Performance Management & PHAB Accreditation: Leveraging Accreditation to Improve Performance

Leslie M. Beitsch Assoc. of OH Health Commissioners September 29, 2015

Performance Management and Quality Improvement: Models that work The session will provide guidance on how a health department can assess and improve its performance management system. Objectives: • Describe and discuss how Public Health Performance Management can be a tool for achieving healthy communities • Assess relative strengths and weaknesses of a performance management system through interactive exercises • Share use of QI tools that can help with assessing and building a performance management (PM)/QI system

Health District Progress towards Accreditation

Conneaut Ashtabula

Lake County

Ashtabula County

Lucas County Williams County

Fulton County Ottawa County Sandusky

Defiance County

Henry County

Wood County

Geauga County ClevelandShaker Heights Cuyahoga County

Lorain Elyria

Erie County

Sandusky County

Trumbull County

Lorain County

Paulding County

Huron County

Seneca County

Medina County

Portage County Kent Summit County

Findlay Putnam County Hancock County

Girard Youngstown

Mahoning County

Shelby Wyandot County Crawford County

Van Wert County

Warren Niles

Allen County

Alliance Ashland Ashland CountyWayne County

Richland County Galion

Canton Stark County Massillon

Salem

Columbiana County

Hardin County

Legend

Mercer County

East Liverpool Carroll County

Marion County

Auglaize County

Union County Piqua

Darke County

Accredited

Delaware County

Licking County

Miami County

Harrison County

Guernsey County

Columbus Franklin County Clark County

Noble County

Fairfield County

Monroe County Perry County

Pickaway County

Morgan County

Fayette County Hocking County

Middletown Butler County Warren County Clinton County Hamilton

Washington County Marietta Ross County

Springdale

Athens County Belpre

Vinton County

HamiltonNorwood County Cincinnati

Belmont County

Muskingum County

Madison County

Preble CountyMontgomery County Oakwood Greene County

Site Visit Action Plan

Coshocton County Coshocton

Champaign County

Submitted SOI Documents Submitted

Jefferson County Steubenville

Shelby County

Not Started

Completed Prereqs

New Philadelphia Tuscarawas County Knox County

Logan County

Started Prep

Holmes County

Morrow County

Highland County Meigs County

Pike County

Clermont County

Jackson County Brown County Adams County Gallia County

Scioto County Portsmouth

Lawrence County Ironton

Improved Outcomes

Aligned Organization

Your Public Health Department

Improve Community Health

Assess Community Health

Higher Quality and Performance

Strategic Planning

Performance Management System

What is Performance Management? • A systematic process by which an organization involves its employees in improving the effectiveness of the organization and achieving the organization’s mission and strategic goals. • By improving performance and quality, public health systems can save lives, cut costs, and get better results. • Enables health departments to be more: – – – –

Effective (Do The Right Things) Efficient (Do It Right) Transparent Accountable

Effective - (Do The Right Things) Efficient - (Do It Right)

What and How How You Do It Wrong

Efficiency

Right

Mgt

Appropriate Things Done Effectively

%

% WTR

Inappropriate Things Done Ineffectively

Inappropriate Things Done Effectively

%

%

Management is doing things right; leadership is doing the right things. Peter F. Drucker

Wrong Things

WTW

What You Do

Appropriate Things Done Ineffectively

Right Things

RTR

Leadership

RTW

Effectiveness

Continuous Quality Improvement System in Public Health

Turning Point Baldrige

QI Teams

LSS

MAPP

MICRO

Big ‘QI’

MACRO

MESO

A

P

C

D

A

P

C

D

Basic Tools of QI Individual ‘qi’

A

P

C

D

INDIVIDUAL

QFD Advance Tools of QI

Little ‘qi’

A

S

C

D

Daily Management

Rapid Cycle

QA, QC, QI Plan • Strategic • Preventive

Assure  Reactive  Works on problems after they occur  Regulatory usually by State or Federal Law  Led by management  Periodic lookback  Schedule  Meets a standard (Pass/Fail)

