PERFORMANCE MANAGEMENT AND QI PRINCIPLES AND STRATEGIES

MINNESOTA’S DEPARTMENT OF HEALTH (MDH) AND COMMUNITY HEALTH BOARDS JANUARY 10, 2011 MarMason Consulting

Marni Mason BSN, MBA

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 More than 30 years in private healthcare and public health as clinician, manager and consultant  Consultant in healthcare performance measurement and improvement (20 years)  PH performance standards and improvement since 2000 and all 3 Multistate Learning Collaboratives (2005-2010)  Consultant for PHAB Standards Development and training of site reviewers (2008-2010)  Surveyor for NCQA (13 years) and Senior Examiner for state Baldrige Quality Award MarMason Consulting

QI for Leadership Series

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   

Session # 1: Overview of Quality Improvement for Leadership

 Quality improvement principles and methods that support performance management in a public health agency ( Jan 10)

Session # 2: Creating a Culture of QI in Your Agency

 Building infrastructure and capacity for quality into agency culture (Feb 7 th )

Session # 3: Strategies and Methods for Continuous Quality Improvement

 How to conduct/lead quality teams (leadership responsibility in steps to building quality improvement); alignment of strategic plan, health assessment and health improvement plan) (Feb 28 th )

Sessions # 4 & 5: Topics TBD

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Today’s Learning Objectives

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 In today’s session the participants will develop a better understanding of:  Performance Management and Integration of QI into the Agency  Principles of Quality Improvement  Plan-Do-Study-Act Cycle for Improvement  Root Cause Analysis MarMason Consulting

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Performance Management

Breakthrough Collaborative

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Business Process Analysis QI Methods & Tools

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Performance Management

Source: Turning Point Performance Management Collaborative, 2003.

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Performance Standards

PERFORMANCE STANDARDS

Establish performance standards  Public Health Accreditation Board (PHAB) standards  National Public Health Performance Standards (CDC) Establish and define outcomes and indicators  Process outcomes  Health outcomes

Performance Measurement

PERFORMANCE MEASUREMENT Monitoring of Performance

• Review of performance (Accreditation/Self Assessment) results • Program evaluation results

Monitoring of Indicators and Outcomes

• Process and short-term outcomes • Health indicators and outcomes

Definition of Quality Improvement

A management process and set of disciplines that are coordinated to ensure that the organization consistently meets and exceeds customer requirements.

QI

Top management philosophy resulting in complete organizational involvement

qi

Conduct of improving a process at the microsystem level Bill Riley and Russell Brewer, Review and Analysis of QI Techniques in Police Departments, JPHMP Mar/April 2009

Quality Improvement Process

 Establish QI structure and capacity in agency  Establishing QI councils and plans  Conducting QI teams  Quality improvement methods and tools  Plan-Do-Check/Study-Act cycle  Rapid Cycle Improvement (RCI)  Improvement collaboratives  Lean Six Sigma  Adapting or adopting model practices

QUALITY IMPROVEMENT PROCESS

Reporting Progress

REPORT PROGRESS

 Performance in standards  Indicators and outcomes  Health indicators  Program evaluation data  Regular data tracking, analysis and review  Basis for QI efforts

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Integration of QI into Agency Culture

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Multilevel Model of Integration*

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 Spread can be defined as moving from common practices to best practices  Diffusion is the rate at which innovation is adopted within an organization or industry * Bill Riley and Russell Brewer, Review and Analysis of QI Techniques in Police Departments, JPHMP Mar/April 2009 MarMason Consulting

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Levels of QI Integration

100 75 50 25 0

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Level 1- No interest or activities Level 2 Awareness, interest and one-time projects Level 3- Multiple teams and QI tools, but no repetition or saturation Level 4- Speciic QI model integrated into agency management structure with continuous improvement

JPHMP Article Recommendations

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      Implement QI as a comprehensive management philosophy rather than a project-by-project approach Top officials must set a vision for the agency and exhibit constant leadership, focus continuously on mission Use the lessons/proven methods from others [general healthcare, police, etc.] to overcome barriers Find creative ways to secure resources for QI Build on existing PH tools and capabilities Conduct a self-assessment for QI readiness in your agency Bill Riley and Russell Brewer MarMason Consulting

Poll Question

How would you describe level of quality improvement integration in your organization? A. Level 1: No interest or activity B. Level 2: Awareness, interest, one time projects C. Level 3: Multiple teams and QI tools but no repetition or saturation D. Level 4: Specific QI model integrated throughout organization

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Let’s Discuss!

What is your experience with the four components of performance management in your Health Department?

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QI Principles and Strategies

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The Quality Environment

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 Agency-wide commitment to assessing and continuously improving quality over time?

 Decisions based on data?

 Agency achieving goals?

 Use data to decide on improvement initiatives and to know if the improvements are successful?

