Public Health Performance Management

1
Public HealthPerformance Management

• Turning Point
• Performance Management National Excellence
  Collaborative
• April 2004

Public Health Performance Management
Curriculum Prepared by Center for Public Health
Practice, UIC School of Public Health
2
Genesis

• Turning Point Performance Management National
  Excellence Collaborative States (AK, IL, MO, MT,
  NH, NY, WV)
• ..to move the field of public health from simply
  measuring performance of individual programs to
  actively measuring and managing the performance
  of an entire agency or system.
• ..from managing silos to managing a system

Source Silos to Systems Using Performance
Management to Improve the Publics Health.
Turning Point Performance Management National
Excellence Collaborative Seattle WA Turning
Point National Program, 2003.
3
Learning Objectives

• Define and describe the key concepts and
  components of performance management
• Identify performance management concepts and
  components in a variety of public health
  organization and system applications
• Describe potential benefits of performance
  management across a range of public health
  organization and system applications
• Assess and enhance performance management
  practices and opportunities in public health work
  settings

4
Todays Program

• Introduction (10 min)
• Pre-Test (10 min)
• Performance Management 101 (50-60 min)
• Applications of Performance Management in Public
  Health Practice (50-60 min)
• Case Studies (60-240 min)
• Review and Summary (45 min)
• Post-Test/Course Evaluation (15 min)

5
Part IIPre-Test
6
Part IIIPerformance Management 101
7
The Words

• Performance
• Execution, Accomplishment, Completion,
  Effectuation
• Management
• Supervision, Direction, Control, Manipulation

8
Basic Concepts

• Performance Management
• Control/Manipulation towards Accomplishment
• Key considerations
• Who or what performs? (subject who/what)
• What is performed? (object do what)

9
Focus on Performance

• Marathon Runner
• Unit Supervisor
• Program Manager
• State Health Agency
• State-Local Public Agency Network
• National Health Priority Initiative
• National Public Health System
• Community Health Improvement Process
• Public Health Workforce Development

10
Managing Performance (Ex 1)

• Marathon Runner
• trains 5x per week at various distances
• records times
• seeks to better last years time

11
Managing Performance (Ex 2)

• Unit Supervisor
• meets with employees annually to review job
  performance and set expectations for next year
• next years salary increment is tied to this
  years job performance?

12
Managing Performance (Ex 3)

• Program Manager
• establishes objectives
• reports quarterly
• seeks continuation funding year after year

13
Common Elementsfrom These Simple Examples?

• Subjects (who or what is to perform) and Objects
  (what is to be accomplished)
• Goals or targets (level of accomplishment)
• Information about performance
• Collection of information
• Modifications/Changes possible

14
Key Components of Performance Management

• Applying Appropriate Standards
• Measuring Key Aspects of Performance
• Reporting and Interpreting Measurements
• Making Changes Based on Measures of Performance

15
Critical components of performance management
Source Silos to Systems Using Performance
Management to Improve the Publics Health.
Turning Point Performance Management National
Excellence Collaborative Seattle WA Turning
Point National Program, 2003.
16

• In the performance management cycle...
• All components should be driven by the public
  health mission and organizational strategy
• Activities should be integrated into routine
  public health practices
• The goal is continuous performance and quality
  improvement

Source Silos to Systems Using Performance
Management to Improve the Publics Health.
Turning Point Performance Management National
Excellence Collaborative Seattle WA Turning
Point National Program, 2003.
17
Arent Performance Managementand Performance
Measurement the Same Thing?