Control • Operational • Real time

Quality Improvement

Inspect •Operational •After the fact

 Proactive  Works on processes  Seeks to improve (culture shift)  Led by staff  Continuous  Proactively selects a process to improve  Exceeds expectations

Components of a PM System Plan SHIP/CHIP (e.g., MAPP) Strategic Plan Operating Plans Financial Plan (Budget)

At least 4 types of plans should be ALIGNED: they should mutually support each other

Focuses on strategic change & efforts to support SHIP/CHIP

Covers all programs or organizational units

SHIP/CHIP

STRATEGIC PLAN

OPERATING PLANS (“Business Plan,” “Service Plan,” or “Performance Plan”)

BUDGET (Financial Plan)

De-siloifying

MCH

Preparedness

HIV

STD

Family Planning

Our Research Found Four Barriers to Strategic Implementation The Vision Barrier Only 5% of the work force understand the strategy The People Barrier Only 25% of managers have incentives linked to strategy

Tyranny of the urgent The Management Barrier

9 of 10 companies fail to execute strategy

85% of executive teams spend less than one hour/ month discussing strategy

60% of organizations don’t link budgets to strategy The Resource Barrier

Today’s Management Systems Were Designed to Meet The Needs of Stable Industrial Organizations That Were Changing Incrementally You Can’t Manage Strategy With a System Designed for Tactics

Baldrige Criteria For Organizational Performance Excellence 2 Strategic Planning

5 Human Resource Focus 7 Business Results

1 Leadership

3 Customer & Market Focus

6 Process Management

4 Information and Analysis

Healthy People 2000/2010 Benchmarks

Mission / Vision Agency Strategic Plan & Performance Report Performance Based Program Budgeting Measures

Quarterly Performance Report

State/Local Performance Standards

CHD Quality Improvement Indicators

Performance Management System

County Health Dept Plan

Program Plans

Local and State Needs Assessments

Federal Grant Requirements

What is Performance Management? •

Core practices and processes generally include: – – – – – – – – – – –

•

goal setting financial planning operational planning data collection consolidation of data data analysis reporting of data quality improvement evaluation of results monitoring of key performance indicators (dashboards) others???

The focus of PM activities is to ensure that goals are consistently met in an effective and efficient manner by an organization, a department, or an employee.

What is Performance Management within Public Health?

“Performance management is the practice of actively using performance data to improve the public's health.

This practice involves the strategic use of performance measures and standards to establish performance targets and goals.”

Source: From Silos to Systems: Using Performance Management to Improve Public Health Systems – prepared by the Public Health Foundation for the Performance Management National Excellence Collaborative, 2003.

Refreshed Framework, 2013

Source: From Silos to Systems: Using Performance Management to Improve Public Health Systems – prepared by the Public Health Foundation for the Performance Management National Excellence Collaborative, 2003. Updated framework by the Public Health Foundation, 2013.

Developed in 2013, adapted from the 2003 Turning Point Performance Management System Framework

Mini-Exercise • Using the Turning Point Model as a reference: – What are examples of activities within your Health Department does that fall within a performance management system? – Cross table discussion – Record and prepare to report out

Performance Standards • Standards may be set based on national, state or scientific organizations, by benchmarking against similar organizations, or by other methods. • Example in practice: Healthy People 2020 objective of a 10% improvement in the cases of pertussis among children under 1 year of age (National Notifiable Diseases Surveillance System) • Consensus nat’l PH standards: – PHAB standards Source: www.HealthlyPeople.gov

Performance Standards • • • •

Identify relevant standards Select indicators Set goals and targets Communicate expectations

Think about: • •

Do you set or use standards, targets or goals for your organization or program? How do you communicate the expectations and strategic direction for your organization or program?

Performance Measurement • How will you measure achievement of the standard you set? – It is important to set criteria and establish scope (programmatic vs. state)

• Example in practice: New Hampshire used the following criteria to select final measures: – Data should be available for several years to show trends. – Data should be reliable, in that we are confident in the accuracy of the data and that it measures what is intended to measure. – The measures should reflect new and growing initiatives. – The measures should be a good indicator of whether or not a program or intervention is working. Source: Improving the Public’s Health in New Hampshire, 2005. http://www.dhhs.nh.gov/dphs/iphnh/documents/report.pdf

Performance Measurement • Refine indicators and define measures • Develop data systems • Collect data

Think about: • •

How do you measure capacity, process or outcomes? (think about all 3!) What tools exist to support the efforts?

