1. Embracing a Culture of Performance Improvement (PI)
Heather Readhead, MD, MPH
Yon Silvia Shin, RN, PHN MSN/MPH
Julia Heinzerling, MPH
Emily Peach, MPH
Joseph Truong, MPH, MPA
May 2012

2. Contents Background Objectives Training Modules Data Management PDSA
Q &A

3. Program Plan
Mission: to improve the quality of public health practices/services to improve health outcomes
Strategy: program management & accountability
Framework/Theory/Terminology
Goals:
to change knowledge, skills, behaviors
to motivate DPH to use them

4. Plan Goals & Objectives
Change knowledge, skills, behaviors
Training & implementation tools
Technical assistance for projects
Communicate progress/results
Motivation for organizational change
Change is mandatory. Progress is not.
Leadership
Incentives
Pilot projects

5. Program Structure QI Division , under DPH Medical Director
PI Team - representatives from DPH programs
PI Team Workgroups—Training, PDSA, Data
Executive leadership/advisory group
Terminology Challenge: Thus far, QI and PI have been used interchangeably within DPH.
Existing QI program  program expansion…

6. Training – Plan A program within a program… Create a program plan:
mission statement
goals & measurable “SMART” objectives
tasks & timelines
Know your grant deliverables.
Know the skills of your staff/workgroup.
Existing QI program  program expansion…

7. Training – Needs Assessment
Survey stakeholders: QI director, staff, DPH learners = end-users, etc.
What resources already exist?
Within our department of public health
Within other departments of public health
Within the world of healthcare/business
What do we need to create or assemble?

8. Training – Needs Assessment
“In-house” resources we may not know about:
QI/PI-trained staff
QI/PI trainings offered to employees
QI/PI work already being done
External resources:
What is out there (reports, guides, powerpoints, eLearning modules)?
Is anything evaluated?
Which do we want to use/promote?

9. Training – Needs Assessment
Self-assessed capacity & empowerment
Obstacles to implementation
Desired training for targeted staff:
Topic
Format
Duration
Continuing education units
Certification
Put it all together: strategic Program Plan + Needs Assessment results  they inform each other…
What do I want to do? What’s the need? May adjust your plan’s goals/objectives…

10. Training – Curriculum NOT – “What do I want to teach?”
INSTEAD – “What do you want your students to be able to do when they finish your training?”
NOT :academic slide presentations
INSTEAD: practical skills training
After this training, the student will be able to do…
Fill in the blank with action verbs, on-the-job tasks…
Your goal is a competency-based curriculum!

11. Training – Curriculum & Lessons
For each competency, break it down into the steps needed to learn and apply:
WHY – attitude & motivation to learn
WHAT – knowledge & content to learn
HOW – skills, practice, application  ACTIVITIES
Then, break it down into discrete lesson plans:
who, what content, what format, what take-away tools, when, where…
The script comes LAST.
For each competency, break it down into the baby steps needed to learn and apply:
Affective domain: WHY – attitude & motivation to learn
Cognitive domain: WHAT – knowledge & content to learn
Psychomotor domain: HOW – skills, practice, application (i.e., how will I do this at work?) ACTIVITIES

12. Training – Learning Theory
BLOOM’S TAXONOMY: domains & levels of learning
Affective domain: WHY – receiving/awareness, responding, valuing, prioritizing, internalizing
Cognitive domain: WHAT – recall/remember, comprehend meaning, apply/use concept, analyze/evaluate, create – design & implement!!!
Psychomotor domain: HOW – perception, readiness to act, imitation, habit/proficiency, skilled response – can face challenges, adaptation/creation
LEARNING STYLES: hearing, reading, seeing, doing
Public Health practitioners generally do not have a teaching credential. 
Here is a “cheat sheet” to keep in mind:

13. Paving a Path toward Performance Improvement
New resources to help Programs reach their own performance improvement goals:
Tools to improve staff knowledge of performance improvement principles, roles, and resources
Streamlined process for providing PI support, tools, training and technical assistance

14. The PI Roadmap Tools for Navigating the PI Process
Written PI plan to guide Department and Program PI efforts
Training and online tools
Uniform system for managing PI support requests
Process map
PI Support Request Form

