PERFORMANCE MANAGEMENT AND BUILDING QI INTO YOUR AGENCY CULTURE MCPP Healthcare Consulting.

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 (2008-

2009)


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


Performance Management

QI Plans & Councils

Business Process Analysis

Public Health Indicators

Standards for Public Health

Performance

AssessmentImproving PH processes

QI Methods & Tools


Application of P-D-S-A


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


Performance Measurement2nd Quadrant


Performance Measurement Definitions


Quality Improvement Process 3rd Quadrant 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. Know your stakeholders and what they need

2. Focus on processes3. Use data for making decisions4. Understand variation in processes5. Use teamwork to improve work6. Make quality improvement continuous7. Demonstrate leadership commitment


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

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

WORK PLAN

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

DATA REPORT

Act• What changes are to be made?• Next cycle?

DOCUMENTATION OF CHANGE - MINUTES

REVISE LOGIC MODELLOGIC MODELREVISE LOGIC MODEL


Learning and Improvement Cycle

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



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

Describe your process (Logic Model or Flow Chart)

Study the exemplary practice process Adopt or adapt as appropriate

http://www.naccho.org/topics/modelpractices

Reporting Progress4th Quadrant

Reporting of Performance (Local and State Standards and Program Evaluation)

Reporting of Indicators and Outcomes Health Indicators Program Evaluation Data

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


Stages of Organizational Performance

Infrastructure Process Coordination Results

Leadership & Decision making

Boards of Health Policies &

Procedures Enforcement/

Investigation Protocols

Financial management

Information & reporting

Set of Core Indicators

Program performance goals/ objectives

Assessment processes

CD investigation case write-ups

EH enforcement action and case files

Education sessions

Work of community groups and coalitions

Communication mechanisms

Public and private work on access to services

Hand-offs between local health and state programs

Program evaluation results

Key indicator outcomes (CD/EH/PP)

Financial performance


Program Maturity

Does Size of Department Matter? 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


Correlation of Budget & FTEs 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


Correlation of Budget to Performance

Slight correlation and relationship between annual budget and overall performance in the Standards


20

Correlation of Per Capita Budget

No correlation or relationship of per capita budget to overall performance in the Standards


Building QI into Your Culture


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.”

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

Demonstrate Leadership Commitment

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



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



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


QI Infrastructure

Governance (formal/informal) Oversight 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


Quality Improvement Plan

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


TACOMA-PIERCE COUNTY HEALTH DEPARTMENT QUALITY IMPROVEMENT (QI) INITIATIVE

QI Time Line at TPCHD


QI Training & Tools

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


QI Infrastructure

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 importantMCPP Healthcare Consulting

QI Plan and Evaluation

Annual QI plan Lists major activities Includes calendar Identifies persons

responsible & time lines

Annual evaluation of QI plan Evaluates QI Council

meetings Analyzes performance

measure data Examines completion

rate of QI plan activities


Quarterly Reporting Form

Plan Item Name/No. Indicator(s) Baseline Data (if applicable) Quarterly Data Data Source Methods Notes Data Explanation/Other Comments


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 Sep 21 Sep 22 (final report) TBD (BOH)

Solid waste code enforcement complaint resolution

John ShermanNov 23

Sep 22 (interim report)Nov 24 (final report)

TBD (BOH)

B. TPCHD Performance Measures

See Section II B Jul 31Oct 31

Jan 31, 2010

Aug 25Nov 24

Feb 23, 2010Mar 3, 2010 (BOH)

C. QI Projects at Request of Director

TBD TBD TBD TBD

D. Program Evaluation Reports

Menu labeling Rick Porso May 25 May 26

MCH home visiting David Vance Oct 26 Oct 27

E. Review of Health Indicators

Three priority indicators (Review of performance measures in Table 2)

Nigel Turner (Chlamydia)

David Vance (LBW)Rick Porso (Adult

Obesity)

Jul 31*Oct 31

Jan 31, 2010

Aug 25Nov 24

Feb 23, 2010Mar 3, 2010 (BOH)


Performance Measures

Twelve department-level measures 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


TPCHD Performance Measures

Measure Indicator ResponsibilityImprove immunization rates

Increase the percentage of kindergarten enrollees that are up to date on their immunizations upon school entry from 86% to 92% by 2014.