18
Performance Measurement

• The regular collection and reporting of data to
  track work produced and results
  achieved.
• Caution! Some view Performance Measurement as
  only the first 3 components of Performance
  Management

Source Liachello P. Guidebook for Performance
Measurement. Seattle WA Turning Point National
Program Office, 199948. Based on Hatry HP et al,
Monitoring the Outcomes of Economic Development
Programs. Washington DC The Urban Institute
Press, 1990.
19
Terminology

• Performance Measure
• A specific quantitative representation of a
  capacity, process, or outcome deemed relevant to
  the assessment of performance (a generic term
  that includes standards, targets, indicators)
• Performance Standard
• Standards are one form of performance measure
  they are generally objective standards or
  guidelines that are used to assess performance.
• Performance Target
• The planned or expected level of performance
• Performance Indicator
• Indicators are another form of performance
  measure they are the data or information that is
  used to assess progress toward a performance
  standard

20
Different Indicators Used to Measure Performance
(Staff Competency)
21
Managers Can UsePerformance Measures to

• Identify aspects of the work that have and have
  not resulted in satisfactory results
• Identify trends
• Further investigate the nature of particular
  problems
• Set targets for future periods
• Motivate managers and staff to improve
  performance
• Hold managers and staff accountable
• Develop and improve programs and policies
• Help design policies and budgets and explain
  these to stakeholders

Source Liachello P. Guidebook for Performance
Measurement. Seattle WA Turning Point National
Program Office, 199948. Based on Hatry HP et al,
Monitoring the Outcomes of Economic Development
Programs. Washington DC The Urban Institute
Press, 1990.
22
Performance Management

• Performance Management is what you do with the
  information youve developed from measuring
  performance.

Source Liachello P. Guidebook for Performance
Measurement. Seattle WA Turning Point National
Program Office, 1999.
23
Critical components of performance management
Source Silos to Systems Using Performance
Management to Improve the Publics Health.
Turning Point Performance Management National
Excellence Collaborative Seattle WA Turning
Point National Program, 2003.
24
Applying Appropriate Standards

• Identify and apply relevant standards
• Standards are one form of performance measure
  they are generally objective standards or
  guidelines that are used to assess performance.
• Identify appropriate indicators
• Indicators are another form of performance
  measure they are the data or information that is
  used to assess progress toward a performance
  standard.
• Set goals and targets
• The planned or expected level of performance
• Communicate expectations

25
Is there a Performance Standards component?

• Have performance goals and targets been
  established, and appropriate indicators
  identified?
• Do these benchmark against similar organizations
  or use national, state, or scientific guidelines?
• Are expectations communicated?

26
Measuring Performance

• Relies on indicators that document where
  performance is in relation to the target or
  standard
• Develop data systems
• Collect data

27
Is there a Performance Measurement component?

• Have the indicators been refined?
• Have data systems been developed?
• Has data been collected?

28
Reporting Progress

• Analyze data
• Convert data into useable information
• Feedback to managers, staff, policy makers, and
  constituents
• Develop a regular reporting cycle

29
Reporting Progress

• Provide context for the report
• How do the performance measures relate to mission
  and goals
• Create clear, easy to read, report designs
• Use simple charts and tables
• Determine Reporting Frequency
• When and how often

30
Is there a Reporting of Progress component?

• Are data analyzed?
• Are data fed back to managers, staff,
  constituents, etc. in useable and understandable
  format?
• Is there a regular reporting cycle in place?

31
Improving Quality

• Establish a program or process to manage change
  and achieve quality improvement in public health
  policies, practice and infrastructure based on
  what is learned through performance measures
• Use data for decisions to improve policies,
  programs, and outcomes
• Manage change
• Create a learning organization

32
Is there a Quality Improvement component?

• Where is the change process?
• Is there a process to manage changes being made?
• Is there a learning organization?

33
For SuccessfulPerformance Management

• All four Performance Management components must
  be present!
• And they must be integrated into the
  organizations or systems core operations!

34
Concepts and Componentsto Assess in Examples

• Something needing improvement (is/is not)
  clearly identified
• Goals or targets for improvement (are/are not)
  established
• Appropriate measures of performance (are/are not)
  collected
• Reports of measurements (do/do not) reach the
  proper parties
• Information from measurements (are/are not) used
  to make improvements

35
Summary - Example 1
36
Summary - Example 2
37
Summary Example 3
38
Summary - Examples 1-3
39
OK, Sounds Simple Enough! But How Does This
Workfor More Complex Examples?

