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Performance Management and Building QI into Your Agency Culture

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1 Performance Management and Building QI into Your Agency Culture
MCPP Healthcare Consulting

2 4/6/2017 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 ( ) MCPP Healthcare Consulting MCPP Healthcare Consulting 2

3 4/6/2017 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 Changed first bullet MCPP Healthcare Consulting MCPP Healthcare Consulting 3

4 Performance Management
Standards for Public Health Public Health Indicators QI Plans & Councils QI Methods & Tools Improving PH processes Performance Assessment Business Process Analysis MCPP Healthcare Consulting

5 Performance Management
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6 Application of P-D-S-A
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7 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 MCPP Healthcare Consulting

8 Performance Measurement 2nd Quadrant
Monitoring of Performance Results of review of performance (Accreditation/Self-Assessment) against local and state Standards Program evaluation results Monitoring of Indicators and Outcomes Process and intermediate outcomes Health status indicators MCPP Healthcare Consulting

9 Performance Measurement Definitions
“regular collection and reporting of data to track work produced and results achieved” Performance measure “the specific quantitative representation of capacity, process, or outcome deemed relevant to the assessment of performance” NOT punishment MCPP Healthcare Consulting

10 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

11 Principles of Quality Management
4/6/2017 Principles of Quality Management Know your stakeholders and what they need Focus on processes Use data for making decisions Understand variation in processes Use teamwork to improve work Make quality improvement continuous Demonstrate leadership commitment MCPP Healthcare Consulting MCPP Healthcare Consulting 11

12 Learning and Improvement Cycle
4/6/2017 Learning and Improvement Cycle Plan Objective Questions and predictions Plan to carry out the cycle (who, what, where, when) Plan for data collection Act What changes are to be made? Next cycle? DOCUMENTATION OF CHANGE - MINUTES REVISE LOGIC MODEL LOGIC MODEL REVISE LOGIC MODEL Study Complete the data analysis Compare data to predictions Summarize lessons Do Carry out the plan Document problems and unexpected observations Begin analysis of the data DATA REPORT WORK PLAN MCPP Healthcare Consulting MCPP Healthcare Consulting 12

13 Tools to Link Work and Outcomes
4/6/2017 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 MCPP Healthcare Consulting MCPP Healthcare Consulting 13

14 Adopt or Adapt Model Practices
4/6/2017 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, Other industries Describe your process (Logic Model or Flow Chart) Study the exemplary practice process Adopt or adapt as appropriate MCPP Healthcare Consulting MCPP Healthcare Consulting 14

15 Reporting Progress 4th 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 MCPP Healthcare Consulting

16 Stages of Organizational Performance
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17 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 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 MCPP Healthcare Consulting

18 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 MCPP Healthcare Consulting 18 18

19 Correlation of Budget to Performance
Slight correlation and relationship between annual budget and overall performance in the Standards MCPP Healthcare Consulting 19 19

20 Correlation of Per Capita Budget
No correlation or relationship of per capita budget to overall performance in the Standards MCPP Healthcare Consulting 20 20 20

21 Building QI into Your Culture
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22 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 MCPP Healthcare Consulting

23 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 MCPP Healthcare Consulting

24 Demonstrate Leadership Commitment
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 MCPP Healthcare Consulting

25 Demonstrate Leadership Commitment
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 MCPP Healthcare Consulting

26 QI Infrastructure Governance (formal/informal) Program structure
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 MCPP Healthcare Consulting

27 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 MCPP Healthcare Consulting

28 Tacoma-Pierce County Health Department Quality Improvement (QI) Initiative

29 QI Time Line at TPCHD MCPP Healthcare Consulting

30 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 Training focuses on descriptions of Model for Improvement, PDSA cycles and gives some examples of common QI tools used. We have a quality planning training in Sep for one of our teams. MCPP Healthcare Consulting 30

31 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 important MCPP Healthcare Consulting

32 QI Plan and Evaluation Annual QI plan Annual evaluation of 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 QI plan includes description of roles/responsibilities and major program activities of the council—quarterly review of the Dept’s work plan, reviewing RCI projects, looking at key health indicators for Pierce County residents, and reviewing program evaluation results. MCPP Healthcare Consulting 32

33 Quarterly Reporting Form
Plan Item Name/No. Indicator(s) Baseline Data (if applicable) Quarterly Data Data Source Methods Notes Data Explanation/Other Comments MCPP Healthcare Consulting

