Quality Improvement

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,

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 2024 QI Projects

ENVIRONMENTAL HEALTH IMPROVEMENT

	AIM Statement	Strategic Alignment	Baseline Data	Measure	Project Charts
CUSTOMER SERVICE SURVEY	By December 31, 2024 increase response to EHI customer service surveys from 2% to 10%.	1. Focus on Core Public Health 2. Advocate for policies that promote population health. 3. Advance a Culture of Quality Maintain and ensure a workforce development plan to support public health competency. Maintain or surpass national public health accreditation standards.	Past surveys have had a low response rate of 2%	10% of entities receiving environmental health (EHI) services will have completed customer service responses.

HEALTH PROMOTION & WELLNESS

	AIM Statement	Strategic Alignment	Baseline Data	Measure	Project Charts
INCREASING EXCLUSIVE BREASTFEEDING RATES IN THE WIC PROGRAM	By December 31, 2024, the percentage of WIC enrolled participants who breastfeed will increase from 11% to 15%.	1. Focus on Core Public Health Assure development and implementation of plans to address health priorities - Maternal and Child Health. 3. Advance a Culture of Quality Maintain and ensure a workforce development plan to support public health competency.	In 2023, 11% of WIC participants breastfed lower than the state program goal of 15%.	15% of enrolled WIC participants will breastfeed.
NOMINATIONS AND DIVERSITY IN THE MAYOR AND CHAIRMAN'S YOUTH LEADERSHIP COUNCIL	By December 31, 2024, the number of High School students participating in the Mayor and Chairman’s Youth Leadership Council identified through community nominations will increase from four (4) to twelve (12) - (300%).	1. Focus on Core Public Health Assure development and implementation of plans to address health priorities – Youth Violence; Mental Health – Suicide and Opioid Overdose. 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.	For the past two years, an average of four (4) nominations per year were submitted for Winnebago County High School students to join the Mayor & Chairman’s Youth Leadership Council	Twelve (12) nominations will be submitted by community partners for Winnebago County High School students to join the Mayor & Chairman’s Youth Leadership Council. Number of High School students participating in the Mayor & Chairman’s Youth Leadership Council.

HEALTH PROTECTION

	AIM Statement	Strategic Alignment	Baseline Data	Measure	Project Charts
RABIES PEP IMPROVEMENT	By December 31, 2024, Winnebago County Health Department will improve the percentage of individuals inadequately treated for low risk animal rabies PEP according to IDPH guidelines from 26% down to 10%.	2. Focus on Core Public Health Advocate for policies that promote population health	Approximately 19% of cases in 2022 were provided PEP that was not warranted under current IDPH guidance for rabies PEP.	90% of the incidence in low risk animal rabies exposure will comply with IDPH Rabies PEP guidelines

PERSONAL HEALTH SERVICES

	AIM Statement	Strategic Alignment	Baseline Data	Measure	Project Charts
ILLINOIS BREAST AND CERVICAL CANCER PROGRAM	By December 31, 2024, IBCCP will increase its caseload by 5% to reach a total caseload of 468.	1. Focus on Core Public Health Assure development and implementation of plans to address health priorities – Maternal and Child Health. 2. Develop and Enhance Systems to Support Core Public Health Organize internally to support strategic initiatives. Engage with community partners to address health priorities. 3. Advance a Culture of Quality Inform community on public health initiatives and impact.	Illinois Breast and Cervical Cancer Prevention (IBCCP) program had a caseload of 427 participants for FY 2023, this was 80% of the assigned caseload goal of 535.	Increase in IBCCP caseload to 468 reaching 85% of caseload goal.

PUBLIC HEALTH EMERGENCY PROCEDURES

	AIM Statement	Strategic Alignment	Baseline Data	Measure	Project Charts
IMPROVING IDENTIFICATION OF ACCESS & FUNCTIONAL NEEDS FOR PUBLIC HEALTH EMERGENCY PLANNING	By December 31, 2024 increase participation in voluntary self-reporting of access and functional needs (AFN) among individuals with disabilities residing in noninstitutional settings in Winnebago County by 50% of 2023 levels.	2. Develop and Enhance Systems to Support Core Public Health Organize internally to support strategic initiatives. Engage with community partners to address health priorities. 3. Advance a Culture of Quality Maintain or surpass national public health accreditation standards.	In 2023, 28 residents self-reported access and functional needs (AFN) to Winnebago County.	Forty-two (42) individuals will have voluntarily selfreported AFN. Number of partners who service individuals with AFN that engage in supporting completion of the selfreport.

