Category Archives: Quality Improvement

What’s in a Name?

What drives you? Where do you get your passion?

Charlie Homer
Charlie Homer

For us at NICHQ it is the smile of a child. The promise of a brighter future. For all children. For all parents. That is what drives us. That is why we get up in the morning and do our work. We strive every day to help you make the systems that produce children’s health become better and better.

And that is why we are changing our name.

When we started NICHQ our focus was exclusively on improving the delivery of healthcare as the vehicle to better child health. We knew that the healthcare children needed and deserved wasn’t the healthcare they were receiving, and we wanted to make it better. We are gratified that we now share this cause with many, many partners. This work is still far from done and remains an essential part of who we are and what we do.

But “fixing healthcare” alone, daunting a task as it is, isn’t enough. It won’t get us to the goal we seek—for all children to achieve their optimal health. We learned this when we started to focus our energies on preventing childhood obesity. We encounter this when we seek to eliminate disparities in breastfeeding. And we are learning it again as we help tackle infant mortality. Healthcare is important—children need access to high quality care. But children also need safe neighborhoods, parents who are healthy themselves, food that is nourishing, and more. Healthcare can’t stand apart from these challenges either, so quality in health care also needs to include links to community to create the conditions that support and produce child health.

To more accurately reflect our purpose, we are making a change in our name, from “healthcare” to “health.” NICHQ’s purpose has always been to improve children’s health. That is our passion and now our name is aligned.

We’re also making one other change: because we’ve been around for 15 years, and there’s still so much work to do, we are also changing from an “initiative” to an “institute.”

You can still call us “NICHQ,” and find us at www.nichq.org, but now NICHQ means the National Institute for Children’s Health Quality.

Shakespeare asked, “What’s in a name? That which we call a rose by any other name would smell as sweet.”

For NICHQ, these changes may be small in terms of words, but they are large in terms of meaning.  Our passion hasn’t changed.  We look forward to getting up tomorrow morning and helping you help more children smile.

Learn more about NICHQ’s name change here.

Life Lessons from a First Grade Teacher

Jonathan Small
Jonathan Small

I will never forget the first time we met Mr. Weinstein, the first grade teacher for three of my four children.

It was open school night, September 1998. He was still a young man, but he was already quite celebrated in our school district. Even then his reputation was so large that I half expected Superman to walk into the class.

My wife and I and all the other parents were awkwardly seated in the little kiddie chairs, our knees in our chests, in a semi-circle at the front of the room. After introducing himself, the teacher opened with these memorable words: “Let me begin by telling you about my big goals for this year.”

Big goals for first grade? Seriously? I immediately began searching my assumptions about what I expected my child to achieve in first grade. My mind went to the usual suspects, the three R’s: some reading, some writing, some ‘rithmetic. But the teacher had a different agenda.

“My first big goal,” he said, “is that they become good citizens of this community. Because that’s what we have here in this classroom – a little community – and I want them to learn how to get along with one another, appreciate each other, and be productive members of the community.”

Wow, I thought. Hard to argue with that. What else has he got?

“My second big goal,” he said, “is that they develop a love for learning – because once they have that, the reading, writing and ‘rithmetic will all follow.”

So true, I thought as the chills started crawling up my back. What could possibly top this? What’s left?

“My third big goal,” he continued, “is that I want your children to fail.” Huh? He went on: “I want them to develop resilience for failure. Because that’s how they learn – by trying and failing.”

I was dumbfounded. His words were so simple, so true, so right on.

But more important than his words were his actions. We had the daily pleasure of seeing his big goals play out in every assignment, every decision, every moment in that classroom. His strong leadership vision was clearly articulated and he followed-through. Without question, the experiences in that classroom changed our children’s lives.

My eldest son is now 22 years old (hard to believe!) and yet I remember that day a decade and a half ago like it was yesterday. So inspired was I by the simple wisdom and clear vision of this special teacher.

These many years later, the life lessons I learned from this teacher are still profoundly influential, especially when viewed through the lens of quality improvement, a framework I would learn later in life:

  1. Think big and set bold aims.
  2. See the big picture and don’t get stuck in the small stuff.
  3. Share your vision with others so we can journey together.
  4. Make the complex simple so everyone can be inspired.
  5. Ensure your daily actions support your long-term vision.
  6. Don’t be afraid to fail because that’s how we learn and grow.
  7. The journey is as important as the destination.
  8. Take care of the people with whom you share your journey.  In the end, it’s all about them.