15. Three Steps Toward Improved Performance
Step 1: Review the PI plan and complete PI training.
Step 2: Identify a PI opportunity and submit a PI Support Request Form to the Division of QI.
Step 3: Complete the support option recommended by the Division of QI.
Short-term Technical Assistance
Training
Longer term Support for a PI Project

16. The PI Process Map
All Aboard the P.I. Express

17. The Final Destination: A PI Project in Every Program
The new PI plan, training, and TA encourage adoption of:
The 4-Step Model: Identify an aim for improvement, develop a plan to address the improvement need, measure impact, and adjust your plan.
PDSA Cycles: Test a promising change rapidly on a small-scale, learn how it works, and refine (as needed) before implementing it broadly.

18. The Role of Data Management
Accurate, timely, and accessible data can help Public Health Programs and stakeholders:
Identify PI needs
Test process changes
Compare outcomes between Programs, Departments and regions
Improve decision-making at the Department and Program level
Background:
The Office of the Medical Director - Quality Improvement Division is responsible for planning, coordinating, and implementing a department-wide performance management system to measure and improve the performance of the public health programs that serve Los Angeles County.
 Why Data Management is important?
The principles of Quality Management are (1) Focus on the Client, (2) Understanding works as systems and processes, (3) Teamwork and (4) Focus on the use of data. Data are needed to analyze processes, identify, and measure performance. Changes can then be tested and the resulting data analyzed to verify that the changes have actually led to improvement.
Quality Improvement and Accurate Data are keys to ensuring appropriate comparisons of programs, departments and regions.
The effective use of information and technology is crucial for health care organizations to meet provider and community needs in today’s complex, evolving environment.
The challenges faced when trying to make sense of large, diverse, and often complex data source are considerable. In an effort to turn information into knowledge, health care organizations, including health departments, are implementing data mining technologies to help control costs and improve the efficacy of patient care. Data mining can be used to identify areas for improvement, predict future outcomes, and improve interventions.
Data is a core business asset that needs to be managed if an organization is to generate a return from it. Providing the infrastructure to maintain high-quality data in house means data owners can quickly achieve important benefits, including:
• Cost savings
• Better decision-making
• Improved client and community service
• More streamlined supply chain management ___ JOSEPH --- CAN you please elaborate on this? I am not certain what this means in the context of Public Health. Thanks!

19. PI Measurement can Enhance Organizational Effectiveness
Each DPH Program tracks population indicators and performance measures.
74 population indicators
227 performance measures
Measures should be:
evidence based
archived/storage for analysis
used for change or improve the care/service
Organizational effectiveness
The QI Division is collecting routine data and reporting for approximately 74 population indicators and 227 performance measures annually. This effort requires integration of numerous datasets and performance reporting requirements within the LAC DPH as well as for the LAC Chief Executive Office, the State of California, and the Department of Health and Human Services (HHS) agency.
Routine data collection for performance measurement has occurred since 2009, and a Data workgroup was created to focus on designing a user-friendly application that efficiently collects, queries and reports performance measurement data that are aligned with the department’s strategic priorities.
Measures should be:
evidence based
archived/storage for analysis
used for change or improve the care/service

20. Building the Performance Improvement Application
Data Workgroup formed to develop a PI Application
Led by the Office of the Medical Director, with representation from 31 DPH programs
Aims of the PI Application
Centralized, more efficient data tracking
Generate cause-effect diagrams, process maps and graphics for storyboards and reports
Aggregate and track results
Use data to learn from other Programs
The Data Workgroup brought PI specialists from ___ PH Programs to develop a centralized online data application .
Developing the Performance Improvement Application (PIA) will solve the current problem of the inefficient data management system in place. The current system consists of separate Excel spreadsheets from the numerous health programs in which data are manually updated, and queried and it lacks convenient performance reporting capability.
An application with dashboard capability is needed to allow for more efficient tracking of performance data, preparing cause-effect diagrams and process maps, and creating storyboards and performance reports.
Performance Improvement Specialists from each program will use this application to input performance improvement specific data that is then automatically stored in a database where OMD can perform data management and analysis as well as generate outcome reports. This system will improve the quality of services implemented by programs as their decisions will be better guided by an improved data management system. This increases OMD’s ability to contribute to LAC’s strategic mission “To protect health, prevent disease, and promote health and well-being.”
Because everyone's data is presented, programs can learn from others who are doing well.
At the highest level, the data quality performance management can be used to assess program-wide performance in meeting data quality expectation. Data quality performance management sets the focus for monitoring the quality at the program level, and performance indicators may need to change to accommodate new performance improvement initiatives and service needs

