Transcript Performance Management and Building QI into Your Culture

PERFORMANCE
MANAGEMENT AND
BUILDING QI INTO YOUR
AGENCY CULTURE
MCPP Healthcare Consulting
Marni Mason BSN, MBA

More than 30 years in private healthcare and
public health as clinician, manager and consultant
 Primary
& specialty care clinic nurse and nursing
director (15 years)
 Consultant in healthcare performance measurement and
improvement (18 years)
 Public health performance management – since 2000
 Surveyor for NCQA (11 years) and Senior Examiner for
state Baldrige Quality Award
 Consultant for PHAB Standards Development (20082009)
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Learning Objectives

In today’s session the participants will develop a
better understanding of:
 Components
of Performance Management
 Methods and Tools for Building QI Culture
 Preparing for Accreditation
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Performance Management
Standards for
Public Health
QI Plans &
Councils
QI Methods
& Tools
Improving PH
processes
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Business
Process
Analysis
Performance Management
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Application of P-D-S-A
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Performance Standards
1st Quadrant

Establish Performance Standards
 NACCHO
– Operational Definition and Standards
 National Public Health Performance Standards (CDC)
 Public Health Accreditation Board Standards
 Local,

State and Tribal Health Departments
Establish and Define Outcomes and Indicators
 Process
and Intermediate Outcomes
 Health Status Indicators
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Performance Measurement
2nd Quadrant
Monitoring of
Performance
• Results of review of
performance
(Accreditation/SelfAssessment) against local
and state Standards
• Program evaluation
results
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Monitoring of
Indicators and
Outcomes
• Process and intermediate
outcomes
• Health status indicators
Performance Measurement Definitions
Performance measurement
• “regular collection and reporting of data to track work produced
and results achieved”
Performance measure
• “the specific quantitative representation of capacity, process, or
outcome deemed relevant to the assessment of performance”
Performance measurement
• NOT punishment
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Quality Improvement Process
3rd Quadrant

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Use data to identify opportunities for improvement
and to make decisions
Quality Improvement Methods:
 Improvement
Collaboratives
 Adapting or Adopting Model Practices
 Establishing QI Councils, Plans, and Teams
 Logic Models, RCI, Business Process Analysis
 QI Tools; Data Analysis and Root Cause
Principles of Quality Management
1.
2.
3.
4.
5.
6.
7.
Know your stakeholders and what they need
Focus on processes
Use data for making decisions
Understand variation in processes
Use teamwork to improve work
Make quality improvement continuous
Demonstrate leadership commitment
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Learning and Improvement Cycle
Act
• What changes are to
be made?
• Next cycle?
DOCUMENTATION OF
CHANGE - MINUTES
Plan
• Objective
• Questions and predictions
• Plan to carry out the cycle
(who, what, where, when)
• Plan for data collection
REVISE
LOGIC MODEL
LOGICLOGIC
MODEL
REVISE
MODEL
Study
Do
DATA REPORT
WORK PLAN
•Complete the data analysis
•Compare data to
predictions
•Summarize lessons
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• Carry out the plan
• Document problems and
unexpected observations
• Begin analysis of the data
Tools to Link Work and Outcomes

Logic Models and detailed high level flow charts
 Identify
customer-supplier relationships
 Client flow, information flow, materials flow, decision
making flow


Data and Analysis tools
PH Memory Jogger
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Adopt or Adapt Model Practices