And I will add one more: don’t be surprised to learn lessons from unexpected sources. After all, who would have thought I could learn so much from my kids’ first grade teacher?

Viewing Health as a System

Charlie Homer
Charlie Homer

More than a decade ago, the Institute of Medicine declared that the purpose of the US healthcare system was to continuously improve the health of the American people. Yet, for a long time the focus of many remained narrowly within the constraints of healthcare—addressing themes such as patient safety, clinical effectiveness and patient centeredness that are critically important but of themselves not likely to change the overall health and well being of the population.

Gradually, and now with increasing force and pace, a movement is building that seeks to recognize the broader influences on health, often summarized as “social determinants of health.” For example, The Robert Wood Johnson Foundation is reframing its strategic focus to emphasize a “culture of health” and the National Quality Forum has several working groups on both measuring population health and moving the nation to health.  Hooray!

NICHQ of course has long had a broad focus on health, strongly driven by our work on addressing childhood obesity. In this work we recognized early on that clinical care is an extremely important element AND that addressing childhood obesity required coordination and integration between the clinic and community to change the context and provide effective services. I suspect that addressing the obesity epidemic is part of what has driven not just NICHQ but the broader health and healthcare community to see the need to bridge healthcare and health in a new way.

What Is the System that Produces Health?

Improvement science teaches us to view outcomes—such as health—as the inevitable product of a system, with the implication that achieving improved outcomes  requires changing the system itself.  A deep understanding of the system and how it functions can enable smarter decisions about selecting high leverage changes in order to improve system performance.

In this case, what is the system that produces the health of a population? How might we describe it and so choose promising points of intervention?

The most common framing that I see is that originally developed by McGinnis and modified by Kindig in creating county health rankings. In this model, the influences on health are broken down into a few simple categories—you might even call them “drivers.” The relative impact of these drivers are then estimated, with healthcare merely 10-20 percent, health behaviors a much higher 30-40 percent, and other factors in between.

All models are simplifications of reality; good models are useful in enabling understanding and driving action. The Kindig model is useful in broadening focus and, presumably, investment from health care to community or, more thoughtfully, assuring that community actions—from highway construction to food pricing—include health considerations if we want to alter societal health.

Yet as a system thinker and a pediatrician inherently oriented to think longitudinally and developmentally, I find the model inadequate. At least in its typical graphic representation, the model fails to emphasize the interaction and interdependence of the factors that when attached to percentages seem independent. Social factors clearly influence the physical environment in which one lives (how many bus depots are adjacent to luxury housing?). Similarly health behaviors—such as healthy eating—are strongly influenced by economic factors and, under ideal conditions, at least marginally influenced by high quality health care.

Envisioning a More Complete Model

So how can we improve the model? I’m early in the process of thinking about this, and thought I’d share my thinking and get some crowd-source reactions and feedback at this early stage.

I initially started to add elements. For example, if we put “personal resilience” in as a driver, we can start to see how supportive relationships can drive better health. If we add a driver for “earlier health status” we can begin to recognize the longitudinal nature of health. Here’s a snapshot of my white board brainstorm:

brainstormBut, ultimately the linear driver framework seems to be an insufficient illustration of the system to truly help set priorities for action. This type of model doesn’t emphasize the interactions among the drivers, nor does it truly address the importance of timing and trajectory (there’s that developmental thinking again!).

Seeking a Systems Model

System diagrams and system modeling may be a more effective approach to framing the complexity of the influences on health, and especially to incorporate the critical role of development and what system modelers might call lagged effects, i.e., the effect of an intervention at one point in time on outcomes at a much later point in time. System modeling has been applied to community health, but the models I have seen don’t adequately account for the later or long-term effects of interventions at earlier points in time, particularly the protective effects of interventions at critical points in development as well as the cumulative effects over time.

Here’s my first rough attempt at a system diagram for health outcomes, presented for others to comment on and improve:

systemdesignCleaned up, it looks like this, more legible but still a draft:

clean system diagramWhat I’ve represented as the outcome is “health now.” A key influence of health now is health at an earlier stage, with this earlier stage health influenced by numerous drivers—many of which are not dramatically different than those in the McGinnis/Kindig model. The distinction is the emphasis on the interaction of these drivers and of the critical impact of health at an earlier stage on later health—in either a virtuous or vicious cycle.

