Joining PHMC in March 2013 to implement Total Quality Management, Nina Boffa had enjoyed a long and successful career in quality and resource management at Thomas Jefferson University Hospitals. A licensed social worker who is certified in Six Sigma methodology, Boffa earned an MSW degree from Temple University and an MBA in healthcare administration from Eastern University. Public Health Directions asked Boffa about her new role, the current healthcare environment and what inspires her to carry out her work.

You worked in the Methodist Hospital division of Thomas Jefferson University Hospitals for 24 years.
What attracted you to PHMC?

I saw the job posting and was excited right away because I like to engage and motivate people. I was also excited because of the all-round diversity at PHMC, from the services and programs to the personnel.

You’ve been working here since October 2012.
What impresses you about PHMC’s behavioral health network?

Its diversity. PHMC’s behavioral health network has such a diverse range of programming. We have a lot of expertise and knowledge in a lot of areas, ranging from addiction services to sexual abuse.

How do you define Total Quality Management (TQM)?

[TQM is a comprehensive, structured approach to organizational management. It seeks to improve the quality of services through ongoing enhancements in response to continuous feedback from customers. At PHMC, our customers include the senior management team and employees at our headquarters, staff at our programs and affiliates, participants in our services and regulatory agencies.

I recently introduced a new way to do TQM for our behavioral health division that I want to roll out accross the enterprise. It involves four sequential categories: Plan, Do, Study and Act (the PDSA cycle). In the last phase, Act, we document the results, inform others about changes to the process and determine the effectiveness of those changes. We make recommendations for addressing the problem in the next PDSA cycle by achieving the goal, adapting the plan or abandoning the plan and starting again.

We understand that different programs have different regulation requirements. We're now introducing universal performance indicators for all programs and affiliates. Our goal is to include TQM in PHMC's daily activities.


How has the Affordable Care Act affected what you're doing?

The Affordable Care Act has made my job a little easier, as everyone now has a renewed interest in quality. Many insurers have incorporated pay for performance into their contracts, so PHMC needs to prove that, as a large public health institute, one of its priorities is quality. We want to be at the forefront of the quality initiatives that are being launched nationwide.

In 2014, the expansion of Medicaid under the Affordable Care Act could potentially extend coverage to 17 million low-income individuals nationwide, depending on whether or not each state accepts the federal Medicaid subsidy. Pennsylvania has not yet accepted the federal Medicaid subsidy.

Beginning October 1, 2013, individuals, families, and owners of small businesses (those with 50 or fewer employees) will be able to shop for health insurance in online marketplaces, similar to travel websites, which means that access to quality health care is very important. Making our processes as efficient as possible will help to ensure that the most vulnerable populations we serve have access to our primary and behavioral health services.

You developed a TQM plan for FY 2014 that uses the Lean methodology.
Wasn't the Lean methodology first used for manufacturing by Toyota?
How do cars relate to health care?

[Laughs] Actually, many healthcare agencies have implemented Lean methodology. It's been used effectively in manufacturing companies for years, particularly in Japan, where it started. Lean thinking begins with driving out waste so that all work adds value and serves customers' needs. If we can identify waste, we can offer more value to our customers.

Let me give you an example. Say the wait time at a clinic is two hours. We'd examine all the steps from the time the person checks in to the time he or she is seen by a clinician. We'd examine which steps add value and which ones don't, and identify the services that have a positive impact on the customer.

Although health care differs in many ways from manufacturing, there are surprising similarities. Whether building a car or providing services to patients, service providers must rely on multiple, complex processes to accomplish their tasks and create value. Waste—of money, time, supplies or good will—decreases value, no matter what the industry.

The commitment to Lean principles has to be embraced not only by those at the very top of the organization, but also by all staff who should be involved in helping to redesign processes to improve flow and reduce waste. Thankfully we have this at PHMC.

I should also mention that my team consists of three full-time employees and one part-time employee, including me—we are a lean department!

What are the barriers to TQM implementation at PHMC?