40
Part IVApplications of Performance
Management in Public Health Practice
41
Public HealthPerformance Measures

• Quantitative measures of capacities, processes,
  or outcomes relevant to the assessment of public
  health performance
• Ex The number of trained epidemiologists
  available to investigate outbreaks (capacity
  measure)
• Ex The percentage of notifiable diseases reports
  submitted within the required time lines (process
  measure)
• Ex Percentage of clients who rate health
  department services as good or excellent
  (outcome measure)

42
Conceptual Framework of the Public Health
System as a Basis for
Measuring Public Health System Performance
P
U
B
Structural Capacity
L
-----------------
M
I
Information Resources
A
C
Organizational Resources
Physical Resources
C
Human Resources
R
H
Fiscal Resources
O
E
A
PHS Mission
C
L
and Purpose
O
T
----------------
Philosophy
N
H
Goals
T
"Core Functions"
Outcomes
Processes
E
S
---------------
-------------------
X
Y
The 10 Essential
Effectiveness
T
S
Public Health
Efficiency
T
Services
Equity
E
M
Source Handler A, Issel M, and Turnock B. 2001.
A conceptual framework to measure performance of
the public health system. Am J Public Health,
911235-1239.
43
Conceptual Framework of the Public Health
System as a Basis for
Measuring Public Health System Performance
Source Handler A, Issel M, and Turnock B. 2001.
A conceptual framework to measure performance of
the public health system. Am J Public Health,
911235-1239.
44
Public Health Performance Measures Capacity,
Process, and Outcomes
Process (Essential Public Health Services)
Capacity
Outcomes
Outputs
Key Processes
Improved organizational performance Improved
program performance
Develop Policy
Improved Outcomes Customer Satisfaction
Increased Value Public Support
Source Turnock BJ. Public Health What It Is
and How It Works, 3rd Edition. Boston MA Jones
Bartlett, 2004.
45
Performance Management in Public Health Practice

• Active and strategic use of performance measures
  to improve the publics health through managing
  public health capacity and processes
• Achieving Healthy People 2010 national health
  goals and objectives
• Improving public health organization and system
  performance (core functions, essential public
  health services, capacity, preparedness, etc.)

46
Public Health Applications

• Human resource development
• Data and information systems
• Customer focus and satisfaction
• Financial systems
• Management practices
• Public Health capacity
• Health status

47
Nearly All SHAs Have Some PerformanceManagement
EffortsHowever, only about half apply
performance management efforts statewide beyond
categorical programs

• Figure 1. Agencies or programs to which SHAs
  apply performance management efforts (N47)

Source Turning Point Survey on Performance
Management Practices in States Results of a
Baseline Survey of State Health Agencies.
Seattle WA Turning Point National Program
Office, 2002.
48
Most SHAs Have Performance Measures, Targets, and
Reports, While Fewer States HaveProcess for
Quality Improvement or Change
Figure 15. Percentage of SHAs that have
specified components of performance management
for public health capacity (N25)
Correlation analysis revealed that there is a
comparatively weak relationship between having
performance targets, performance measures or
performance reports and having a process for
quality improvement (QI)/change.
Source Turning Point Survey on Performance
Management Practices in States Results of a
Baseline Survey of State Health Agencies.
Seattle WA Turning Point National Program
Office, 2002.
49
Most States Use Neither Incentives nor
Disincentives to Improve Performance
Figure 18. Percentage of SHA performance efforts
that include incentives or disincentives to
improve performance (N40)
Note Respondents could choose more than one
response, so total does not equal 100.
Source Turning Point Survey on Performance
Management Practices in States Results of a
Baseline Survey of State Health Agencies.
Seattle WA Turning Point National Program
Office, 2002.
50
SHAs Most Likely to Have Components of
Performance Management for Health StatusLeast
Likely for Human Resource Development
Figure 8. Areas most and least likely to have
performance targets, measures or standards,
reports, and processes for quality improvement
(QI)/change, of SHAs that apply performance
management efforts SHA wide, SHA wide and to
local public health agencies, or to local public
health agencies only (N25)
Source Turning Point Survey on Performance
Management Practices in States Results of a
Baseline Survey of State Health Agencies.
Seattle WA Turning Point National Program
Office, 2002.
51
Performance Measure Sources
Source Turning Point Survey on Performance
Management Practices in States Results of a
Baseline Survey of State Health Agencies.
Seattle WA Turning Point National Program
Office, 2002.
52
Lessons Learned

