Performance Management and Quality Improvement in Public Health Oregon APHA QI Training Series

1. Performance Management and Quality Improvement in Public HealthOregon APHA QI Training Series Marlene Mason, MarMason Consulting May 1, 2012

2. More than 30 years in private healthcare and public health as clinician, manager and national consultant Consultant in general healthcare performance measurement and quality improvement (20+ years) Consultant PH performance standards and improvement since 2000 and for all 3 Multistate Learning Collaboratives (2005-2011), including more than 50 QI teams from > 6 states National trainer and presenter for QI and Accreditation in more than 20 states and for ASTHO, NACCHO, NIHB, NNPHI, and RWJF Consultant for PHAB Standards Development and training of site reviewers (2008-2010) Surveyor for National Committee for Quality Assurance-NCQA (14 years) and Senior Examiner for WA state for national Baldrige Performance Criteria Owner and Managing Consultant of MarMason Consulting, LLC based in Seattle, WA MarMason Consulting Marlene (Marni) Mason

3. Participants in this session will be able to: Apply Performance Management concepts to continue performance management activities and enhance the alignment of the agency Strategic Plan, QI Plan and Health Improvement Plan Describe the link of Performance Management to successful PHAB Accreditation and Domain 9 Development of Effective QI Plans and the link to PHAB standard 9.2 Discuss the effective use of data and steps for establishing a performance measurement system, including using Line of Sight concept MarMason Consulting Today’s Learning Objectives

4. It’s a jumble of concepts and terminology! Performance Measurement Public Health Indicators Lean Six Sigma QI Plans & Councils Standards for Public Health QI Methods & Tools Rapid Cycle Improvement Breakthrough Collaborative Self-Assessment or Accreditation MarMason Consulting

5. Performance Management Definition • Performance management is “the use of performance measurement information to help set agreed-upon performance goals, allocate and prioritize resources, inform managers to either confirm or change current policy or program directions to meet those goals, and report on the success in meeting those goals” Guidebook for Performance Measurement , Turning Point Project MarMason Consulting

6. PERFORMANCE STANDARDS • Identify relevant standards • Select indicators • Set goals & targets • Communicate expectations • PERFORMANCE MEASUREMENT • Refine indicators & define measures • Develop data systems • Collect data PERFORMANCE MANAGEMENT SYSTEM • REPORTING OF PROGRESS • Analyze data • Feed data back to managers, staff, policy makers, constituents • Develop a regular reporting cycle • QUALITY IMPROVEMENT PROCESS • Use data for decisions to improve policies, programs & outcomes • Manage changes • Create learning organization Turning Point Performance Management Collaborative, 2003

7. Performance Standards PERFORMANCE STANDARDS Establish infrastructure, capacity and work process performance standards • Public Health Accreditation Board (PHAB) standards • National Public Health Performance Standards (CDC) Establish outcomes and indicators • Process outcomes • Health risk and status outcomes • Social determinant indicators MarMason Consulting

8. MarMason Consulting 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 and social determinant indicators

9. Quality Improvement Process 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 MarMason Consulting

10. Do Plan Check Act QI Built into the PHAB Standards 5.2.1 L: Conduct a process to develop a community health improvement plan. 5.2.2 L: Produce a community health improvement plan…. 5.2.3 A: Implement elements and strategies of the health improvement plan, in partnership with others 5.2.4 A: Monitor progress on implementation of strategies in the community health improvement plan in collaboration with broad participation from stakeholders and partners MarMason Consulting

11. A management process and set of disciplines that are coordinated to ensure that the organization consistently meets and exceeds customer requirements. Definition of Quality Improvement QI Top management philosophy resulting in complete organizational involvement qi Conduct of improving a process at the micro system level Bill Riley and Russell Brewer, Review and Analysis of QI Techniques in Police Departments, JPHMP Mar/April 2009 MarMason Consulting

12. Results of measurement of performance in standards Results of monitoring indicators and outcomes Health risk, health status, environmental and social determinant indicators Program evaluation data Results of QI projects and efforts Regular data tracking, analysis and review Basis for QI efforts Reporting Progress REPORT PROGRESS MarMason Consulting

13. MarMason Consulting Application P-D-S-A for Performance Mngmt 2011 Performance Report available at http://www.doh.wa.gov/phip/doc/phs

14. MarMason Consulting Establishing and implementing performance management systems helps state agencies: Align agency plans to reduce duplication and increase efficiency and effectiveness Prioritize planning and improvement efforts Address accreditation requirements Demonstrate the results of PH programs and services through performance measurement and reporting Effective Performance Management

15. MarMason Consulting Adapted from KCHD Strategic Management System

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17. MarMason Consulting Link to PHAB v1-Standard 9.1

18. What is your experience with the four components of performance management at your agnecy? MarMason Consulting Let’s Discuss!

