The Winnebago County Health Department continuously strives to improve our policies and processes to provide the opportunity for the best possible health for all Winnebago County residents. WCHD also works to address systemic processes that result in health disparities. WCHD is committed to continuous quality improvement through systematic assessment, implementation, and evaluation of actions to improve health.
What is Quality Improvement (QI)?
Quality improvement is a continuous and ongoing effort to achieve equity and improve the health of the community by achieving measurable improvements. Areas for measurable improvement include: efficiency, effectiveness, performance, accountability, and healthy outcomes,Â
QI provides a venue to address public health challenges through communication and collaboration that improves tools used in implementing programs. QI utilizes the Plan-Do-Study-Act method to implement changes and evaluate the outcomes. QI is fundamental to public health as one of the 10 essential public health services: Improve and innovate public health functions through ongoing evaluation, research, and continuous quality improvement.
Currently, WCHD’s QI projects focus on processes that respond to community needs and improve population health.
WCHD 2023 QI Projects
ENVIRONMENTAL HEALTH IMPROVEMENT
| AIM Statement | Strategic Alignment | Baseline Data | Measure | Project Charts | |
|---|---|---|---|---|---|
|
ENVIRONMENTAL HEALTH: DIGITIZATION PROJECT |
By December 31, 2023, have at least 10,000 well/septic records scanned and recorded in the spreadsheet to facilitate record retrieval and documentation of systems in Winnebago County. |
2. Develop and Enhance Systems to Support Core Public Health Organize internally to support strategic initiatives |
Information on wells and septic systems maintained on paper by address. Estimated number of paper records = 10.000. | By December 31, 2023 have a minimum of 10,000 records scanned and recorded in the spreadsheet. |
|
|
ENVIRONMENTAL HEALTH: CLERIFICAL PERFORMANCE |
By December 2023, create detailed Clerical Procedures for the EHI Clerical Procedures Guide to include data entry and payment processing for all environmental health services and invoicing in the CDP software system, intake phone calls, and handling of environmental mail and email. |
3. Advance a Culture of Quality Maintain and ensure a workforce development plan to support public health competency. |
• Duplicate entries, clerical errors and missing information: 3-5 per week • Basic information and complaint follow up calls transferred to EH inspectors/supervisors - 3-5 per day • Current staff backup is only EH clerical supervisor • Supervisor training/interventions – 1-2 daily |
By December 2023, • Reduce clerical errors, missing information, and duplicate entries to 0-1 per week. • Decrease number of basic information and complaint follow up calls transferred to EH inspectors/supervisors to 3-5 per week; • Reduce supervisor data correction and assistance to 1-2 times per week. • Ability in future to more easily train environmental health clerical staff with proper resources. |
|
HEALTH PROMOTION & WELLNESS
| AIM Statement | Strategic Alignment | Baseline Data | Measure | Project Charts | |
|---|---|---|---|---|---|
|
WINNEBAGO COUNTY TOBACCO FREE COMMUNITIES COALITION |
Increase participation of representatives from 2 to 12 key community sectors to build community support for the education, awareness, and development of policies around the use of tobacco products in particular electronic (e) cigarettes by youth under the age of 21 years by June December 31, 2023. |
1. Focus on Core Public Health Advocate for policies that promote population health 2. Develop and Enhance Systems to Support Core Public Health Engage with community partners to address health priorities 3. Advance a Culture of Quality Inform community on public health initiatives and impact |
Only 2 Community Sectors represented. | Community partners from 12 Community Sectors will participate as active members of a Tobacco Free Communities Coalition by meeting monthly and completing one (1) awareness event by July 1, 2023. |
|
| WCHD COORDINATED INTAKE & REFERRAL SYSTEM | By the end of the IGrow Fiscal Year (June 30, 2023), 10% of the IGrow referrals will come from external sources (Rockford Housing Authority, Crusader Community Health, Winnebago County Housing Authority, State Insurance Agencies). |
1. Focus on Core Public Health Assure development and implementation of plans to address health priorities. 2. Develop and Enhance Systems to Support Core Public Health Engage with community partners to address health priorities |
46% of the IGrow referrals come internally from the WCHD WIC Program | By the end of the IGrow Fiscal Year (June 30, 2023), 10% of the IGrow referrals will come from other sources (Rockford Housing Authority (RHA), Crusader Community Health, Winnebago County Housing Authority, State Insurance Agencies). |
|
HEALTH PROTECTION
| AIM Statement | Strategic Alignment | Baseline Data | Measure | Project Charts | |
|---|---|---|---|---|---|
| RABIES PEP IMPROVEMENT | Reduce rate of administration of Rabies PEP (Post-exposure Prophylaxis) that does not follow IDPH guidelines from 20% to 5% by healthcare providers in Winnebago County by December 31, 2023. |
1. Focus on Core Public Health Advocate for policies that promote population health |
Approximately 19% of cases in 2022 were provided PEP did not follow IDPH guidance for rabies PEP. | 95% of incidence in the administration of PEP will be in compliance with IDPH guidelines. |
|
PERSONAL HEALTH SERVICES
| AIM Statement | Strategic Alignment | Baseline Data | Measure | Project Charts | |
|---|---|---|---|---|---|
| CASE MANAGEMENT FAILED VISIT RATE | Decrease the rate of failed home visits from 18% (approximately 2 out of 10 home visits) to 10% (1 out of 10 home visits) across all programs providing home visits by December 2023. | 1. Focus on Core Public Health. Assess the health status of the population. Assure development and implementation of plans to address health priorities. | For the period September to November 2022, home visiting programs had a failed visit percentage of 18% (approximately 2 out of every 10 planned planned/scheduled home visits failed). Data on reasons from client perspective on failed visits will need to be assessed. | Overall reduction in failed home visit appointments by 5% (from current 18% to 13%). |
