performance management and qi principles and strategies minnesota’s department of health (mdh) and...
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PERFORMANCE MANAGEMENT AND QI PRINCIPLES AND STRATEGIES
MINNESOTA’S DEPARTMENT OF HEALTH (MDH) AND COMMUNITY HEALTH BOARDS JANUARY 10, 2011
MarMason Consulting
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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 AwardMarMason Consulting
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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 7th) 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 28th)
Sessions # 4 & 5: Topics TBDMarMason Consulting
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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
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Performance Management
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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
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Performance Management
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Source: Turning Point Performance Management Collaborative, 2003.
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Performance Standards
Establish performance standardsPublic Health Accreditation Board (PHAB) standardsNational Public Health Performance Standards (CDC)
Establish and define outcomes and indicatorsProcess outcomesHealth outcomes
PERFORMANCE STANDARDS
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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
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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.
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
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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
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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
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Integration of QI into Agency Culture12
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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
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*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
0
25
50
75
100
Level 1- No interest or activities
Level 2-Awareness, interest and
one-time projects
Level 3- Multiple
teams and QI tools, but no
repetition or
saturation
Level 4- Speciic QI
model integrated
into agency management
structure with
continuous improvement
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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 [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
agencyMarMason Consulting
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Bill Riley and Russell Brewer
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Poll Question
How would you describe level of quality improvement integration in your organization? A. Level 1: No interest or activityB. 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
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Let’s Discuss!
What is your experience with the four components of performance management in your Health Department?
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QI Principles and Strategies
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The Quality Environment
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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?
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Principles of Quality Management
1. Know your stakeholders and what they need
2. Focus on processes3. Use data for making decisions4. Use teamwork to improve work5. Make quality improvement continuous6. Demonstrate leadership commitment
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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
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Public Sector Map
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School Boards
•Public schools•BIA schools•Charter schools
•Private faith based schools
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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”
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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
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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
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The Logic of Public Health
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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
So that
So that
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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
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Poll Question
How frequently do you/your organization use data to target improvement efforts? A. RarelyB. SometimesC. OftenD. Always
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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 Tools Numerical Tools
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MarMason Consulting[See Goal/QPC PH Memory Joggers]
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Power of Root Cause AnalysisW. 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.
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* The Public Health Quality Improvement Handbook, page 22
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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?
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PoorHIV Testing
ClientTest 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
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Example of Fishbone
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WIC clients do not redeem all of
the farmer’s market coupons
People Access
Page 1
WIC Client Redemption of Farmer’s Market Coupons
Methods Materials
Customer Service
PersonalCultural
Hours
Knowledge Deficit
Language
Variety/Selection
Preferences
Client has more distractions in the summer
Limited WIC Providers
Locations
Small dollar value
No change is given
Distribution
Frequency Timing
Staff explanations of Farmer’s Market option
Limited supply
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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
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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
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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”
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*PH Memory Jogger page 12
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Uptake of Vaccines Example (Kittitas, WA)
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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
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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
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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 MODELLOGIC MODELREVISE LOGIC MODEL
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PDSA Improvement Cycle
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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
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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
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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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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
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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
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Agency Level Performance Measures
Measure 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.
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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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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Embracing Quality in Local Public Health: Michigan’s Quality Improvement Guidebook, 2008, www.accreditation.localhealth.net
Public Health Memory Jogger, GOAL/QPC, 2007, www.goalqpc.com
Breakthrough Method and Rapid Cycle Improvement www.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
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
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What questions do you have?
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