Healthcare Management for Local Councils by fjm15005

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									PERFORMANCE
MANAGEMENT AND
BUILDING QI INTO YOUR
AGENCY CULTURE
MCPP Healthcare Consulting
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 (2008-
      2009)
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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




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Performance Management


        Standards for
        Public Health
                                 QI Plans &
                                  Councils



                                              QI Methods
                                                & Tools
     Improving PH            Business
       processes             Process
                             Analysis




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Performance Management




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Application of P-D-S-A




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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




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Performance Measurement
2nd Quadrant




Monitoring of
Performance                   Monitoring of
• Results of review of        Indicators and
  performance                 Outcomes
  (Accreditation/Self-
  Assessment) against local   • Process and intermediate
  and state Standards           outcomes
• Program evaluation          • Health status indicators
  results




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Performance Measurement Definitions




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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
Principles of Quality Management

1.     Know your stakeholders and what they need
2.     Focus on processes
3.     Use data for making decisions
4.     Understand variation in processes
5.     Use teamwork to improve work
6.     Make quality improvement continuous
7.     Demonstrate leadership commitment

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    Learning and Improvement Cycle
   Act                             Plan
                                   • Objective
   • What changes are to           • Questions and predictions
     be made?                      • Plan to carry out the cycle
   • Next cycle?                     (who, what, where, when)
                                   • Plan for data collection
   DOCUMENTATION OF                 LOGIC LOGIC MODEL
                                   REVISE MODEL
                                  REVISE LOGIC MODEL
   CHANGE - MINUTES




   Study                           Do
    •Complete the data analysis    • Carry out the plan
    •Compare data to               • Document problems and
     predictions                     unexpected observations
    •Summarize lessons             • Begin analysis of the data
   DATA REPORT                     WORK PLAN
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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




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    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
               Other industries

             Describe your process (Logic Model or Flow Chart)
             Study the exemplary practice process
             Adopt or adapt as appropriate
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Reporting Progress
4th Quadrant

   Reporting of Performance (Local and State
    Standards and Program Evaluation)
   Reporting of Indicators and Outcomes
     HealthIndicators
     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
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Stages of Organizational
Performance
      Infrastructure                   Process        Coordination             Results


      Leadership &              Assessment          Communication         Program
       Decision making            processes            mechanisms             evaluation
      Boards of Health          CD investigation    Public and             results
      Policies &                 case write-ups       private work on       Key
       Procedures                EH enforcement       access to services     indicator
      Enforcement/               action and case     Hand-offs              outcomes
       Investigation              files                between local          (CD/EH/PP)
       Protocols                 Education            health and state      Financial
      Financial                  sessions             programs               performance
       management                Work of
      Information &              community
       reporting                  groups and
      Set of Core                coalitions
       Indicators
      Program
       performance
       goals/ objectives


                    Program Maturity



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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
    2008 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

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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
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 Correlation of Budget to Performance

Slight correlation
and relationship
between annual
budget and
overall
performance in
the Standards


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 Correlation of Per Capita Budget

No correlation
or relationship
of per capita
budget to
overall
performance in
the Standards


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                                    20
         Building QI into Your Culture




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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
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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
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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



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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



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QI Infrastructure
   Governance (formal/informal)
     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
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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



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TACOMA-PIERCE COUNTY
HEALTH DEPARTMENT
QUALITY IMPROVEMENT (QI)
INITIATIVE
QI Time Line at TPCHD




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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
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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

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QI Plan and Evaluation
   Annual 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
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Quarterly Reporting Form
   Plan Item Name/No.
   Indicator(s)
   Baseline Data (if applicable)
   Quarterly Data
   Data Source
   Methods Notes
   Data Explanation/Other Comments


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       QI Calendar (TPCHD example)

                                           III. 2009 Quality Improvement Council Calendar
                                        Staff Responsible Completion Date QI Council Review             Additional
                                                                                Date                   Review Dates
          A. Rapid Cycle
           Improvement Projects
            Purchasing                     Marcy Kulland        Sep 21        Sep 22 (final report)       TBD (BOH)
            Solid waste code               John Sherman                      Sep 22 (interim report)      TBD (BOH)
            enforcement complaint                               Nov 23        Nov 24 (final report)
            resolution
          B. TPCHD Performance            See Section II B       Jul 31            Aug 25
             Measures                                            Oct 31            Nov 24              Mar 3, 2010 (BOH)
                                                              Jan 31, 2010       Feb 23, 2010
          C. QI Projects at Request            TBD               TBD                  TBD                    TBD
            of Director
          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       Nigel Turner         Jul 31*           Aug 25
            (Review of performance          (Chlamydia)          Oct 31            Nov 24              Mar 3, 2010 (BOH)
            measures in Table 2)         David Vance (LBW)    Jan 31, 2010       Feb 23, 2010
                                          Rick Porso (Adult
                                              Obesity)
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Performance Measures
   Twelve department-level measures
       Modeled after Healthy People 2010 Leading Health
        Indicators . . . plus two more
   Approx. 10-20 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