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Principles of Quality Management

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Know your stakeholders and what they need Focus on processes Use data for making decisions Use teamwork to improve work Make quality improvement continuous Demonstrate leadership commitment MarMason Consulting

1. Know Your Stakeholders

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 Identify stakeholders and their needs  Sector Mapping  Community Assessment  Advisory Council Input  Survey Data & Focus Groups  Force Field Analysis  Set goals based on stakeholder needs MarMason Consulting

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Public Sector Map

National Institute of Health Office of the Insurance Commissioner Dept. of Social & Human Services

•Aging & Adult Services •Med. Asst. Admin •Division of Developmental Disabilities.

•Mental Health Division

Public Hospital Districts

Department of Health

•Chronic Disease & Risk Reduction •Diabetes Prevention & Control •Community & Rural Health •Community & Family Health •Maternal Support Srvcs •Women, Infants & Children •Licensing Boards

Head Start Programs

Department of Defense

•Tri-Care •Prime

Governor / Legislature

Office of the Superintendent of Public Instruction Employment Security Department

•Worksource

Department of Veterans Affairs

School Boards •Public schools •BIA schools •Charter schools •Private faith based schools

Dept. of Corrections

•Prisons

Department of Labor & Industries Health Care Authority

•Public Employees Benefit Board •Basic Health Plan

State Board of Health

Local Health Jurisdictions Local Governments Public Library System

These are examples of partners in the public health system:

Bold

= Large agency or organization,

Italics

= Type of organization, not a specific entity, Regular= Specific organization or entity MarMason Consulting

2. Focus on Work Process

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   85% of poor quality is a result of poor work processes, not of staff doing a bad job Processes often “go wrong” at the point of the “handoff” Attend to improving the overall process, not just one part—some of the most complex processes are the result of creating a “work around” MarMason Consulting

Measure processes that are:

 Important and relevant to population  Control vs. Influence  High-risk  Health Alerts, Drinking Water, CD Investigations  High-volume  WIC, Food Safety, OSS, Immunizations  Problem-prone  Emergency Preparedness

Tools to Link Work and Outcomes

Logic models and work flow charts  Customer-supplier relationships  Client flow, information flow Data and analysis tools  Root cause tools: fishbone diagram, Pareto chart  Force field analysis  Interrelationship digraph Note: See PH Memory Joggers at GOAL/QPC or QI tools at ASQ

The Logic of Public Health

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We inspect restaurants

So that # of inspections

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# of critical violations So that

Public is sold food that is safe to eat

% of critical violations corrected within 24 hours So that

There are fewer incidents of foodborne illness

rate of foodborne illness

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3. Use Data to Make Decisions

    Use performance assessment data to target improvement Use data analysis tools to develop information Analyze data to identify root cause Use data to monitor performance outcomes MarMason Consulting

Poll Question

How frequently do you/your organization use data to target improvement efforts? A. Rarely B. Sometimes C. Often D. Always

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Use Data to Make Decisions

Conceptual Tools

 Affinity Diagram  Brainstorming  Process Flow Chart  Cause and Effect Diagram (Fishbone)  Five Why’s  Matrix Diagram MarMason Consulting

Numerical Tools

 Check Sheet  Bar Chart  Histogram  Pareto Chart  Control Chart  Run Chart

[See Goal/QPC PH Memory Joggers]

Power of Root Cause Analysis

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W. Edwards Deming transformed quality control processes by applying his beliefs  Measuring outputs/outcomes at the end ignores root cause and ensuing poor results.

 Addressing root causes through ongoing evaluation and quality improvement avoids problems and improves quality.

 Ongoing measurement with feedback loops helps processes.

* The Public Health Quality Improvement Handbook, page 22 MarMason Consulting

Root Cause Analysis

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 Goal:  To find the real cause of a problem or issue  Understand the impact to the organization  Resolve it with a permanent fix  We need to determine:     what happened?

why it happened?

where it happened?

how to eliminate it? MarMason Consulting

Cause and Effect Diagram

Test Location Client Inconvenient Too Public Don’t see benefit Fearful Don’t Want Test Poor HIV Testing Not Client Centered Not Offered Not Respectful Poor Experience Counseling Staff

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Example of Fishbone

WIC Client Redemption of Farmer’s Market Coupons

People

Knowledge Deficit Client has more distractions in the summer Language Variety/Selection Preferences Personal Cultural Customer Service

Access

Limited WIC Providers Locations Hours

WIC clients do not redeem all of the farmer’s market coupons

Distribution Frequency Staff explanations of Farmer’s Market option Timing

Methods

Limited supply Small dollar value

Materials

No change is given Page 1 MarMason Consulting

4. Use Teamwork

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 QI efforts need buy-in from all stakeholders  Creative ideas are needed  Division of labor is needed  Process often crosses functions  Solution generally affects many MarMason Consulting

Tips for Effective QI Teams

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 Teams should develop a clear charge and support resources  Teams should adopt working agreements (cell phone etiquette to decision procedures)  Teams should assign roles of facilitators and recorders  Team process has predictable stages that are useful to keep in mind:  Forming, Storming, Norming, Performing MarMason Consulting

Affinity Diagram*

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  Why use it?