• State performance management practices are
  widespread, although often not system-wide or
  with processes leading to quality improvement or
  changes.
• States generally report their efforts result in
  improved performance, with positive outcomes
  broadly defined.
• No single or composite framework is used in most
  states, and there are insufficient data to inform
  choices in performance management approach.

53
Managing Performance (Ex 4)

• State Health Agency
• Mission to protect and promote the health of the
  states population
• Local public health agencies are units of state
  health agency
• Health status other info collected
• Resources deployed to local units based on
  progress toward pre-established targets

54
Components PresentIn This Example?

• Something needing improvement (is/is not)
  clearly identified
• Goals or targets for improvement (are/are not)
  established
• Appropriate measures of performance (are/are not)
  collected
• Reports of measurements (do/do not) reach the
  proper parties
• Information from measurements (are/are not) used
  to make improvements

55
Summary Example 4
56
Managing Performance (Ex 5)

• State-Local Public Health Agency Network
• Mission to protect and promote
• State certifies local public health agencies
• Core function based standards applied
• Annual grants made to local agencies meeting
  standards via formula based on population and
  need

57
Components PresentIn This Example?

• Something needing improvement (is/is not)
  clearly identified
• Goals or targets for improvement (are/are not)
  established
• Appropriate measures of performance (are/are not)
  collected
• Reports of measurements (do/do not) reach the
  proper parties
• Information from measurements (are/are not) used
  to make improvements

58
Summary Example 5
59
Managing Performance (Ex 6)

• Congress appropriates 1 billion annually x5
  years for state-based efforts to respond to
  childhood obesity epidemic
• States must
• Appoint State Coordinators
• Establish broadly based advisory committee
• Prepare timelines for state and local plans,
  information and surveillance systems, lab
  services, professional training, media
  strategies, etc.
• Renewal funding available to continue and extend
  these activities

60
Components PresentIn This Example?

• Something needing improvement (is/is not)
  clearly identified
• Goals or targets for improvement (are/are not)
  established
• Appropriate measures of performance (are/are not)
  collected
• Reports of measurements (do/do not) reach the
  proper parties
• Information from measurements (are/are not) used
  to make improvements

61
Summary Example 6
62
Summary - Examples 4-6
63
Managing Performance (Ex 7)

• National Public Health System
• Healthy People 2000 Objective 8.14 calls for 90
  of population to be served by LHD effectively
  carrying out IOM core functions
• Core functions further described in Essential
  Public Health Services framework
• Replaced by Infrastructure Chapter in Healthy
  People 2010

64
Comparison of Performance Measures Aggregated by
Core Function
65
Components PresentIn This Example?

• Something needing improvement (is/is not)
  clearly identified
• Goals or targets for improvement (are/are not)
  established
• Appropriate measures of performance (are/are not)
  collected
• Reports of measurements (do/do not) reach the
  proper parties
• Information from measurements (are/are not) used
  to make improvements

66
Summary Example 7
67
Example 7 to the Next Level

• Which PM components could be enhanced? How?
• For a companion effort at the state (or local)
  level, describe how the various PM components
  would be used.
• Have you been (are you now) involved in a similar
  effort? If so which PM components are in place?
  How could these be improved?