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
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Describe your process (Logic Model or Flow Chart)
Study the exemplary practice process
Adopt or adapt as appropriate
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Reporting Progress
4th Quadrant
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Reporting of Performance (Local and State
Standards and Program Evaluation)
Reporting of Indicators and Outcomes
 Health
Indicators
 Program Evaluation Data
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Requires regular tracking, analysis and review to
tell you if you are achieving your agency goals
Provides the basis for deciding on QI efforts and
the baseline information for measuring the impact
of quality improvement activities
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Stages of Organizational
Performance
In fra stru ctu re
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L eadership &
D ecision m aking
B oards o f H ealth
P olicies &
P rocedures
E nforcem ent/
Inv estigation
P rotocols
F inancial
m anagem ent
In form ation &
reportin g
S et of C ore
Indicators
P rogram
p erform an ce
goals/ objectives
P ro cess
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A ssessm ent
processes
C D investigation
case w rite-u p s
E H enforcem ent
action and case
files
E ducation
sessions
W ork of
com m unity
groups and
coalitions
Program M aturity
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C o o rd in a tio n
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
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C om m unication
m echanism s
P ublic and
private w ork on
access to services
H and -offs
betw een local
health and state
program s
R esu lts
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P rogram
evaluation
results
K ey
indicator
outcom es
(C D /E H /P P )
F inancial
perform an ce
Does Size of Department Matter?
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Good News! Smaller LHDs can demonstrate
standards at same level as large LHDs
“Money (and staff) matter, but they aren’t all that
matters” (Joan Brewster)
In Washington, 40% of the higher performers in the
2008 review cycle were smaller LHDs (less than 2
million annual budget). A couple of higher
performers were LHDs with annual budgets of
approximately $600,000
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Correlation of Budget & FTEs
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Relationship of budget and FTEs to overall
performance in the Standards is nearing random
(little or no correlation)
Five non-urban LHJs with budgets of $2 million or
less had > 60% demonstrated
There is variability not connected to budget or size,
other drivers of high performance are local
priority-setting; leadership; local funding; staff skill,
training and experience; and documentation and
data systems
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Correlation of Budget to Performance
Slight correlation
and relationship
between annual
budget and
overall
performance in
the Standards
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Correlation of Per Capita Budget
No correlation
or relationship
of per capita
budget to
overall
performance in
the Standards
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20
Building QI into Your Culture
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Definition of Quality Improvement*
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“A management process and set of disciplines that
are coordinated to ensure that the organization
consistently meets and exceeds customer
requirements.”
Uppercase QI = top management philosophy
resulting in complete organizational involvement
Lowercase 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
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Demonstrate Leadership Commitment
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Build a QI culture
Connect the organization’s strategic plan to
performance improvement
Know and use quality principles
Encourage all staff to use quality improvement in
daily work
Reward improvements
Ensure adequate QI infrastructure for quality
assessment and improvement activities
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Demonstrate Leadership Commitment
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Clearly stated and enacted constancy of purpose—
a deep understanding of the vision and mission
Regular review of key indicator data
Decisions made on data rather than hunches or
opinions
Long range view supports search for root causes
and permanent solutions rather than quick fixes
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Demonstrate Leadership Commitment
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Focus on systems rather than individuals
Continued identification of improvement
opportunities
Publicize successes
Clear communication agency-wide regarding the
commitment to quality and the change processes
necessary to implement improvement
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QI Infrastructure
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Governance (formal/informal)
 Oversight
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and accountability
Program structure
Who will do what when, with what processes for
recommending or deciding
Staff
 Support
for ongoing monitoring and analysis, for
training and facilitating improvement activities

Data system
 Collect
data and report in a user friendly way
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Quality Improvement Plan
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Goals and objectives
Monitoring activities associated with important
aspects of programs/services
Planned QI efforts (in process, new) and timelines
Evaluation of current QI efforts
Annual evaluation of QI work plan and program
description, with proposed revisions
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TACOMA-PIERCE COUNTY
HEALTH DEPARTMENT
QUALITY IMPROVEMENT (QI)
INITIATIVE
QI Time Line at TPCHD
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QI Training & Tools
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QI Principles, Methods
and Tools
Just-in-time training for
QI project teams, RCI
method
Performance measures
QI Council training on
QI concepts
QI concepts staff can
use in daily work
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QI Infrastructure
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Must have director and other senior management
LEADING the initiative
Establish a steering committee or leadership group to
direct and oversee agency efforts (e.g. QI Council)
Leadership and key staff on QI Council
QI Plan and regular evaluation of QI efforts
Assessment staff is an excellent resource
Start small; get people excited about a single project
Celebration of successes is important
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QI Plan and Evaluation
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Annual QI plan
Lists major activities
 Includes calendar
 Identifies persons
responsible & time lines
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Annual evaluation of QI
plan
Evaluates QI Council
meetings
 Analyzes performance
measure data
 Examines completion
rate of QI plan activities

