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Overview of Domain 9 - California Department of Public Health

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					PHAB Standards & Measures: Domain 9




                             Pooja Verma, MPH
                               Program Analyst
                              Accreditation & QI
                                      NACCHO
PHAB Domain 9: Performance Management & QI


Domain 9 includes two standards:

   Standard 9.1: Use a Performance Management
   System to Monitor Achievement of Organization
   Objectives
   Standard 9.2: Develop and Implement Quality
   Improvement Processes Integrated into Organization
   Practice, Programs, Processes, and Interventions
Performance Management System




    Source: Turning Point Performance Management Collaborative, 2003.
9.1.1A: Engage staff at all organization levels in
establishing or updating a PM system

Required documentation:
1. Engaging leadership/management in establishing or
   updating a performance management system


2. Engaging staff at all other levels in establishing or
   updating a performance management system
9.1.2 A: Implement a performance system


Required documentation:
1. A completed Performance Management self-assessment
    a) Turning Point Performance Management National
       Excellence Collaborative
    b) Baldrige Performance Excellence Program


2. A current, functioning performance management
   committee or team
9.1.3 A: Use a process to report on achievement of
goals, objectives, and measures set by the PM system

Required documentation:
1. Written goals and objectives which
   include time frames for measurement
    a) Programmatic example
    b) Administrative example


2. Demonstration of a process for monitoring
   performance of goals and objectives
9.1.3 A: Use a process to report on achievement of
goals, objectives, and measures set by the PM system

Required documentation:
1. Analysis of progress toward achieving goals and
   objectives, and identify areas for improvement
    a) Programmatic example
    b) Administrative example


2. Documentation of results and next steps
9.1.4 A: Implement a systematic process for assessing
customer satisfaction with health department services
Required documentation:
1. Description of the process used to collect and
   analyze feedback from 2 difference customer
   groups
    a) Collect – surveys, forms, etc.
    b) Analyze – narrative, reports, memo
9.1.5 A: Provide staff development opportunities
regarding performance management
Required documentation:
1. Documentation of staff development in
   performance management
     Those directly involved with implementing the
      PM system must be trained
     Training rosters, curriculum, presentations,
      consultants, TA, etc.
Performance Management Resources


•   Performance Management Self-Assessment Tool:
    http://www.collaborativeleadership.org/pages/pdfs/CL_self-
    assessments_lores.pdf
•   Turning Point Resources:
    http://www.turningpointprogram.org/Pages/perfmgt.html
•   PHF’s Performance Management & QI Website:
    http://www.phf.org/focusareas/PMQI/Pages/default.aspx
•   Public Health Performance Management Centers for Excellence:
    http://www.doh.wa.gov/PHIP/perfmgtcenters/index.htm
 PHAB Standard 9.2


Develop and improve quality improvement processes
integrated into organizational, practice, programs, processes,
and interventions
Measure 9.2.1: Establish a QI program based on organizational
policies and direction

Measure 9.2.2: Implement QI activities
Quality Improvement

 The use of a deliberate and defined improvement
 process 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. *


   * Definition developed by the Accreditation Coalition Workgroup
   and approved by the Accreditation Coalition on June 2009
9.2.1 A: Establish a QI program based on
organization policies and direction

                          QI Plan

           I. Definitions of quality terms
                i. QI
                ii. PDCA
                iii. …..
           II. Desired future state of quality

          III. Key elements of QI governance
                i. Structure
                ii. Membership
                iii. Roles/responsibilities
                iv. Staffing support
                v. Resources
9.2.1 A: Establish a QI program based on
organization policies and direction

                       QI Plan

          IV. QI training

           V. Project selection and alignment
              with strategic plan

           VI. Goals, objectives, measures, and
             time-framed targets
                 i. Performance measures
                ii. Person(s) responsible/timeframes
               iii. Activities/projects
               iv. Prioritization process
9.2.1 A: Establish a QI program based on
organization policies and direction

                          QI Plan

           VII. Monitoring and reporting

           VIII. Ongoing communication
                   i. Storyboards
                 ii. Staff meeting updates
                 iii. Board of Health meeting minutes
                 iv. ……..

           VI. Evaluate QI plan
                  i. Progress toward G&Os
                 ii. Lessons learned
                iii. Revise/update
9.2.2 A: Implement quality improvement
activities

Required documentation:


1. Documentation of QI activities based on QI plan
    a) Programmatic example         Project work plans,
    b) Administrative example       storyboards, etc.
9.2.2 A: Implement quality improvement
activities

Required documentation:
2. Demonstrate staff participation in QI activities based on
   the QI plan
    a)   Meeting minutes
    b)   Memos
    c)   Reports
    d)   Committee or project responsibilities listings
 NACCHO QI TA & Resources:
 www.naccho.org/QI

• Roadmap to   an Organizational Culture of QI

• Example QI plans and templates

• Stories of Measurable Improvement in Public Health Database

• QI 101 “Ready-made” Training for Staff

• ABCs of PDCA Guide

• Example QI storyboards and case examples
Thank You!



                 Pooja Verma
              Accreditation & QI
                  NACCHO
               (202) 507-4206
             pverma@naccho.org
              www.naccho.org/QI

				
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