Even this graphic model doesn’t adequately emphasize the particular importance of influences on health at particular times—such as infancy and late adolescence/early adulthood. Yet it does start to elevate the importance of interventions to improve health at an early stage in life—interventions both through health care (e.g., for those at great biologic vulnerability such as extreme prematurity) AND through enhancing the economic and social conditions and capabilities of parents and community.

Getting this right isn’t just an academic exercise. Without attention to time, policy makers may focus all of their efforts on behaviors and conditions at a late (adult) stage and fail to achieve the desired health impact that earlier childhood interventions might have. Similarly, without attention to the interaction among these factors—such as the impact of environmental exposures on epigenetics or the potential for healthcare to influence health behaviors—the potential benefits of some interventions or potential harms of exposures will be vastly underestimated.

I look forward to your help in improving the model and truly focusing all of our efforts on improving health.

Time to Pause, Celebrate, and Keep Pushing Ahead

Shikha Anand
Shikha Anand

If you’ve read anything about obesity in the lay press over the past week, you already know that there has been a decline in the prevalence of obesity in American preschoolers. The CDC’s latest National Health and Nutrition Examination Survey (NHANES) data, published in the Feb. 26 issue of the Journal of the American Medical Association, show a significant decline in obesity among children aged 2 to 5 years. Obesity prevalence for this age group went from nearly 14 percent in 2003-2004 to just over 8 percent in 2011-2012. This information has been rippling throughout the press this week, with headlines like “U.S. Childhood Obesity Rates Fall 40% in Decade.”

For me, this news is both exhilarating and anxiety provoking. On one hand I have been working throughout that period alongside countless others to achieve a population decrease in body mass index (BMI) and the news that the day may have finally come for one segment of the pediatric population is incredibly encouraging. On the other hand, the rate is still 8.1 percent, as compared to 4.1 percent in the 1971-1974 NHANES cohort, and celebrating too early could distract from the fact that there is so much more work to be done, especially for our most vulnerable children.

The first question that crossed my mind when the news first landed in my inbox is whether the tide has really turned. Experts agree that the sampling methodologies in NHANES are robust and the data are valid. The pressing questions are (a) whether we are really seeing a trend and (b) whether that trend applies to the most vulnerable children.

There are two ways in which I think about data like this.  The first is with a gut check—does this jive with what I see in my Community Health Center patients?  Although I am not sure that my observation techniques are sensitive enough to see a change from 12 percent in the last cohort to 8 percent in this one, it does seem like recent changes in WIC, SNAP and childcare settings, among others, have made families in my clinic more aware of the impact of healthy eating and active living on the weight and health of their children. And when I saw an obese 2-year-old child this week, I actually thought to myself that I had not seen an obese preschooler in at least a few clinic sessions—certainly a change from five years ago. So is it possible that the tide has turned for preschoolers based on my clinical experience with an underserved urban population? I think so.

But I would be hard pressed to claim that my clinical experience is sufficient to validate public health trends. So I did what improvement junkies do. I went back to the numbers.  The most recent data stratified by race and ethnicity has not yet been made available so I was only able to look for a trend among all preschoolers. I plotted the NHANES data from 1999 to 2012 using CDC data to determine if there really is a trend, creating a graph of obesity prevalence over time, what is known in quality improvement as a run chart.

shikhaA run chart is designed for the early detection signals of improvement over time through recognition of non-random patterns in the data. The first possible pattern is a “shift,” defined as six or more successive points that are all above or below the median, which in this case is 10.6 percent. If our recent changes in policy and practice had caused a shift beginning in 2005-2006, we would see that the next six points fall below the median. But in fact, the four points from the 2005 cohort to the 2011 cohort alternate between being above and below the median, indicating we don’t have enough data to see a shift and that we don’t appear to be on our way to one just yet. We can also look for a “trend,” defined as five or more consecutive points that are either ascending or descending. Similar to the case of the shift, we neither have enough data points, nor do we have indication that we are on our way to a trend. So despite the change in prevalence, it is challenging to use the data to either establish a new, lower baseline prevalence or to attribute the decrease to the changes we have made to the environments of preschoolers.