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Quarterly Reporting Form
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Plan Item Name/No.
Indicator(s)
Baseline Data (if applicable)
Quarterly Data
Data Source
Methods Notes
Data Explanation/Other Comments
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QI Calendar (TPCHD example)
III. 2009 Quality Improvement Council Calendar
Staff Responsible Completion Date QI Council Review
Date
Additional
Review Dates
A. Rapid Cycle
Improvement Projects
Purchasing
Marcy Kulland
Solid waste code
enforcement complaint
resolution
John Sherman
Sep 21
Sep 22 (final report)
TBD (BOH)
Sep 22 (interim report)
Nov 24 (final report)
TBD (BOH)
Nov 23
Jul 31
Oct 31
Jan 31, 2010
Aug 25
Nov 24
Feb 23, 2010
Mar 3, 2010 (BOH)
TBD
B. TPCHD Performance
Measures
See Section II B
C. QI Projects at Request
of Director
TBD
TBD
TBD
Rick Porso
May 25
May 26
David Vance
Oct 26
Oct 27
Nigel Turner
(Chlamydia)
David Vance (LBW)
Rick Porso (Adult
Obesity)
Jul 31*
Oct 31
Jan 31, 2010
Aug 25
Nov 24
Feb 23, 2010
D. Program Evaluation
Reports
Menu labeling
MCH home visiting
E. Review of Health
Indicators
Three priority indicators
(Review of performance
measures in Table 2)
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Mar 3, 2010 (BOH)
Performance Measures
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Twelve department-level measures
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Modeled after Healthy People 2010 Leading Health
Indicators . . . plus two more
Approx. 10-20 performance measures per business unit
Percent of solid waste complaints responded to within 20
days
 Reduce the rate of positivity at Infertility Prevention Project
(IPP) sites
 Percentage of Positive Steps clients who engage in services
for 30. days or more who have a 10% reduction on three
youth violence risk factors