21. PI Application Key Features
Easy import and export options
Query capability for data management and analysis
Standardized reports at the push of a button
Tracks indicators over time
High impact visual representations of data
Bar graphs, trend lines, dashboards, etc.
Import capability for GIS mapping
Future interface with Business Intelligence Software
The data we collect will also help PH programs determine meaningful things to measure.
The Performance Improvement Application (PIA) will allow for standardized and timely sharing of performance reports throughout the department. This will be achieved by creating a centralized PIA with the following key features:
query capability for data management & analysis.
The dashboard streamlines data collection, making it easier for front-line teams to use it in decision-making. In the past, it would take up to three weeks each quarter to collect this data. Now, electronic and user-friendly quarterly reports are generated at the push of a button. At the present technology within seconds, staff can compare such things as their home's rate of infection, prevalence of falls and depression among residents. They can track indicators over time and have best practice information at their fingertips to help improve outcomes. They can also enter interventions and improvement plans that are designed to meet performance targets.
standardized options for a variety of high-impact visual representations for data analysis e.g. bar graphs, trend lines, charts showing progress toward benchmarks, dashboard, etc.
data can be imported for GIS mapping
convenient import and export data and text information for updates and maintenance as needed
ability to add new data into the data system as needed
automatic data updates from existing program databases when feasible
future interfacing with Business Intelligence Software to customize specific report as needed

22. Good Data In = Great Outcomes
Database/
Application
process
outcomes
The data we collect will also
help DPH programs determine
meaningful things to measure and improve

23. Data Management (Cont.)
Evidence
Variability
Your Clinic
HI JOSEPH- Would you mind providing a bit more detail for this slide to explain the message you’d like promoted? I apologize but I need a little more help to tie this into the data mgt discussion. Is the evidence related to INTERVENTIONS or MEASURES? Also- can you further explain what qualitative data we gather from programs/health systems to assess perceptions and barriers?
This graph shows the yellow line means the more evidence you have support your indicators, the greater chance to reduce your variability in the services. The red line means if you don’t have any evidence or defined indicators, then you will not have the ability to improve your services/treatment.
We gather qualitative data from programs and health systems to assess perceptions/barriers/enables of success.
Performance Measures/ Performance Indicators
Ability to Improve your Services/Treatment

24. Building a PI Infrastructure Challenges and Lessons from the PDSA Group
The collaborative process takes time.
Program involvement makes it more likely that resources are relevant and used.
Build sufficient time for Program input into timelines.
Department and Program priorities lead to starts and stops. Maintain momentum by:
Keeping Programs informed through ed updates.
Encouraging volunteers to keep projects moving between meetings.

25. Building a PI Infrastructure Challenges and Lessons from the PDSA Group
Limited staffing impacts capacity to participate.
Defer meetings that are not needed and allow participation by phone.
Simplify forms and processes.
Help Programs improve systems that can save time.
PI expertise within the Department varies.
Recruit a PI liaison from each Program.
Assess training needs. Offer beginner and advanced options.
Create a repository of tools.
Tailor TA and support to Program needs and resources.

26. Lessons Learned Any major change takes courage and patience.
Leadership from top
First direct, then inspire
Focus
Perseverance not brain surgery
Accountability
Start with people
Reward and recognition
Low performers
Any major change takes courage and patience.
What we Learned
Joseph- would you mind elaborating on a couple of these bullets? Not sure what you intended to be talked about in relation to “First direct, then inspire” or “Lower performers” or “ Change is mandatory. Progress is not” Thanks!

27. Next Steps Release PI plan, process map and PI Support Request Form
Launch Training Program
Marketing Campaign
Finalize Data Application

28. Questions

29. Thank You