 To allow a QI team to creatively generate a large number of ideas/issues and organize in natural groupings to understand the problem and potential solutions.

What does it do??

  Encourages creativity by everyone on team Breaks down communication barriers  Encourages non-traditional connections among ideas/issues   Allows breakthroughs to emerge naturally Encourages ownership of results  Overcomes “team paralysis”

*PH Memory Jogger page 12

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Uptake of Vaccines Example (Kittitas, WA)

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5. Make QI Continuous

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 QI is a system-wide approach to assessing and continuously improving quality of the processes and services over time   See inter-relationships, not parts Understand the flow of work, not the one-time snapshot  Detail the work processes  Determine cause and effect relationships  Identify points of highest leverage  Improve and innovate, not just change for change’s sake MarMason Consulting

Improvement Model - PDSA Cycle

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 The Plan Do Check/Study Act Cycle is a trial-and learning method to discover what is an effective and efficient way to design or change a process  The “check” or “study” part of the cycle may require some clarification; after all, we are used to planning, doing/acting. It compels the team to learn from the data collected, its effects on other parts of the system, and under different conditions, such as different communities MarMason Consulting

PDSA Improvement Cycle

Act

• What changes are to be made?

• Next cycle?

Plan

• Objective • Questions and predictions • Plan to carry out the cycle (who, what, where, when) • Plan for data collection

DOCUMENTATION OF CHANGE - MINUTES REVISE LOGIC MODEL REVISE LOGIC MODEL 41

Study

•Complete the data analysis •Compare data to predictions •Summarize lessons

DATA REPORT

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Do

• Carry out the plan • Document problems and unexpected observations • Begin analysis of the data

WORK PLAN

Poll Question

Do you use the PDSA cycle in your organization? A. Not familiar with the PDSA cycle B. Familiar with PDSA cycle but don't use C. Familiar with cycle and use occasionally D. Knowledgeable about the cycle and use consistently

Make QI Continuous

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   Use conclusions from data analysis to identify areas for improvement Charge QI team and provide support  Provide QI training  Develop AIM statement  Use tools to understand root causes  Use data for baseline and analysis  Design process improvement to address root causes Train staff on the process improvement MarMason Consulting

Adopt or Adapt Model Practices

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     Use data to identify need for improvement Identify exemplary practices in:  Other local and state health departments,  CDC and other national organizations, www.naccho.org/topics/modelpractices  Other industries Describe your process (Logic Model or Flow Chart) Study the exemplary practice process Adopt or adapt as appropriate MarMason Consulting

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6. Demonstrate Leadership Commitment

       Build a QI culture in your agency Connect the organization’s strategic plan to performance improvement Know and use quality principles Initiate and support QI teams Encourage all staff to use quality improvement in daily work Reward improvements Assure adequate QI infrastructure for quality assessment and improvement activities MarMason Consulting

QI Culture and QI Council

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 Critical to make data/reporting meaningful to staff  Performance measures:  More is not better  Resource level declines after the first data reporting period  Staff need lots of practice/training to develop good performance measures  RCI/QI projects:  Quality planning is more appropriate than QI for some projects with long-term outcomes MarMason Consulting

Agency Level Performance Measures

Measure Indicator

Improve immunization rates Reduce tobacco use Reduce overweight & obese populations Increase healthy physical activity Increase the percentage of kindergarten enrollees that are up to date on their immunizations upon school entry from 86% to 92% by 2014.

Decrease the percentage of adult smokers to 16% by 2014.

Reduce the rate of increase for adult obesity to 0% by 2014.

Increase the percent of youth who are physically active for at least 60 minutes per day from 16.8% to 18.5% by 2014.

Reduce substance abuse Increase responsible sexual behavior Increase the number of adults receiving opiate treatment service by 23% by 2014, to 800 patients.

Increase the percentage of sexual partners treated for sexually transmitted diseases by 10% by 2014.

Responsibility

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Change vs. Improvement

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 W. Edwards Deming stated “Of all changes I’ve observed, about 5% were improvements, the rest, at best, were illusions of progress.”  We must become masters of improvement  We must learn how to improve rapidly  We must learn to discern the difference between improvement and illusions of progress MarMason Consulting

Some QI References

      Embracing Quality in Local Public Health: Michigan’s Quality Improvement Guidebook, 2008, www.accreditation.localhealth.net

Public Health Memory Jogger, GOAL/QPC, 2007, www.goalqpc.com

Breakthrough Method and Rapid Cycle Improvement www.ihi.org

Bialek R, Duffy DL, Moran JW. The Public Health Quality Improvement Handbook. Milwaukee, WI: ASQ Quality Press; 2009 Guidebook for Performance Measurement, Turning Point Performance Management National Excellence Collaborative, 2004, http://www.phf.org/pmc_guidebook.pdf

Mason M, Schmidt R, Gizzi C, Ramsey S. Taking Improvement Action Based on Performance Results: Washington State’s Experience. Journal of Public Health Management and Practice. Jan/Feb 2010; 16(1): 24-31

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What questions do you have?

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