34 MCPP Healthcare Consulting

35 QI Calendar (TPCHD example)
III 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 Sherman Nov 23 Sep 22 (interim report) Nov 24 (final report) B. TPCHD Performance Measures See Section II B Jul 31 Oct 31 Jan 31, 2010 Aug 25 Nov 24 Feb 23, 2010 Mar 3, 2010 (BOH) C. QI Projects at Request of Director 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* MCPP Healthcare Consulting

36 Performance Measures Twelve department-level measures
Modeled after Healthy People 2010 Leading Health Indicators plus two more Approx 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 MCPP Healthcare Consulting

37 TPCHD Performance Measures
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. Nigel Turner Reduce tobacco use Decrease the percentage of adult smokers to 16% by 2014. Rick Porso 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. David Vance Increase responsible sexual behavior Increase the percentage of sexual partners treated for sexually transmitted diseases by 10% by 2014. Increase access to care Increase the number of children enrolled annually in health insurance programs by 42% by 2014. 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. Improve mental health Decrease adult mental health problems in 20% of families provided TPCHD evidenced-based program services by 2014. 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. MCPP Healthcare Consulting

38 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 MCPP Healthcare Consulting

39 STD Reporting of Race/Ethnicity
First RCI Project STD Reporting of Race/Ethnicity Collected data to identify “root cause” of problem Pilot tested an education intervention Interdisciplinary team approach; clear prioritization from management cleared use of resources We learned some valuable lessons, clarified some assumptions around this issue, and validated the importance of our Network Nurse model in communicating with providers. MCPP Healthcare Consulting

40 Final On-Site Septic System Inspections
Second RCI Project Final On-Site Septic System Inspections Collected data to identify “root causes” of problem Re-prioritized work duties Monitored work flow MCPP Healthcare Consulting

41 MCPP Healthcare Consulting

42 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 In 2008 the QI Council selected 14 performance measures to track and report each quarter to demonstrate progress toward the department’s goals and objectives. 79% of those measures achieved their selected target/benchmark. Each TPCHD business unit also tracks and reports performance measures to monitor progress toward program objectives. At the end of 2008, 87% of these program-level measures showed progress toward or had achieved the target/benchmark. MCPP Healthcare Consulting 42

43 Washington State Department of Health Quality Improvement (QI) Initiative
43

44 PM System and QI Structure
Performance Management System QI Structure Organizational Strategic Planning Quality Steering Committee Performance Management and Accountability PALS (Performance Accountability Liaisons) This approach is consistent with the Baldrige National Quality Award and Washington State Quality Award (WSQA) frameworks for pursuing and achieving organizational excellence in seven criteria categories: Leadership; Strategic Planning; Customer and Market Focus; Measurement, Analysis and Knowledge; Workforce Focus; Process Management; and Organizational Results. These various components of the agency’s vision of always working for a safer and healthier Washington work together in a continuous cycle, moving the agency toward its goals as illustrated in the handout. Project Mgmt. Resource Team Operational/Business Planning and Performance Process Improvement Teams Focused Quality Improvement Efforts 44

45 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 Quality Steering Committee Quality Steering Committee – At the executive level provides agency oversight and guidance for performance management activities Primary responsibilities include review and approval of the agency QI plan annually Encouraging and fostering a supportive QI environment Championing QI activities, tools and techniques Selecting and supporting agency QI projects MCPP Healthcare Consulting 45

46 The Quality Improvement Process
Step #1: Clarify the purpose. Step #2: Select & build the team. Step #3: Examine the process. Step #4: Analyze data and generate solutions. Step #5: Take appropriate action. Step #6: Provide closure. We are using a simple 6 step process: Clarify the purpose Select and build the team Examine the process Analyze data and generate solutions Take appropriate action Provide closure MCPP Healthcare Consulting 46

47 Integration of QI into Agency Culture
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48 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 MCPP Healthcare Consulting

49 Levels of QI Integration
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50 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 agency Bill Riley and Russell Brewer MCPP Healthcare Consulting

51 Actions to Prepare for an Accreditation Review
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52 Establish HD Workgroup
Assign coordinator for preparation project ( 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 MCPP Healthcare Consulting

53 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 MCPP Healthcare Consulting

54 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! MCPP Healthcare Consulting

55 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 MCPP Healthcare Consulting

56 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.

57 MindManager Overview A look at the big picture.

58 MindManager Overview “Read Me” Text
Read Me file serves as an introduction or overview and allows you to provide explanations, e.g. how you met the standard.

59 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 MCPP Healthcare Consulting

60 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%) MCPP Healthcare Consulting

61 4/6/2017 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 MCPP Healthcare Consulting MCPP Healthcare Consulting 61

62 What questions do you have?
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