Nigel Turner

Reduce tobacco use Decrease the percentage of adult smokers to 16% by 2014. Rick PorsoReduce overweight & obese populations

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

Increase healthy physical activity

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

Rick Porso

Reduce substance abuse

Increase the number of adults receiving opiate treatment service by 23% by 2014, to 800 patients.

David Vance

Increase responsible sexual behavior

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

Nigel Turner

Increase access to care

Increase the number of children enrolled annually in health insurance programs by 42% by 2014.

David Vance

Decrease injury and violence

Reduce youth violence risk factors among 75% of youth who participate in TPCHD youth violence prevention services for at least 30 days.

David Vance

Improve mental health Decrease adult mental health problems in 20% of families provided TPCHD evidenced-based program services by 2014.

David Vance

Improve environmental quality

Increase the percent of water systems that meet drinking water standards from 80% to 90% by 2014.

Steve Marek

Effectively respond to public health emergencies

Respond within one hour in 100% of situations where TPCHD receives a notice of need for public health response to an incident within Pierce County.

Joby Winans

Decrease rates of key communicable diseases

Increase the percent of ten key communicable diseases for which the trend in incidence rate is flat or decreasing from 38% to 50% by 2014.

Nigel Turner


QI Activities - TPCHD

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


First RCI Project

STD Reporting of Race/Ethnicity

1. Collected data to identify “root cause” of problem

2. Pilot tested an education intervention

Percent of STD Case Reports That Include Race Data (Among Pilot Providers)

74

55

0

10

20

30

40

50

60

70

80

Pre Post

Pe

rce

nt


Second RCI Project

Final On-Site Septic System Inspections

1. Collected data to identify “root causes” of problem

2. Re-prioritized work duties

3. Monitored work flow

Percent of Septic Systems That Received a Final Inspection

94

70

0102030405060708090

100

Pre Post

Pe

rce

nt


TPCHD Results of QI Initiative Most performance

measures at department- and 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


WASHINGTON STATE DEPARTMENT OF HEALTH QUALITY IMPROVEMENT (QI) INITIATIVE

PM System and QI Structure

Focused Quality Improvement Efforts

Focused Quality Improvement Efforts

Organizational Strategic PlanningOrganizational

Strategic Planning


and Accountability


and Accountability

Operational/Business Planning and Performance

Operational/Business Planning and Performance

Quality Steering Committee


Performance Management System QI Structure

PALS(Performance Accountability Liaisons)

PALS(Performance Accountability Liaisons)

Project Mgmt. Resource TeamProject Mgmt. Resource Team

Process Improvement Teams

Process Improvement Teams

Quality Improvement Organizational Structure



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


Step #5:Take

appropriate action.

Step #5:Take

appropriate action.

Step #6:Provide closure.

Step #6:Provide closure.

Step #4:Analyze data and generate

solutions.

Step #3:Examine the

process.

Step #3:Examine the

process.

Step #1:Clarify the purpose.

Step #1:Clarify the purpose.

Step #2:Select & build

the team.

Step #2:Select & build

the team.

The Quality Improvement Process


Integration of QI into Agency Culture


Multilevel Model of Integration* 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


Levels of QI Integration

0

25

50

75

100

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 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 agencyBill Riley and Russell Brewer


ACTIONS TO PREPARE FOR AN ACCREDITATION REVIEW


Establish HD Workgroup

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


Conduct Self-Assessment

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


Tell Your Story….

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!


Organizing Your Documents

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


Electronic System MindManager

How does MindManager help you prepare for your review?

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 Build documentation into regular

processes: Use summary formats for regular reporting Minutes of working committees Case write-ups, logs, and progress reports Emphasize conclusions, actions and results


We Can Make Significant Improvement 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%)


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


What questions do you have?


PERFORMANCE MANAGEMENT AND BUILDING QI INTO YOUR AGENCY CULTURE MCPP Healthcare Consulting.

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