19. Practice review of PHAB requirements for Performance Management Work in duos and review the Kitsap Strategic Management System policy against the PHAB standard 9.1 requirements. MarMason Consulting

20. Community Health Assessment Standard 1.1 Health Improvement Plan Standard 5.2 Department Strategic Plan Standard 5.3 MarMason Consulting The Three Prerequisites

21. MarMason Consulting CHA/CHIP/SP/QI Plan

22. Domain 1: Conduct and disseminate assessments focused on population health status and PH issues facing the community MarMason Consulting

23. Domain 5: Develop public health policies/plans MarMason Consulting

24. Domain 5: Develop public health policies/plans MarMason Consulting

25. They Are All Linked Employee Survey Data Health of Washington Budget Customer Survey Data Implementation of Strategies, Operational Activities and Process Improvements Management Review and Analysis of Performance Tools Creation of GMAP Dashboard* Public Health Standards Results Strategic Plan GMAP HealthMAP Legislative Agenda Data Analysis Data Collection POG / Activity Inventory WSQA Assessment Results Annual Self Assessment Ask yourself questions such as, how well are we doing? How do we collect data? What do we do with it? Is our strategic plan working? Who is involved? Use the Baldrige framework of Leadership, Strategic Planning, Customer Focus, Information & Analysis, Human Resource, Process Management and Performance Results to guide the assessment. 1 or 2 opportunities for improvements Slide courtesy of WA Centers for Excellence * = performance measurement tools

26. PHAB Strategic Plan Requirements 5.3.1A Description of elements of the planning process used to develop the organization’s strategic plan: a. Membership of the strategic planning group b. Strategic planning process steps 5.3.2A Health department strategic plan dated within the last five years that includes: • a. Mission, vision, guiding principles/values • b. Strategic priorities • c. Goals and objectives with measurable and time-framed targets • d. Identification of external trends, events, or factors that may impact community health or the health department • e. Assessment of health department strengths and weaknesses • f. Link to the health improvement plan and quality improvement plan 5.3. 3A: Annual reports of progress towards goals and objectives contained in the plan, including monitoring and conclusions on progress toward meeting targets

27. Let’s Discuss How can your agency can establish a performance management system and improve the alignment of Strategic, CHIP and QI goals and objectives? MarMason Consulting

28. Short Break! Be Back in 15 minutes, please!

29. The Quality Environment • 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? • Measurement of results and progress are outcome based? MarMason Consulting

30. Principles of Quality Improvement 1 Know your stakeholders and what they need 2 Focus on processes 3 Use data for making decisions 4 Use teamwork to improve work 5 Make quality improvement continuous 6 Demonstrate leadership commitment MarMason Consulting

31. Why do we need a systematic model for improvement? • “All improvements require change but not all change will result in improvement. A primary aim of the science of improvement is to increase the chance that a change will actually result in sustained improvement from the viewpoint of those affected by the change.” The Improvement Guide, 1996

32. PDCA/PDSA Cycle definition • 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 Plan Act Study Do

33. Learning and Improvement Cycle Act Plan • What changes are to be made? • Next cycle? • 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 LOGIC MODEL REVISE LOGIC MODEL Study Do • Complete the data analysis • Compare data to • predictions • Summarize lessons • Carry out the plan • Document problems and • unexpected observations • Begin analysis of the data DATA REPORT WORK PLAN

34. MarMason Consulting Plan Adapted from The ABC’s of PDCA, Gorenflo and Moran Check/ Study 7. Develop Improvement Theory • Identify and • Prioritize Opportunities • Review analysis • and make conclusions 2. Develop AIM Statement 8. Develop Action Plan Act 3. Describe the Current Process Do Adopt Standardize/ Hold the Gains 1.Test the Improvement 4. Collect Data on Current Process DO - Modify/ Try Again Adapt 2. Collect and Analyze the data 5. Identify All Possible Causes 3. Document Problems, Observations, and Lessons Learned Abandon Plan 6. Identify Potential Improvements

35. Tying It all Together • Problem to Consider – AIM • Describe current process • Identify Stakeholders Needs & Prioritize Issues • Identify Potential Root Cause • Sector Maps • Force Field Analysis • Affinity Diagram • Prioritization Tools • Work Flow Chart (Swim Lane) • Value Stream Mapping • SPIROC • Fishbone Diagram • 5 WHYs • Data Collection to Identify Root Causes • Modify Intervention or Implement if Improved Outcomes Pareto Charts • Work Flow Charts • Analysis Reports • Plan & Test Potential Solution • Translate Data Into Information • Analyze Information & Develop Solutions • Gantt Chart • Data Collection • Run Charts, Pie Charts • Data Analysis Tools • Adapt Promising Practices

