PERFORMANCE MANAGEMENT AND QI PRINCIPLES AND STRATEGIES

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

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Marni Mason BSN, MBA

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 AwardMarMason Consulting

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QI for Leadership Series

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 7th) 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 28th)

Sessions # 4 & 5: Topics TBDMarMason Consulting

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Today’s Learning Objectives

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

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Performance Management

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QI Plans &

Councils

Business Process Analysis

Public Health Indicators

Standards for

Public Health

Self-Assessment or Accreditation

Breakthrough Collaborative

QI Methods & Tools

Lean Six Sigma

Performance

Measurement

Performance Management

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Source: Turning Point Performance Management Collaborative, 2003.

Performance Standards

Establish performance standardsPublic Health Accreditation Board (PHAB) standardsNational Public Health Performance Standards (CDC)

Establish and define outcomes and indicatorsProcess outcomesHealth outcomes

PERFORMANCE STANDARDS

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

PERFORMANCE MEASUREMENT

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.

Bill Riley and Russell Brewer, Review and Analysis of QI Techniques in Police Departments, JPHMP Mar/April 2009

QI Top management philosophy resulting in complete organizational involvement

qi Conduct of improving a process at the microsystem level

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

Performance in standards Indicators and outcomes

Health indicators Program evaluation data

Regular data tracking, analysis and review

Basis for QI efforts

REPORT PROGRESS

Integration of QI into Agency Culture12

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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

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*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

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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 [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

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Bill Riley and Russell Brewer

Poll Question

How would you describe level of quality improvement integration in your organization? A. Level 1: No interest or activityB. 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

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

1. Know your stakeholders and what they need

2. Focus on processes3. Use data for making decisions4. Use teamwork to improve work5. Make quality improvement continuous6. Demonstrate leadership commitment

1. Know Your Stakeholders

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

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Public Sector Map

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School Boards

•Public schools•BIA schools•Charter schools

•Private faith based schools

2. Focus on Work Process

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”

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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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There are fewer incidents of

foodborne illness

Conditions in the restaurant don’t

create unsafe food

Public is sold food that is safe to eat

We inspect restaurants

# of inspections

% of critical violations corrected

within 24 hours

rate of foodborne illness

# of critical violations

So that

So that

So that

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

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Poll Question

How frequently do you/your organization use data to target improvement efforts? A. RarelyB. SometimesC. OftenD. Always

Use Data to Make Decisions

Affinity Diagram Brainstorming Process Flow Chart Cause and Effect

Diagram (Fishbone) Five Why’s Matrix Diagram

Check Sheet Bar Chart Histogram Pareto Chart Control Chart Run Chart

Conceptual Tools Numerical Tools

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MarMason Consulting[See Goal/QPC PH Memory Joggers]

Power of Root Cause AnalysisW. 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.

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* The Public Health Quality Improvement Handbook, page 22

Root Cause Analysis

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?

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PoorHIV Testing

ClientTest Location

Don’t see benefit

Counseling

Not Client Centered

Inconvenient

Staff

Not Respectful

Fearful

Not Offered Poor Experience

Too Public

Don’t Want Test

Cause and Effect Diagram

Example of Fishbone

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WIC clients do not redeem all of

the farmer’s market coupons

People Access

Page 1

WIC Client Redemption of Farmer’s Market Coupons

Methods Materials

Customer Service

PersonalCultural

Hours

Knowledge Deficit

Language

Variety/Selection

Preferences

Client has more distractions in the summer

Limited WIC Providers

Locations

Small dollar value

No change is given

Distribution

Frequency Timing

Staff explanations of Farmer’s Market option

Limited supply

4. Use Teamwork

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

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Tips for Effective QI Teams

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

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Affinity Diagram*

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”

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*PH Memory Jogger page 12

Uptake of Vaccines Example (Kittitas, WA)

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5. Make QI Continuous

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

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Improvement Model - PDSA Cycle 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

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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

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PDSA Improvement Cycle

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

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

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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

Describe your process (Logic Model or Flow Chart)

Study the exemplary practice process Adopt or adapt as appropriate

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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

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QI Culture and QI Council

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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Agency Level Performance Measures

Measure Indicator Responsibility

Improve 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.

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

Reduce overweight & obese populations

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

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.

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

Increase responsible sexual behavior

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

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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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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

Some QI References

What questions do you have?

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