Reporting Progress • Reporting Progress - How a public health agency tracks and reports progress depending upon the purpose of its performance management system and the intended users of performance data. A robust reporting system makes comparisons to national, state, or local standards or benchmarks to show where gaps may exist within the system. • Periodicity is important • Consistently a weak area in nat’l surveys

Reporting of Progress • Analyze and interpret data

• Report results broadly • Develop a regular reporting cycle

Think about: • Do you document or report your unit / program’s progress? • Is this information regularly available? To whom? • What is the frequency of analysis and reporting?

Quality Improvement • Use data for decisions to improve policies, programs and outcomes • Manage changes • Create a learning organization • Implement priority QI activities

Think about: • •

•

Do you have a quality improvement process? What do you do with information gathered through reports? Do you have the capacity to take action for improvement when needed?

Visible Leadership • Visible Leadership - Senior management commitment to a culture of quality that aligns performance management practices with the organizational mission, – regularly takes into account customer feedback – enables transparency about performance compared with targets for conversations between leadership and staff.

Visible Leadership • Engage leadership in performance management • Align performance management with organizational priorities • Track and incentivize progress Think about: •

•

Does senior management take a visible role in performance management? Is performance management emphasized as a priority and goal for your work?

PM Frameworks from the Field

Minnesota Public Health System

Nebraska Division of Public Health

Washington State Department of Health

ODH STATE HEALTH IMPROVEMENT PLAN

Five-Year Strategic Plan

ODH QUALITY IMPROVEMENT PLAN

STRATEGIC IMPLEMENTATION PLAN

PROGRAM WORK PLANS

INDIVIDUAL PERFORMANCE PLANS

30,000 FT

20,000 FT

10,000 FT

SEA LEVEL

Definition of Quality Improvement In Public Health

“Quality improvement in public health is the use of a deliberate and defined improvement process, such as Plan-Do-Check-Act, which is focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community.” Defining Quality Improvement in Public Health; Journal of Public Health Management & Practice: January/February 2010 - Volume 16 - Issue 1 - p 5–7, Riley, William J. PhD; Moran, John W. PhD, MBA, CQIA, CQM, CMC; Corso, Liza C. MPA; Beitsch, Leslie M. MD, JD; Bialek, Ronald MPP; Cofsky, Abbey -

Continuous Improvement Act

Check/ Study

Plan

Do

PDCA was made popular by Dr. Edwards Deming who is considered by many to be the father of modern quality control

The continuous improvement phase of a process is how you make a change in direction. The change usually is because the process output is deteriorating or customer needs have changed.

Source: ABCs of the PDCA Cycle, G. Gorenflo and J. Moran, http://www.phf.org/pmqi/resources.htm

Plan

1. Identify and Prioritize Opportunities

2. Develop AIM Statement

7. Develop Improvement Theory

8. Develop Action Plan

3. Describe the Current Process

4. Collect Data on Current Process

5. Identify All Possible Causes

6. Identify Potential Improvements

Do 1.

Implement the Improvement

2. Collect and Document The data

3. Document Problems, Observations, and Lessons Learned

Check/ Study

1. Reflect on the Analysis

2. Document Problems, Observation, and Lessons learned

Act Adopt Adapt

Abandon

Standardize

Do

Plan

Mini-Exercise: Making A Performance Management System Work • At the Table: Identify Your Primary Strength : – Describe the “Success Factors” of this strength • • • •

What systems and expectations make this work? What training has occurred? What does leadership do to make this work effectively? How can we Sustain this strength?

Refreshed Framework, 2013

Source: From Silos to Systems: Using Performance Management to Improve Public Health Systems – prepared by the Public Health Foundation for the Performance Management National Excellence Collaborative, 2003. Updated framework by the Public Health Foundation, 2013.

