Improving service delivery in a county health department WIC clinic: an application of statistical process control techniques

Connecting the Dots between Barriers to W.I.C. Access and Adult and Child Food Insecurity: A Survey of Missouri Residents

Background. Previous research has explored the impact of W.I.C. on recipients' health, but less is known about the connection between barriers to W.I.C. access and health outcomes. We fill in a gap in the literature by studying the relationship between barriers to Special Supplemental Nutrition Program for Women, Infants, and Children (W.I.C.) access and adult and child food insecurity. Methods. After survey administration, we analyzed a cross-sectional sample of 2244 residents in Missouri who have used W.I.C. or lived in a household with a W.I.C. recipient in the past three years. We ran logistic regression models to understand the relationships among barriers to W.I.C. utilization, adult food insecurity, and child food insecurity. Results. Having special dietary needs (for adults), lacking access to technology, encountering inconvenient clinic hours of operation, and experiencing difficulties taking off work were associated with increased adult food insecurity. Difficulties finding WIC-approved items in the store, technological barriers, inconvenient clinic hours, difficulties taking off work, and finding childcare were associated with increased child food insecurity. Conclusion. Barriers to accessing and utilizing W.I.C. are associated with adult and child food insecurity. However, current policies suggest promising approaches to curbing these barriers.

Attitude Disparity and Worrying Scenarios in Genetic Discrimination-Based on Questionnaires from China

Objectives: As genetic testing is increasingly used in non-medical fields, the judgment of people's potential conditions based on predictive genetic information inevitably causes genetic discrimination (henceforth GD). This article aimed to systematically investigate the disparity in attitudes and worrying scenarios concerning GD in China. Methods: A questionnaire survey of 555 respondents was conducted. Statistical tests were used to examine disparity in attitudes between gender, age, and education. A descriptive analysis was also conducted to explore other worrying scenarios. Results: It shows that (1) men are more tolerant of GD compared to women, and (2) participants aged between 18 and 30 years old possess the highest objection to GD. However, (3) no indication can attest to the relationship between educational level and perspective on GD. In addition, (4) the acceptance of gene testing in the three most common scenarios is ranked in descending order as follows: partner choice, insurance services, and recruitment. Moreover, (5) worrying scenarios relating to GD include: education, social occasions, medical services, fertility, shopping, and so on. Conclusions: Based on the results, suggestions proposed include developing a blacklist mechanism in the field of genetic data application and strengthening the security regulations for the commercial use of genetic data.

"It Was Actually Pretty Easy": COVID-19 Compliance Cost Reductions in the WIC Program

In recent years, scholars have examined the barriers to accessing public assistance benefits. Research identifies learning, compliance, and psychological costs as deterring program use. Compliance costs reflect the burdens of following program rules, which may entail providing documentation, responding to discretionary demands of bureaucrats, or attending appointments to maintain benefits. Studies identify one element of compliance costs-quarterly appointments-as a barrier to continued WIC participation. This article draws on 44 in-depth qualitative interviews with participants in the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC). We examine how WIC participants perceive the reduction of compliance costs following the implementation of remote appointments in response to the COVID-19 pandemic. WIC participants report satisfaction with remote appointments and a reduction in the compliance costs of accessing and maintaining benefits. We conclude by recommending longer term changes to policy and practices to increase access and continuity in WIC receipt.

The Contribution of Variable Control Charts to Quality Improvement in Healthcare: A Literature Review

Objective

To conduct a literature review to determine where and how variable control charts have contributed to quality improvement in healthcare.

Methods

A targeted literature search of the ABI/INFORM Global, Science Direct, Medline and Google Scholar databases was conducted, which yielded 6875 papers. Screening articles on the basis of title and abstract resulted in references to 163 articles, leading to the identification of 29 articles published between 1992 and 2019 that met the inclusion criteria. Common themes, variables and units of analysis were then analyzed.

Results

Variable control charts have been applied in 11 different healthcare contexts, using 17 different variables, at various levels within healthcare organizations. The main reason for applying variable control charts is to demonstrate a process change, usually following a specific change or quality intervention. The study identified various limitations and benefits of applying variable control charts. The charts are visually easy to understand for both management and employees, but they are limited by their requirement for potentially complex and resource-intensive data collection.

Conclusion

Variable control charts contribute to quality improvement in healthcare by enabling visualization and monitoring of variations and changes in healthcare processes. The methodology has been most frequently used to demonstrate process shifts after quality interventions. There still is a great potential for more studies applying variable control charts.

Measuring the Cost and Value of Quality Improvement Initiatives for Local Health Departments

OBJECTIVE

To demonstrate an approach to measuring the cost and value of quality improvement (QI) implementation in local health departments (LHDs).