|
| REFUGEE DEPRESSION SCREENING | Increase mental health screening in the Refugee Population age 18 and over served by WCHD programs to 90% by December 31, 2023. |
1. Focus on Core Public Health Assess the health status of the population Assure development and implementation of plans to address health priorities |
The Integrated Clinic is not performing routine depression screening on refugees at the time of clinic visits. Standard tool that is valid for Refugee Population (PHQ-2) has not been routinely implemented and/or documented in the clinic environment. | 90% of Refugees over the age of 18 being seen in WCHD clinics will have a documented PHQ-2 in their electronic health record. |
|
PUBLIC HEALTH EMERGENCY PROCEDURES
| AIM Statement | Strategic Alignment | Baseline Data | Measure | Project Charts | |
|---|---|---|---|---|---|
|
N95 FIT TESTING FOR LTC FACILITIES |
By June 30, 2023, a system for training and deploying Medical Reserve Corp (MRC) volunteers to provide N95 fit testing to congregate living facility staff. |
2. Develop and Enhance Systems to Support Core Public Health Organize internally to support strategic initiatives 3. Advance a Culture of Quality Maintain and ensure a workforce development plan to support public health competency |
After Action Report (AAR) for COVID-19 response indicated that healthcare workers (HCW) in congregate living facilities had not been fit tested for appropriate PPE. | • Number of MRC volunteers trained to provide fit testing. • Number of HCW staff in congregate living facilities tested by MRC staff. |
|
|
QUALTRICS STANDARD OPERATING PROCEDURE FOR PROGRAM MANAGERS |
By October 1, 2023, team will develop and disseminate Standard Operating Procedures (SOP) for Qualtrics project management and data considerations, utilizing lessons learned from developing Qualtrics for COVID-19 vaccination project. |
2. Develop and Enhance Systems to Support Core Public Health Organize internally to support strategic initiatives 3. Advance a Culture of Quality Maintain or surpass public health accreditation standards |
There is currently no SOP for Qualtrics project management. | Completed SOP with presentation provided to Leadership team. |
|
HEALTH ADMINISTRATION/SUPPORT CENTERS
| AIM Statement | Strategic Alignment | Baseline Data | Measure | Project Charts | |
|---|---|---|---|---|---|
| IMPROVING COMMUNICATION WITH HARD TO REACH POPULATIONS | Identify 5 organizations that serve or represent hard-to-reach population to develop a collaboration to identify 15 hard to reach population representatives to serve on a WCHD Communications Community Group and develop communications systems/pathways to support public health message development and distribution by December 31, 2023. |
2. Develop and Enhance Systems to Support Core Public Health Engage community partners to address health priorities. 3. Advance a Culture of Quality Inform community on public health initiatives and impact |
There are currently no communication channels dedicated to hard to reach populations in Winnebago County. | A WCHD Communications Community Group (WCCG) will have identified membership needs, filled at least 70% of those roles, and developed and distributed 2 communications messages with the WCCG by the end of 2023. |
|
| REVIEW OF OPERATIONAL POLICIES | By December 2023, 50% of Personnel and Core Public Health Policies will be revised and approved by the Board of Health. |
2. Develop and Enhance Systems to Support Core Public Health Organize internally to support strategic initiatives |
There are currently 105 Personnel and Core Public Health Policies that have not been reviewed and/or updated. | Fifty-three (53) policies will have been revised and approved by the Board of Health by December 31, 2023. |
|
| VIOLENCE REDUCTION WORKGROUP SUSTAINABILITY PROJECT | Increase the number of agencies who consistently participate in at least 70% of the Violence Reduction Workgroup meetings by 50% by December 31, 2023. |
1. Focus on Core Public Health Assure development and implementation of plans to address health priorities 2. Develop and Enhance Systems to Support Core Public Health Engage with community partners to address health priorities |
Of approximately 60 community partners who have signed up to the TIC (Trauma Informed Community Workgroups) approximately 15 (25%) consistently participate (attend 75%) of meetings. | Twenty-three (23) community serving partners will consistently participate in Violence Reduction Workgroups by December 31, 2023. |
|
PREVIOUS QI PROJECTS
QI Project
Process for Reporting Communicable Disease From Laboratories and Infection Control Partners.
Description
WCHD worked to modernize the reporting system for communicable disease from laboratories and infection control partners.
Outcomes/Results
Utilize REDcap, a secure electronic system, for sharing reporting data and reducing reporting time.
QI Project
To Preventing Childhood Lead Poisoning Through Adjustments in Blood Lead Levels
Description
WCHD focused on addressing the change in the blood lead level that indicated concern for childhood lead poisoning. This change in process resulted in inadequate staffing to handle the increased case load.
Outcomes/Results
Expanded capacity by hiring a nurse to serve as a case manager, developing a flow chart of program processes, and aligning staff responsibilities to improve coordination.Â
Â
QI Project
Implement A Vaccine Registration System That Will Allow For Appointment To Be Made based on priority.
Description
WCHD worked to ensure a vaccine registration system for COVID-19 that would meet the demands of the public health response in an equitable method, so that individuals would receive vaccine appointments based on their individual risks and priority.
Outcomes/Results
Purchased and implemented a data management system, called Qualtrics, for use in the COVID-19 vaccination effort. This online software system allowed individuals to register for the COVID-19 vaccine, make appointments based on priority, and complete a post-vaccination survey to add to vaccine safety information. The system also provided WCHD with a quick way to communicate back with registered individuals electronically about appointments and follow-up needs. In additions, the system provided vaccination monitoring at the community population level with easy-to-read dashboards showing who was getting vaccinated and how many vaccine doses were administered through WCHD.