36. Embracing Quality in Local Public Health: Michigan’s Quality Improvement Guidebook, version 2; April 2012, http://mphiaccredandqi.org/Guidebook.aspx 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, Moran J, Understanding and Controlling Variation in Public Health. Journal of Public Health Management and Practice. Jan/Feb 2012; 18(1), 74–78 Some QI References MarMason Consulting

37. Small group work What specific aspects of performance management have you established in your agency? What are the 2 next steps you will consider for moving ahead on the performance management system? MarMason Consulting

38. LUNCH BREAK! Be Back in an hour, please!

39. Establishing Effective QI Plans and Programs

40. Capacities/Steps for Building a PM/QI Culture • Leadership commitment and knowledge • Establishing performance standards [capacity, infrastructure, work process, coordination and results] • Performance measurement processes, including data collection, analysis and reporting • QI Plan, including infrastructure, oversight, resources, QI activities and teams, training and evaluation • Consistently “Closing the PDSA Loop” [making conclusions from data and results and taking action for improvement] • Recognition and actions to hold the gains MarMason Consulting 40

41. Demonstrate Leadership Commitment • Build QI culture • Connect strategic plan to performance improvement • Know and use quality principles • Initiate and support QI teams • Reward improvements • Assure adequate QI infrastructure for quality assessment and improvement activities • Establish performance measurement system MarMason Consulting

42. Governance (formal/informal) Oversight and accountability through QI Council or Leadership Team QI Program Plan (infrastructure & capacity) Who will do what when, with what processes for recommending or deciding QI activities Staff Support for ongoing monitoring and analysis, for training and facilitating improvement activities Data system Collect data and report in a user friendly way MarMason Consulting QI Infrastructure

43. MarMason Consulting Forming a Quality Improvement Council • Establish Oversight group of 7-10 members, maybe ongoing leadership team, or mix of leaders, managers and front line staff • Set regular meeting times, once a month • Charter or description in QI Plan • Regular reports of progress

44. Purpose Responsibilities and Scope QC Structure and Meetings Guiding Principles and team norms Annual Work plan Staff support Annual District QI Plan Performance monitoring and reporting Communication plan MarMason Consulting Kitsap PH District Quality Council Charter

45. Spokane Regional Health District (large health department) Customer Service HIPAA Compliance Program Evaluation Strategic Plan review Communication Plan MarMason Consulting Additional QI Council Activities

46. MarMason Consulting Link to PHAB v1-Standard 9.2

47. Mission, Vision, (Scope), Goals and objectives Organizational Structure Resources, Roles and responsibilities Monitoring activities associated with important aspects of programs/services Planned QI efforts (in process, new) and timelines Monitoring progress and results of current QI efforts Annual evaluation of QI work plan and program description, with proposed revisions MarMason Consulting Quality Improvement Plan

48. Purpose and Scope • The QI Plan should describe the purpose for the QI activities conducted by the health department, including a description of the scope of the activities. • The scope may be as limited as conducting one or two quality improvement efforts or a comprehensive, formal initiative that is integrated across all sections of the health department. • This section could also describe the alignment with other agency-wide policies such as the strategic plan and the community health improvement plan.

49. Purpose and Scope – Spokane RHD • Quality Improvement is an integrative process that links knowledge, structures, processes and outcomes to enhance quality throughout an organization. • Vision: The Quality Council (QC) will aid in creating, implementing, maintaining, and evaluating the quality improvement (QI) efforts at Spokane Regional Health District (SRHD) with the intent to improve the level of performance of key processes and outcomes. • Goals: The Quality Council’s goals in supporting this effort are: • Identify, review, monitor and make recommendations on QI processes/efforts • Review QI Plan at least annually and adjust as required • Identify and meet QI training needs • Provide guidance, support, and resources for QI efforts • Recognize and acknowledge QI efforts • (See Appendix A: QC Goals and Activities Work Plan)

50. Structure – governance and resources • Describe the structure for the oversight and direction of the QI activities: • as simple as having the QI team leader report progress to the agency leadership team or as formal as a separate committee for initiating, reviewing and recognizing QI efforts. • support the alignment of agency-wide activities and the performance measurement processes. • explain the roles and responsibilities of specific leaders and staff in the health department, including responsibilities for participation or leadership of the QI oversight group • Describe the resources for conducting QI activities such as staff designated to work on QI activities and data analysis resources,. • Potential attachments: QI Council Charter, QI organizational chart, diagram of QI activities related to strategic initiatives and/or health improvement plans.