DESIGN

We conducted cost estimation for 4 LHD QI projects and return-on-investment (ROI) analysis for 2 selected LHD QI projects.

SETTING AND PARTICIPANTS

Four Nebraska LHDs varying in rurality and jurisdiction size.

MAIN OUTCOME MEASURES

Total costs, unit costs, incremental cost-effectiveness ratios, and ROI.

RESULTS

The 4 QI projects vary significantly in their cost estimates. Estimated ROI ratios for 2 QI projects predicted significant savings in health care utilization for respective program participants. A QI project focused on improving breastfeeding rates in WIC (women, infants, and children) clients had a predicted ROI ratio of 3230% and a QI project for improving participation in a Chronic Disease Self-Management Program would need only 34 new participants to have a positive ROI.

CONCLUSIONS

We demonstrated how data can be collected and analyzed for cost estimation and ROI analysis to quantify the economic value of QI for LHDs. Our ROI analysis shows that QI initiatives have great potential to enhance the value of LHDs' public health services. A better understanding of the costs and value of QI will enable LHDs to appropriately allocate and utilize their limited resources for suitable QI initiatives.

Control Charts in Healthcare Quality Improvement

Objectives: Use of Shewhart control charts in quality improvement (QI) initiatives is increasing. These charts are typically used in one or more phases of the Plan Do Study Act (PDSA) cycle to monitor summaries of process and outcome data, abstracted from clinical information systems, over time. We summarize methodological criteria of Shewhart control charts and investigate adherence of published QI studies to these criteria.

Methods: We searched Medline, Embase and CINAHL for studies using Shewhart control charts in QI processes in direct patient care. We extracted methodological criteria for Shewhart control charts, and for the use of these charts in PDSA cycles, from textbooks and methodological literature.

Results: We included 34 studies, presenting 64 control charts of which 40 control charts plotted two phases of the PDSA cycle. The criterion to use 10–35 data points in a control chart was least adhered to (48.4% non-adherence). Other criteria were: transformation of the data in case of a skewed distribution (43.7% non adherence), when comparing data from two phases of the PDSA cycle the Plan phase (the first phase) needs to be stable (40.0% non-adherence), using a maximum of four different rules to detect special cause variation (14.1% non-adherence), and setting control limits at three standard deviations from the mean (all control charts adhered).

Conclusion: There is room for improvement with regard to the methodological construction of Shewhart control charts used in QI processes. Higher adherence to all methodological criteria will decrease the risk of incorrect conclusions about the process being monitored.

Use of a mixed-method approach to evaluate the implementation of retention promotion strategies in the New York State WIC program

This research assessed the implementation of strategies piloted at 10 Special Supplemental Nutrition Program for Women, Infants and Children (WIC) clinics aimed at increasing retention in the program, by enhancing participants' shopping experiences. Under WIC Retention Promotion Study: Keep, Reconnect, Thrive (WIC RPS), clinics were recruited and assigned to implement one or a combination of strategies: a standardized Shopping Orientation (SO) curriculum, a Guided Shopping Tour (GST), and a Pictorial Foods Card (PFC) from November 2012 through August 2013. This paper presents results from the process evaluation of the retention strategies, using a mixed-methods comparative case study design employing WIC administrative data, interviews, and focus groups. Qualitative data were inductively coded, analyzed and mapped to the following implementation constructs: organizational capacity, fidelity, allowable adaptations, implementation challenges, and participant responsiveness, while quantitative data were analyzed using SAS to assess reach and dose. Several sites implemented the SO and PFC interventions with the necessary fidelity and dose needed to assess impact on participants' shopping experiences. Sites that were assigned the GST strategy struggled to implement this strategy. However, use of the standardized SO enabled staff to use a "consistent list of shopping tips" to educate participants about the proper use of checks, while use of the PFC increased participants' awareness of the variety of WIC-allowable foods. During follow-up telephone calls, 91 percent of participants reported the shopping tips as helpful. Future analyses will assess the impact of enhanced shopping experience on retention at intervention sites.

Public health accreditation: rubber stamp or roadmap for improvement

OBJECTIVES

We identified the characteristics of local health departments (LHDs) that intended to seek accreditation, and also examined the association between that intent and a complete community health assessment (CHA), community health improvement plan, agency strategic plan, or other specific accreditation requirements.

METHODS

We analyzed data from the 2010 profile survey of LHDs conducted by the National Association of County and City Health Officials (n = 267).