I feel very fortunate in that I haven't come across any barriers, except time. There's much to do and not enough hours in the day. Employees at all levels—from the direct line person to the senior team—have been extremely welcoming and supportive.

What inspires you to carry out this work?

I really enjoy empowering people and seeing the changes they make to achieve the desired results. Employees usually have the answers needed to improve a process, increase efficiency and decrease redundancy because they're the ones who are closest to the work. The problem is that until very recently, we weren't leveraging their insight in the best way possible.

What do you do in your spare time?

I love to laugh, especially those deep, belly laughs. It's a great way to reduce stress. I spend time with my husband, my extended family and great friends; I like to surround myself with people who enjoy life. And my husband and I love to travel. Last year we went to Italy and Puerto Rico. This year we've planned a trip to Mexico. I'm also a member of a book club and I like to read novels, most recently The Twelve Tribes of Hattie by Ayana Mathis and Fifty Shades of Grey by E. L. James.

Through PHMC's strategic planning process, staff and stakeholders recognized that expanding service lines and programs dedicated to children

and youth would further the organization's program network. This past Spring PHMC welcomed Turning Points for Children, an accredited human services agency, into the affiliate family. Turning Points for Children provides critical resources, life skills and supportive partnerships to vulnerable youth who may be at risk for abuse or neglect. The agency's work also includes teaching parenting skills to teen and adult parents and relative caregivers, as well as strengthening families through an evidenced-based, after-school program in 30 public and charter elementary and middle schools in Philadelphia. Since 2011, through its Family Finding program, Turning Points for Children has been the sole organization in Philadelphia that connects children who have been placed in foster care with relatives they've lost contact with and who can be an important, supportive resource for them. Turning Points for Children helps families raise safe, healthy, educated and strong kids.

The City of Philadelphia is focused on Improving Outcomes for Children by establishing Community Umbrella Agencies, offering stronger coordination of services for youth and families involved in the child welfare system. Turning Points for Children was recently identified as a Community Umbrella Agency.

Turning Points for Children's affiliation with PHMC makes strategic sense: Turning Points for Children brings direct experience in providing high-quality outcomes in child welfare services and parenting education, and PHMC brings its legacy of managing large, complex health and human service challenges, often as an intermediary.

The affiliation strengthens both organizations' missions and helps both organizations better serve the Philadelphia community by integrating programs and services to serve children and families in early childhood education, family treatment therapy and primary care and behavioral health. As with all PHMC affiliations, Turning Points for Children benefits from economies of scale and new opportunities for staff career advancement, professional development and training.

"The affiliation is helping Turning Points for Children and PHMC expand our reach and improve outcomes to vulnerable children and families by providing comprehensive prevention and intervention services like behavioral health, primary care and other health and wellness services," said Mike Vogel, CEO, Turning Points for Children, and Managing Director, Children and Family Social Services.

In the PHMC health network, Beyond Care is more than a catchphrase—it reflects our commitment to offering the holistic, patient-centered care that our community deserves. It means that our consumers get high-quality care from a team of experts who organize a customized approach around their needs. Beginning this Fall, you'll start to see our new Beyond Care logo across the PHMC health network,
including our five nurse-managed Federally Qualified Health Centers (FQHCs). The Beyond Care commitment further signifies our dedication to providing high-quality community-based health care that is accessible, affordable and convenient.

Our Beyond Care promise is just one of the ways we are working to meet and exceed the highest standards of patient care. Recently PHMC's health network, with our nurse-managed model, joined a select group of FQHC's in the country and state to achieve accreditation from The Joint Commission for Ambulatory Health Care and certification as a Primary Care Medical Home. The Joint Commission is the nation's oldest and largest accreditation and certification body, providing standards to more than 20,000 health-related organizations to guide how they administer care and continuously improve performance. To receive accreditation and certification, PHMC was assessed on nearly 1,000 highly rigorous requirements and demonstrated a highly coordinated collaborative effort among teams.