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       TPCHD Performance Measures
          Measure                 Indicator                                                                 Responsibility
          Improve immunization     Increase the percentage of kindergarten enrollees that are up to date Nigel Turner
          rates                    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.              Rick Porso
          Reduce overweight &      Reduce the rate of increase for adult obesity to 0% by 2014.             Rick Porso
          obese populations
          Increase healthy        Increase the percent of youth who are physically active for at least 60   Rick Porso
          physical activity       minutes per day from 16.8% to 18.5% by 2014.
          Reduce substance         Increase the number of adults receiving opiate treatment service by      David Vance
          abuse                    23% by 2014, to 800 patients.
          Increase responsible    Increase the percentage of sexual partners treated for sexually           Nigel Turner
          sexual behavior         transmitted diseases by 10% by 2014.
          Increase access to       Increase the number of children enrolled annually in health              David Vance
          care                     insurance programs by 42% by 2014.
          Decrease injury and      Reduce youth violence risk factors among 75% of youth who                David Vance
          violence                 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         David Vance
                                  TPCHD evidenced-based program services by 2014.
          Improve environmental Increase the percent of water systems that meet drinking water              Steve Marek
          quality                 standards from 80% to 90% by 2014.
          Effectively respond to Respond within one hour in 100% of situations where TPCHD                  Joby Winans
          public health          receives a notice of need for public health response to an incident
          emergencies            within Pierce County.
          Decrease rates of key   Increase the percent of ten key communicable diseases for which the Nigel Turner
          communicable            trend in incidence rate is flat or decreasing from 38% to 50% by
          diseases                2014.

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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

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First RCI Project
                     STD Reporting of Race/Ethnicity

                                                  Percent of STD Case Reports That Include
   1. Collected data to                      80
                                                     Race Data (Among Pilot Providers)

      identify “root                         70

      cause” of
                                             60



                                   Percent
                                             50                                  74
      problem                                40
                                             30             55
                                             20
   2. Pilot tested an                        10
                                              0
      education                                            Pre                  Post

      intervention
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Second RCI Project
              Final On-Site Septic System Inspections

   1. Collected data to                         Percent of Septic Systems That Received a

      identify “root                      100
                                                             Final Inspection


      causes” of                           90
                                           80




                                Percent
                                           70
      problem                              60                                   94
                                           50
                                           40              70
   2. Re-prioritized                       30
                                           20
      work duties                          10
                                            0
                                                          Pre                  Post
   3. Monitored work
      flow
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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
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WASHINGTON STATE
DEPARTMENT OF HEALTH
QUALITY IMPROVEMENT (QI)
INITIATIVE
   PM System and QI Structure
Performance Management System           QI Structure

       Organizational                Quality Steering
      Strategic Planning               Committee

       Performance
                                              PALS
       Management               (Performance Accountability Liaisons)
     and Accountability


     Operational/Business              Project Mgmt.
   Planning and Performance            Resource Team



       Focused Quality                 Process
     Improvement Efforts          Improvement Teams
Quality Improvement Organizational
Structure

                             Quality Steering
                               Committee

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




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The Quality
Improvement Process

  Step #1:                     Step #2:             Step #3:
  Clarify the                Select & build        Examine the
   purpose.                    the team.             process.




             Step #4:                 Step #5:         Step #6:
            Analyze data                Take            Provide
            and generate             appropriate        closure.
             solutions.                action.



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                             Integration of QI into
                             Agency Culture
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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


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Levels of QI Integration

   100

                                                                       Level 4-
     75                                                              Speciic QI
                                                                        model
                                                                     integrated
                                                       Level 3-     into agency
                                                                   management
     50                                                Multiple
                                                                      structure
                                                     teams and
                                                                         with
                                                       QI tools,
                                        Level 2-                    continuous
                                                        but no
                                      Awareness,                   improvement
     25                               interest and
                                                      repetition
                                                           or
                        Level 1- No     one-time
                                                     saturation
                        interest or     projects
                         activities
       0


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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


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                             ACTIONS TO PREPARE FOR
                             AN ACCREDITATION
                             REVIEW
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Establish HD Workgroup
   Assign coordinator for preparation project (12-18
    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

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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




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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!


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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



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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.
MindManager
Overview
A look at the big picture.
MindManager Overview




                       “Read Me” Text
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




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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%)

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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

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What questions do you have?




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