RESULTS

Those LHDs that conducted a CHA (adjusted odds ratio [AOR] = 0.62; 95% confidence interval [CI] = 0.38, 1.00; P = .05) and developed a strategic plan (AOR = 0.30; 95% CI = 0.12, 0.74; P = .01) were less likely to have an intent to pursue accreditation in the first 2 years of the program. By contrast, those LHDs that were engaged in quality improvement (QI) activities were approximately 2.6 times more likely to pursue accreditation compared with those LHDs that did not have any QI activities (P < .001).

CONCLUSIONS

Based on our findings, national public health accreditation might be the vehicle LHDs could use to improve their operating environments, better manage their resources, and reap the rewards associated with meeting national industry standards.

A WIC-based curriculum to enhance parent communication with healthcare providers

The objectives describe a curriculum to support parent-provider communication about child development, and to demonstrate its impact and effectiveness when delivered by staff from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). A curriculum was developed by a university-WIC partnership for a WIC center-based health education class to teach parents about child development and how to talk to their child's doctor about development. During a 90-min training session, university pediatricians used this curriculum and trained WIC paraprofessionals to conduct a 20-30 min center-based education session. WIC paraprofessionals completed an on-line survey to obtain their demographic characteristics, and their attitudes and perceptions about the training sessions and their experiences teaching the center-based health education session to parents. Approximately 500 WIC paraprofessionals received the 90-min training session across 60 centers in the Public Health Foundation Enterprises WIC Program in Southern California. About 250 WIC paraprofessionals completed the on-line survey and over 80 % of WIC staff reported that they had learned new information about child development as a result of the training, and 87 % of the WIC staff reported that the training was sufficient to feel comfortable teaching the class content to parents. We demonstrated the ability to build WIC paraprofessional capacity to promote parental participation in child developmental surveillance and communication with their child's doctor. With appropriate training, WIC staff are interested in supporting population-based efforts to improve parent-physician communication about child development that can complement WIC's existing maternal and child health topics.

Developing a taxonomy for the science of improvement in public health

CONTEXT

Quality improvement (QI) methods have been used for almost a decade in public health departments to increase effectiveness and efficiency. Although results are rapidly accumulating, the evidence for the science of improvement is shallow and limited. To advance the use and effectiveness of QI in public health, it is important to develop a science of improvement using practice-based research to build an evidence base for QI projects.

OBJECTIVES

This purpose of this study is to advance the science of improvement in public health departments with 3 objectives: (1) establish a taxonomy of QI projects in public health, (2) categorize QI projects undertaken in health departments using the taxonomy, and (3) create an opportunity modes and effects analysis.

DESIGN

This study is a qualitative analysis of archival data from 2 separate large databases consisting of 51 QI projects undertaken in public health departments over the last 5 years.

SETTING AND PARTICIPANTS

The study involves 2 separate QI collaboratives. One includes Minnesota health departments; the other is a national collaborative.

MAIN OUTCOME MEASURES

We propose a standardized case definition, common metrics, and a taxonomy of QI projects to begin building the evidence base for QI in public health and to advance the science of continuous quality improvement.

RESULTS

All projects created an aim statement and used metrics while 53% used a specific QI model with an average of 3.25 QI techniques per project. Approximately 40% of the projects incorporated a process control methodology, and 60% of the projects identified the process from beginning to end, while 11 of 12 PHAB (Public Health Accreditation Board) domains were included.

CONCLUSIONS

The findings provide a baseline for QI taxonomy to operationalize a science of improvement for public health departments.

Quality improvement interventions in public health systems: a systematic review

CONTEXT

Public health leaders are making difficult decisions about how to maximize the effectiveness of public health services with diminishing funds. Quality improvement (QI) interventions seek to improve the efficiency and effectiveness of public health programs, services, or organizations. The purpose of this study was to review the literature to describe public health system QI interventions and their impact on public health practices and health outcomes.

EVIDENCE ACQUISITION

A systematic review was conducted using PRISMA guidelines. Three databases were searched for peer-reviewed articles that included public health quality improvement-related terms in their abstracts. Articles published in 1990-2010 that described results from QI interventions conducted within the U.S. public health system were included.

EVIDENCE SYNTHESIS

Fifteen studies were identified, reporting on 18 separate QI interventions. Studies fell naturally into three functional categories: organization-wide QI, program- or service-specific QI, and administrative or management function QI. Few of the studies linked their improvements directly to a health outcome or predictors of health outcomes. Studies generally were implemented in state-level or large local public health departments.

CONCLUSIONS

Formally published QI interventions may not be representative of typical, smaller-scale QI activities. Collection and distribution of QI results associated with proven, effective public health interventions and that quantify the benefits of QI practices in public health should be a goal. More research is needed to definitively "connect the dots" between QI efforts, resulting practice improvements, and actual (or predictors of) health outcome improvements. Future studies should examine QI in diverse public health systems.