1. PERFORMANCE MANAGEMENT AND QI PRINCIPLES AND STRATEGIES MINNESOTA’S DEPARTMENT OF HEALTH (MDH) AND COMMUNITY HEALTH BOARDS JANUARY 10, 2011 MarMason Consulting

2. 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 Award MarMason Consulting 2

3. 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 7 th )  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 28 th )  Sessions # 4 & 5: Topics TBD MarMason Consulting 3

4. 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 MarMason Consulting 4

5. Performance Management MarMason Consulting 5 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

6. Performance Management MarMason Consulting 6 Source: Turning Point Performance Management Collaborative, 2003.

7. Performance Standards Establish performance standards  Public Health Accreditation Board (PHAB) standards  National Public Health Performance Standards (CDC) Establish and define outcomes and indicators  Process outcomes  Health outcomes PERFORMANCE STANDARDS

8. 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

9. 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

10. 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

11. 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

12. Integration of QI into Agency Culture 12 MarMason Consulting

13. 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 MarMason Consulting 13 * Bill Riley and Russell Brewer, Review and Analysis of QI Techniques in Police Departments, JPHMP Mar/April 2009

14. Levels of QI Integration MarMason Consulting 14

15. 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 agency MarMason Consulting 15 Bill Riley and Russell Brewer

16. Poll Question How would you describe level of quality improvement integration in your organization? A. Level 1: No interest or activity B. 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

17. Let’s Discuss! What is your experience with the four components of performance management in your Health Department? MarMason Consulting 17

18. QI Principles and Strategies 18 MarMason Consulting

19. The Quality Environment MarMason Consulting 19  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?

20. MarMason Consulting 20 Principles of Quality Management 1.Know your stakeholders and what they need 2.Focus on processes 3.Use data for making decisions 4.Use teamwork to improve work 5.Make quality improvement continuous 6.Demonstrate leadership commitment

21. 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 MarMason Consulting 21

22. Public Sector Map MarMason Consulting 22 Department of Defense Tri-Care Prime Office of the Insurance Commissioner Governor / Legislature Office of the Superintendent of Public Instruction Health Care Authority Public Employees Benefit Board Basic Health Plan Department of Veterans Affairs Department of Labor & Industries Public Library System Head Start Programs Employment Security Department Worksource National Institute of Health Dept. of Corrections Prisons State Board of Health Local Governments Local Health Jurisdictions Public Hospital Districts Department of Health Chronic Disease & Risk Reduction Diabetes Prevention & Control Community & Rural Health Community & Family Health Maternal Support Srvcs Women, Infants & Children Licensing Boards Dept. of Social & Human Services Aging & Adult Services Med. Asst. Admin Division of Developmental Disabilities. Mental Health Division These are examples of partners in the public health system: Bold= Large agency or organization, Italics= Type of organization, not a specific entity, Regular= Specific organization or entity Bullets refer to examples of organizations and are not a comprehensive listing. School Boards Public schools BIA schools Charter schools Private faith based schools

23. 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” 23 MarMason Consulting

24. 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

25. 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

26. The Logic of Public Health MarMason Consulting 26 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

28. 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 28 MarMason Consulting

29. Poll Question How frequently do you/your organization use data to target improvement efforts? A. Rarely B. Sometimes C. Often D. Always

30. 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 ToolsNumerical Tools 30 MarMason Consulting [See Goal/QPC PH Memory Joggers]

31. Power of Root Cause Analysis W. 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. MarMason Consulting 31 * The Public Health Quality Improvement Handbook, page 22

32. 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? MarMason Consulting 32

33. Poor HIV Testing Client Test 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

34. Example of Fishbone MarMason Consulting 34

35. 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 35 MarMason Consulting

36. 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 MarMason Consulting 36

37. 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” MarMason Consulting 37 *PH Memory Jogger page 12

38. Uptake of Vaccines Example (Kittitas, WA) MarMason Consulting 38

39. 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 MarMason Consulting 39

40. 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 MarMason Consulting 40

41. 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 MODEL LOGIC MODEL REVISE LOGIC MODEL MarMason Consulting 41 PDSA Improvement Cycle

42. 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

43. 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 MarMason Consulting 43

44. 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 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 MarMason Consulting 44

45. 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 45 MarMason Consulting

46. 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 MarMason Consulting 46

47. Agency Level Performance Measures MeasureIndicatorResponsibility 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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49. 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 MarMason Consulting 49

50.  Embracing Quality in Local Public Health: Michigan’s Quality Improvement Guidebook, 2008, www.accreditation.localhealth.netwww.accreditation.localhealth.net  Public Health Memory Jogger, GOAL/QPC, 2007, www.goalqpc.comwww.goalqpc.com  Breakthrough Method and Rapid Cycle Improvement www.ihi.orgwww.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 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

51. What questions do you have? MarMason Consulting 51