Recognition by The Joint Commission furthers our mission to create and sustain healthier communities by taking our already great patient-focused quality care to an even higher level. We now have additional processes in place to ensure ongoing, continuous improvement with a focus on quality, safety and accessibility. To our patients, The Joint Commission seal of approval offers unbiased third-party recognition that our health centers deliver excellent care to meet their needs. To industry stakeholders, such as payers, funders and healthcare providers interested in nurse-managed health care facilities, accreditation demonstrates PHMC's adherence to rigorous quality and safety standards. In addition, three of our health centers have received National Committee for Quality Assurance (NCQA) recognition as a Level 2 Patient-Centered Medical Home.

With the trend in health care moving toward pay for performance and reimbursement based on high-quality care, Joint Commission accreditation and NCQA certification become even more critical.

Our health network is going Beyond Care in other ways, as we grow to meet the changing needs of our community. Over the next few months we will expand two major health centers to serve the homeless and public housing communities. PHMC's Rising Sun Health Center moved to a new facility in July, with 12 exam rooms, all-purpose meetings rooms, elder-care facilities and an expanded clinical team to serve the growing needs of Philadelphia's Olney neighborhood. PHMC Health Connection will also move to a larger space, increasing the number of exam rooms from three to 13 to better serve the primary health care needs in North Philadelphia.

PHMC has a long history of providing early childhood education quality improvement and can now help more community-based providers strengthen their services.

PHMC early education programs include : the Southeast Regional Key, which supports quality child care programming in 1,400 family, group and center-based facilities; and Out-of-School Time, which serves 18,000 youth in after-school and summer programs. In addition, PHMC is partnering with the United Way of Greater Philadelphia and Southern New Jersey, the Economy League of Greater Philadelphia, and the Delaware Valley Association for the Education of Young Children (DVAEYC), on a kindergarten readiness assessment for use statewide to demonstrate the impact of high-quality early learning experiences.

PHMC's newest program in this area is the Head Start Fund. The fund will provide grants to community-based providers to help them meet and maintain Head Start standards, as well as investigate the impact of Head Start slots on provider finances.
The School District of Philadelphia began transitioning Head Start slots in spring 2011 with 27 community-based providers. In June 2013, the district selected more providers for the 2013–2014 school year,

bringing the total to 35 providers, some previously selected who added slots and some new. All of the providers chosen by the district are rated three or four in the Keystone STARS Performance Standards. Keystone STARS is an initiative of Pennsylvania's Office of Child Development and Early Learning that promotes quality improvement among child care and Head Start programs. Child care facilities are rated on a scale of one to four stars, with four being the highest rating. Head Start regulations are very specific and require that providers have appropriate furniture, equipment, books and educational materials that relate to development domains, such as Literacy Knowledge & Skills and Mathematics Knowledge & Skills.

PHMC has a history of working with DVAEYC and Public Citizens for Children and Youth (PCCY) on early learning projects. "When we heard that the school district was transferring Head Start slots from district buildings to community-based sites, we realized that the providers might need external support to continue to offer quality care, and to meet the Head Start standards and regulations," says Farrah Parkes, Senior Director of Targeted Solutions, PHMC. "We decided to explore this further to get a better understanding of the challenges facing the providers as they add Head Start slots."

PHMC and DVAEYC interviewed 24 of the 27 community-based providers currently providing Head Start services on behalf of the school district. "When we interviewed the providers, the issues facing them included lack of money to buy furniture for designated reading and writing areas, numeric and counting charts, games and other educational materials," says Sharon Easterling, executive director of DVAEYC. "Almost every provider interviewed indicated that additional financial support for start-up costs would have been beneficial in 2011 and/or that they would need to identify additional starter funding in order to expand in 2013."

As a partnership, PHMC, DVAEYC and PCCY approached the William Penn Foundation for funding, knowing that one of the foundation's goals is to increase access to high-quality affordable early care and education. The foundation awarded PHMC a grant of $725,000 in April 2013 to establish the Head Start Fund to assist community-based child care providers in absorbing 2,000 high-quality Head Start slots. The fund offers equipment and material grants, partnering with DVAEYC to facilitate the purchases through the SharedSource Pennsylvania platform, also funded by the foundation.