HEALTH ADMINISTRATION/SUPPORT CENTERS

	AIM Statement	Strategic Alignment	Baseline Data	Measure
COMMUNICATIONS: HARD TO REACH COMMUNICATION CHANNELS	By December 31, 2024, identify a trusted WCHD connection and communications pathway for 50% (6/12) of the identified populations and develop a culturally relevant public health message for 25% (3/12) of the identified groups.	2. Develop and Enhance Systems to Support Core Public Health Engage community partners to address health priorities. 3. Advance a Culture of Quality Maintain and ensure a workforce development plan to support public health competency. Inform community on public health initiatives and impact	There are currently no communication channels dedicated to hard to reach populations have been officially recognized and documented as a systemic process to ensure continuous operational utilization.	A WCHD Communication Pathway is documented for reaching 6 (50%) of the 12 identified populations and WCHD has developed culturally relevant public health messages with 3 of the 12 (25%) groups by the end of 2024
COMMUNICATIONS: WEBSITE UPDATES FROM USER FEEDBACK	By December 31, 2024, Identify and initiate a process for collecting feedback from website users and utilize the feedback to set a baseline of data and initiate a minimum of three (3) modifications based on the data to the website.	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 is no process for implementing user feedback into the updates and modification of the current website.	Development of process flow to make changes based on feedback data. Three (3) modifications will be made to website based on feedback data.
PUBLIC HEALTH POLICY: ROUTINE RECORDS DESTRUCTION & ARCHIVING	By December 31, 2024, increase documentation reviews for destruction and/or archiving by 20%.	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. Maintain or surpass national public health accreditation standards.	There is no regular collection and review of physical documents for destruction eligibility.	WCHD Centers shall have searched and collected eligible physical documents for destruction/archiving reflecting 20% of records in their Center.
STRATEGIC INITIATIVES: IMPROVING COLLABORATION TO ADDRESS STRATEGIC INITATIVES	By December 31, 2024, increase the amount of time strategic leads are working collaboratively by 50% to improve strategic workgroup efficiency in goal attainment and enhance staff engagement in strategic workgroups.	1. Focus on Core Public Health Assure development of plans to address health priorities. 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. Maintain or surpass national public health accreditation standards.	Currently, Leadership dedicates approximately 45 minutes per month to discuss Strategic Initiatives as a group. The majority of that time involves each Director reporting on the progress of their strategic workgroup.	Increased time spent on collaboration by strategic work group will increase to 60 minutes (as compared to progress report) per month. The Strategic Workgroups will have: • Enhanced collaboration among leads • Expanded group collaboration • Lead and co-lead ownership of some goal setting • Increased efficiency, and, • Improved staff engagement/satisfaction
FINANCE: INCREASING UTILIZATION OF AWARDED FUNDS SOR STATE OPIOID REPSONSE PROGRAM	By June 30, 2024, increase the utilization rate of the State Opioid Response program to 60% (mid-year)	1. Focus on Core Public Health Assure development and implementation of plans to address health priorities – Opioid Overdose. 2. Develop and Enhance Systems to Support Core Public Health Engage with community partners to address health priorities. Organize internally to support strategic initiatives.	Over the past three (3) years WCHD has used less than the amount awarded through SOR2 program funding to address the opioid crisis. FY2021 – 70.3% FY2022 – 76.2% FY2023 – 60.1%	Increased utilization of SOR2 program funding.
DATA AND QUALITY: IMPROVING DATA REQUEST EFFICIENCY AND ACCESSIBILITY	By December 31, 2024, reduce the number of business days to respond to data requests by 30% dependent on system.	1. Focus on Core Public Health Assess health status of the population. 2. Develop and Enhance Systems to Support Core Public Health Organize internally to support strategic initiatives. Engage with community partners to address health priorities. 3. Advance a Culture of Quality Maintain and ensure a workforce development plan to support public health competency. Inform community on public health initiatives and impact.	Challenges with data retrieval, definition, and access exist within the multiple WCHD data systems and have not been documented or addressed (the estimated time to complete a data request ranges from 3 days to 30 days .	Reduction in the number of business days to respond to data requests.