions SUPPORTING DOCUMENTS AND LINKS Lean training: https://opha.on.ca/What-We-Do/Projects/quality-improvement.aspx IDEAS training: https://www.ideasontario.ca NBPSDHU Dimensions of Quality

“We don’t want staff to feel like this is an expertise that belongs to someone else and that they have to ask someone to do it for them. We felt, in terms of creating a culture of CQI, it was really important that staff were trained so they could be more autonomous in their QI activities.”