So where does that leave me? Trend or no trend, this news means thousands and thousands fewer preschoolers are obese in 2011-2012 vs. 2003-2004 and this fact will have an enormous impact on our health resources and outcomes as they mature. And these data give us hope that sustainable improvement could be just around the corner. In any case, we must continue to invest heavily in activities and policies that promote healthy weight to create a change in prevalence that will persist over time. If nothing else, this is a moment to pause, applaud all of the wonderful changes we have made to date, and energize ourselves for the long road ahead—to the day when we have reversed the trend for ALL Americans, regardless of age, race, or class.

Far From Gold Medal Performance

JS Profile
Jonathan Small

The Olympics were a source of great pride and entertainment for millions of people around the world. I was personally glued to the TV for two weeks and was filled with admiration and respect for these impressive athletes. I frequently found myself thinking about all the hard work and sacrifices needed for them to reach the pinnacle of their sport. I was inspired.

And then the director cut to commercial and I had the displeasure of seeing this ad from Cadillac. In it, actor Neal McDonough glorifies the value of hard work while berating the more leisurely lifestyle of other countries:

Other countries, they work. They stroll home. They stop by the café. They take August off. Off. Why aren’t you like that? Why aren’t we like that? Because we’re crazy-driven, hard-working believers, that’s why.

Then as he revs up his spanking new electric Caddy in the driveway of his ultra luxury home, he ponders the acquisition of material goods and posits they are “the upside of only taking two weeks off in August, n’est-ce pas?”

OK, fine. But what’s the downside? What price does our society pay for discouraging leisure time and mental health days? How much social capital do we lose when we don’t stop by the café?  How many families have dissolved under the pressure of our cultural norms? How many children lack the support systems necessary to achieve their optimal health? And don’t even get me started about maternity leave and childcare benefits.

The US has higher rates of infant mortality and childhood obesity than most other industrialized nations and lags behind in breastfeeding rates as well. These statistics are nothing to brag about. When viewed through a disparities lens, they are even more troubling. For example, the risk of infant death for babies born to non-Hispanic black women is more than two times greater than the risk of infant death for non-Hispanic white women. That’s horrific and embarrassing.

Maybe these “other countries” have something figured out about life balance, n’est-ce pas?

Certainly there is reason for optimism. Recent reports show obesity rates coming down and breastfeeding rates on the rise.  Infant mortality rates are also moving in the right direction and we are confident national initiatives will continue to drive them down.

But we have a long way to go before we get a gold medal in child health outcomes. I suggest we begin in a humble place – with the recognition that, while we may have much to teach other countries, we also have a lot to learn. Of course, this approach would not be very effective for selling cars.

Should We Ban Valentine’s Day Candy in Schools?

Karen Sautter Errichetti
Karen Sautter Errichetti

As a school committee member, one of the questions I get asked most often about any holiday we celebrate in schools is “Will you be banning sweets this year?” I’m always surprised by this question because the practice of bringing in sweet treats is itself a longstanding cultural tradition in my school system.  In fact, I think there would be people with pitchforks and torches in my yard if we banned this practice.

A friend sent me this article this morning with the provocative title “School Bans Valentine’s Day Candy,” making me revisit this topic.  In this case, the principal explained the rationale for the ban to parents like this:

We are working to encourage healthy practices as well as manage food choices in classrooms where food allergies are present in order to maintain a safe environment.
Similarly, other schools across the US have made the choice to limit or ban candy and other indulgent food. The rationale is the same in almost every case: wellness and safety.
At a recent staff gathering at NICHQ I asked the question: Why do we ban things in the name of health? In public health, we use law and regulation to ensure public safety and prevent illness and death. It seems like the right thing to do: ban the things that are bad for people and promote or incentivize the things that are good for health.  In particular, schools become targets for these kinds of strategies. But what is the evidence that this actually works?
In our work to prevent childhood obesity, for example, many states have implemented policies to limit or ban sweetened beverages in public schools. The link between sugary drinks and obesity is well-researched. According to the Harvard School of Public Health, children and adults are drinking more sugary drinks than ever before, and there is evidence that both children and adults are better able to control their weight when they reduce their consumption of sugared beverages.
Based on this evidence, it seems like the right thing to do to ban sugary drinks in schools. Unfortunately, the literature presents a mixed bag regarding whether these policies actually reduce student consumption of those drinks overall, and in turn reduces obesity.  A 2012 national survey in 40 states by Taber et al. illustrates this point.  Taber and his colleagues found that while fifth and eighth grade public school students reduced their access to sugar-sweetened beverages, these children had not reduced their consumption of these drinks. It’s still early in our battle with childhood obesity, and many child advocates are still experimenting with these policies.
If I’ve learned one thing from NICHQ’s work in the obesity space, it is that there is no one magic bullet to prevention and reduction of obesity.  It takes multi-sector partnerships including all stakeholders to try to move the big dot toward healthier children. Policies to restrict access to foods linked with increased obesity are only part of an arsenal of tools we have tried to curb obesity.  As we continue to experiment using policies limiting or banning access as a means to improve public health, we can benefit from applying quality improvement approaches to test our ideas.
In our community of North Reading, my school committee has never voted to ban candy or any other food item in my history of being on the committee. We prefer to think of policy as something we create in the greater context of student well-being and change, setting the foundation for application of evidence-based practice. Simply banning a food item is a band-aid on a larger problem that deserves a comprehensive approach. We still have a long way to go on the topic of childhood obesity, and we owe it to our children to think outside the cupcake.
What are your thoughts about banning Valentine’s Day candy to improve child health? Please share your thoughts by commenting!
Karen Sautter Errichetti is a two-term elected member of the North Reading School Committee in Massachusetts.  The views expressed in this post are those of the author and do not necessarily reflect those of NICHQ.

The Secret Ingredient to Fixing Systems Problems

Cindy Hutter
Cindy Hutter

In full disclosure, I didn’t see this firsthand. The photo was passed on to me with the caption, “You had one job.” Instead of the chuckle it was intended to elicit, the message made me a little irritated. I started to think of all the places where there was a breakdown in the system that allowed these mislabeled products to hit the grocery shelf.

No matter how automated a factory is, surely someone must have noticed that the incorrect packaging was being used on the hamburger buns. Did a factory worker raise a red flag? If she did, was it ignored? As the stock boy was unpacking the hamburger rolls at the local grocer, didn’t he notice? Was he on such autopilot that he genuinely missed it? Or did he simply think it wasn’t a big enough issue to care?

What about every other stock boy or girl at all the supermarkets that received the mislabeled products. Did none of them notice? If someone did notice and called the manufacturer, did the company care? Did the bun company call back the mislabeled products? What happens if someone eats one of those buns and has an allergic reaction because the product inside was not as advertised on the package?

Yes, the difference between a hamburger bun and hotdog bun, which most likely are made with the same ingredients and the same process, sans the shape, won’t likely cause harm. However, what if that mislabeling was on a product that contained peanuts? Or a household cleaner with toxic ingredients? Or even a medication? These might have serious consequences.

Working in a quality improvement organization, we view undesirable outcomes as the byproduct of poorly performing systems. We teach that to uncover the problem in a system causing the unwanted result, you need knowledge or information.

It sounds simple enough. Of course you need knowledge and information to get to the root of a problem and make a change that will hopefully result in improvement. But more often than any of us like to admit, decisions get made without enough knowledge.

For example, I bought a Kindle because I thought it would help me to read more. It hasn’t. Whether I have a hard copy or an electronic copy of a book isn’t the issue; it’s carving out time to read that is the problem. If I had spent even a few minutes asking myself questions about why I don’t read enough, I could have saved the money I invested.

Or to go back to our bun example, the bun company’s vice president of operations may decide the root of the problem is a shortage of hamburger bun bags at his factories. But, even after the additional bags arrive at the factories, the mislabeling issues continue. A little knowledge seeking, perhaps talking to some of the workers, would lead him to the real problem: workers can’t detect the blue and green colors that are meant to distinguish the hamburger and hotdog bun bags or simply can’t read the language.

The mantra in quality improvement is “every system is perfectly designed to get the results it gets.” Regardless of your system of choice—your workplace, your home, your community—you’ll need knowledge to improve the system and get the results you want. It’s impossible to be a change agent without being a knowledge seeker first.