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TPCHD Performance Measures
Measure
Indicator
Improve immunization
rates
Reduce tobacco use
Increase the percentage of kindergarten enrollees that are up to date Nigel Turner
on their immunizations upon school entry from 86% to 92% by 2014.
Decrease the percentage of adult smokers to 16% by 2014.
Rick Porso
Reduce overweight &
obese populations
Increase healthy
physical activity
Reduce substance
abuse
Increase responsible
sexual behavior
Increase access to
care
Decrease injury and
violence
Reduce the rate of increase for adult obesity to 0% by 2014.
Rick Porso
Increase the percent of youth who are physically active for at least 60
minutes per day from 16.8% to 18.5% by 2014.
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.
Increase the number of children enrolled annually in health
insurance programs by 42% by 2014.
Reduce youth violence risk factors among 75% of youth who
participate in TPCHD youth violence prevention services for at least
30 days.
Rick Porso
Decrease adult mental health problems in 20% of families provided
TPCHD evidenced-based program services by 2014.
David Vance
Improve mental health
Improve environmental Increase the percent of water systems that meet drinking water
quality
standards from 80% to 90% by 2014.
Effectively respond to
Respond within one hour in 100% of situations where TPCHD
public health
receives a notice of need for public health response to an incident
emergencies
within Pierce County.
Decrease rates of key
communicable
diseases
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Responsibility
David Vance
Nigel Turner
David Vance
David Vance
Steve Marek
Joby Winans
Increase the percent of ten key communicable diseases for which the Nigel Turner
trend in incidence rate is flat or decreasing from 38% to 50% by
2014.
QI Activities - TPCHD
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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
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First RCI Project
STD Reporting of Race/Ethnicity
80
70
Percent
1. Collected data to
identify “root
cause” of
problem
Percent of STD Case Reports That Include
Race Data (Among Pilot Providers)
60
50
74
40
30
55
20
2. Pilot tested an
education
intervention
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10
0
Pre
Post
Second RCI Project
Final On-Site Septic System Inspections
2. Re-prioritized
work duties
3. Monitored work
flow
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Percent of Septic Systems That Received a
Final Inspection
Percent
1. Collected data to
identify “root
causes” of
problem
100
90
80
70
60
50
40
30
20
10
0
94
70
Pre
Post
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TPCHD Results of QI Initiative
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Most performance
measures at departmentand business unit-level
achieved their stated
target
Improvements sustained
for RCI/QI projects
Health indicator projects
met 100% of annual
performance measures
Funding & staffing for QI
has increased
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WASHINGTON STATE
DEPARTMENT OF HEALTH
QUALITY IMPROVEMENT (QI)
INITIATIVE
PM System and QI Structure
Performance Management System
Organizational
Strategic Planning
Performance
Management
and Accountability
Operational/Business
Planning and Performance
Focused Quality
Improvement Efforts
QI Structure
Quality Steering
Committee
PALS
(Performance Accountability Liaisons)
Project Mgmt.
Resource Team
Process
Improvement Teams
Quality Improvement Organizational
Structure
Quality Steering
Committee
Primary responsibilities include:
 Reviewing and approving the agency QI plan annually
 Encouraging and fostering a supportive QI environment
 Championing QI activities, tools and techniques
 Selecting and supporting agency QI projects
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The Quality
Improvement Process
Step #1:
Clarify the
purpose.
Step #4:
Analyze data
and generate
solutions.
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Step #2:
Select & build
the team.
Step #5:
Take
appropriate
action.
Step #3:
Examine the
process.
Step #6:
Provide
closure.
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
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Levels of QI Integration
100
75
50
25
0
Level 1- No
interest or
activities
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Level 2Awareness,
interest and
one-time
projects
Level 3Multiple
teams and
QI tools,
but no
repetition
or
saturation
Level 4Speciic 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 [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
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ACTIONS TO PREPARE FOR
AN ACCREDITATION
REVIEW
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Establish HD Workgroup
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Assign coordinator for preparation project (12-18
months in advance)
Assign specific categories/standards to individuals
(usually managers)
Develop detailed work plan that addresses each
standard
Establish meeting schedule for workgroup
Report progress and barriers to leadership team
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Conduct Self-Assessment
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Use accreditation standards and documentation
guidelines to conduct objective review against the
standards
Identify documentation that shows performance
Identify areas not meeting the standard as areas
for improvement
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Tell Your Story….
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Reviewers will not be familiar with your HD or even
your state
Provide short summary or note that describes your
processes for the topic being addressed
Be “laser focused” on the specific requirement of
that measure
Provide only the documentation that is needed to
demonstrate performance. More is not better!
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Organizing Your Documents
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Collect and organize all documents for reviewers to review
 Online document library with folders for each standard and
measure
 PHAB accreditation submittal system
State page number (or highlight with text box) where specific
information addressing the measure is located if document
more than 3 pages long
Can use same document for multiple measures—just indicate
all measures that are relevant and page of document
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Electronic System MindManager
How does MindManager help you prepare for your
review?
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Electronic mind mapping tool.
Visual diagram that looks like a tree with a main topic and as many
sub-topics as you like exploding out in branches.
Ability to give context and relationships that are difficult to see in a
linear document.
Consolidate multiple sources of information.
Establishes greater accountability by enabling team members to
track assignments.
Reviewers love having everything in one location.
MindManager
Overview
A look at the big picture.
MindManager Overview
“Read Me” Text
Documentation in Daily Work
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Build documentation into regular processes:
 Use
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summary formats for regular reporting
Minutes of working committees
Case write-ups, logs, and progress reports
Emphasize conclusions, actions and results
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We Can Make Significant
Improvement
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Significant improvement was shown in the following measures
that were comparable:
 4.2L Health care providers receive information, through
newsletters and other methods, about managing reportable
conditions. (from 74% to 92%)
 4.5L A notifiable conditions tracking system documents the
initial report, investigation, findings and subsequent reporting
to state and federal agencies (from 82% to 100%)
 4.8L (EH Only) A tracking system documents environmental
health investigation/compliance activities … as required.
(from 67% to 94%)
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Change vs. Improvement

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
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What questions do you have?
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