Mini-Exercise: Where We Can Improve • At the Table: Identify Your Weakest Quadrant • Review Your Self-Assessment Data. – Identify and Summarize Barriers You Encounter – Brainstorm Ideas for Improving this weakest link

Radar Chart

Rating Scale  0 – nothing in place  1 – just getting started  2 – moving in the right direction  3 – adequate; have made good progress over the last year

 4 – very good performance; plans in place to expand the QI program throughout the organization  5 – off the chart!!! we have institutionalized QI

Phase 1: No Knowledge of QI

Phase 2: Not Involved with QI

Phase 3: Informal or Ad Hoc QI

Phase 4: Formal QI in Specific Areas

 Agency Characteristics  Transition Strategies  Resources

Phase 5: Formal AgencyWide QI

Phase 6: QI Culture

Phase 1: No Knowledge of QI

Phase 2: Not Involved with QI

Phase 3: Informal or Ad Hoc QI

•Lack of understanding of QI •Competing priorities •Satisfaction with status quo •Don’t value or link QI to PH practice •Data not used in decision-making

•Begin to understand QI •Little expectations for using QI •Staff view QI as a “trend” •Few QI trainings or resources •Limited use of data •Not customer-focused

•Informal QI efforts •QI not part of organization’s strategy •Some performance monitoring and data use •Staff anxiety •QI training periodically available

Phase 4: Formal QI in Specific Areas

Phase 5: Formal AgencyWide QI

Phase 6: QI Culture

•Greater reliance on data •Multiple QI champions exist •QI training/resources readily available •Data driven decision making •Discrete QI projects •Improvements not

•Most staff engaged with QI •Formal PM system in place •All agency plans linked •Discrete and interdepartmental QI projects •Standardization in processes

•All staff are committed to QI •Emerging issues do not impede QI •Ongoing training •Data and QI tools used daily •Customer is front and center •Demonstrating ROI

What is your vision of Your QI culture?  A good QI culture is the one that looks at the challenges and the problems in public health as opportunities rather than unsolvable frustrations.  This culture would make our organization a place where employees feel empowered to solve problems. Leadership, QI tools, attitude, and the PI team are our assets to achieve that empowerment.

Mini-Exercise • Which exit is your health dept. at right now?

• What exit do you plan to be in 12 months?

Transtheoretical Model

Behavior Change

Ready

Pros and cons - acknowledgement Not ready – resist change

Health Behavior Change Model. The model originates from directly observing how people really did or didn’t change in response to urgent medical needs.

Development of a PM System A well functioning Performance Management System is one that the entire organization can provide input to, find useful, guides day-to-day operations, and helps direct focus to areas needing improvement.

Development of a PM System Performance Management Systems all share the same common purpose of providing business intelligence  On a timely basis  To help make informed decisions at all levels of the organization To ensure that all processes are efficient and effective and Deliver the products and services that our customers desire.

Development of a PM System A well-developed Performance Management System is the CNS of the organization since it is providing real time/regular ongoing business intelligence about performance: goals effectiveness and efficiency of programs and services, performance of processes customer satisfaction levels  providing knowledge to help leadership prioritize areas needing improvements.

Development of a PM System A Performance Management System Should Answer The Following Questions:  How are we doing  Why?

 What should we be doing?  Does it match the need(s) of our customer?  How fast can we improve?

Outcome

Influence

Process

Capacity Control

AIM Internal

• Discrete • Measureable •Time Bound

Operational

External

Strategic

Characteristics of QI “Small QI” Program or activity level Great way to learn a specific model “Large QI” Organization-wide System focused

Realizing Public Health Transformation Through QI • Set focus on a vital few priorities • Create a sense of urgency for measurable results and a culture of quality • Engage every employee • Build QI time into daily workload (not extra job) • Adopt fact-based decision making • Reward and celebrate progress

Transformational Change • Change requires more than an effort by a charismatic leader with strong personal beliefs and practices. • Individual employees are often left out of the equation. • They may receive skill instruction and development that does not prepare them to re-envision their work and make the deep personal changes needed to be more effective in a radically altered environment.

A leader is one who knows the way, goes the way, and shows the way. John C. Maxwell