68
Examples and Case Studies

• Marathon Runner
• Agency Supervisor
• Program Manager
• State Health Agency (C)
• State-Local Public Agency Network (D,E)
• National Health Priority Initiative
• National Public Health System
• Community Health Improvement Process (A)
• Public Health Workforce Development (B)

69
Part VCase Studies
70
Part VIReview and Summary
71
Critical components of performance management
Source From Silos to Systems Using Performance
Management to Improve the Publics Health.
Turning Point Performance Management National
Excellence Collaborative Seattle WA Turning
Point National Program, 2003.
72
Apply Standards, Set Targets
73
Measure Performance
74
Report Information
75
Quality Improvement
76

• In the performance management cycle...
• All components should be driven by the public
  health mission and organizational strategy
• Activities should be integrated into routine
  public health practices
• The goal is continuous performance and quality
  improvement

Source From Silos to Systems Using Performance
Management to Improve the Publics Health.
Turning Point Performance Management National
Excellence Collaborative Seattle WA Turning
Point National Program, 2003.
77
For SuccessfulPerformance Management

• All four Performance Management components must
  be continuously integrated into the core
  operations of the agency or system

78
Capacity Accountability
79
Public Health Agency as a Learning
OrganizationCore Organizational Competencies
SupportStrategic Planning / Change Processes
lt Strategy Formation gt
lt Implementation gt
Health System
Forces / Trends
Stakeholders
MANDATES
External Environment
Core Functions Essential Public Health Services
Opportunities / Threats
Actions
Results
Organizational Systems Design Development
Planning to Plan
Strategic Issues
Strategies
Vision Mission Values
Strengths / Weaknesses
Internal Environment
Competencies
Capacity
Barriers
Adapted from John M. Bryson (c) 1985. In Bryson,
J.M. Roering, W.D. (1988). Initiation of
strategic planning by governments. Public
Administration Review, Nov.- Dec., 995 -1004.
80
Success Factors

• Integrate PM into routine public health processes
• Sustainable PM meets state and local needs and
  political realities
• NPHPS, management models and tools provide a head
  start
• Early stakeholder involvement increases support
  and chances of success

81
Success Factors (contd)

• Align PM measures, activities, and spending with
  public health priorities
• Trained staff, dedicated resources, and PM
  culture are essential
• Baseline and trends important
• New or adapted information and management systems
  are necessary for cross-program management
• Incentives motivate performance and quality
  improvement

82
Why UsePerformance Management?

• To improve public health practice and maximize
  its effectiveness. This requires
• More than setting goals/targets alone more than
  measurement alone. These are necessary, but not
  sufficient, components
• All four PM components must be continuously
  integrated into the core operations of the
  agency/system

83
Why Use Performance Management?

• Quality improvement efforts
• Policy change
• Resource allocation change
• Program change

Managerial Action
84
Part VIIPost-Test Course Evaluation
85
Performance Mgt Resources

• Turning Point PM National Excellence
  Collaborative
• Guidebook for Performance Measurement. Seattle
  WA Turning Point National Program Office, 1999.
• Performance Management in Public Health A
  Literature Review. Seattle WA Turning Point
  National Program Office, 2002.
• Turning Point Survey on Performance Management
  Practices in States Results of a Baseline Survey
  of State Health Agencies. Seattle WA Turning
  Point National Program Office, 2002.
• From Silos to Systems Using Performance
  Management to Improve the Publics Health.
  Seattle WA Turning Point National Program
  Office, 2003.
• Public Health Foundation
• Performance Management Toolkit (online via
  www.phf.org)

86
Part VCase Study A Community Health
Improvement Process Using MAPP
87
Community
The CHIP Process
Health Needs
Assessment
Community
Health Plan
Evaluation
Program Development
Implementation
88
The MAPP Model
89
Another View of MAPP Model
Evaluate
Community Health Status Assessment
Community Generated Themes
Organize For Success
Review Mandates, Mission, Stakeholder
Expectations, and Goals
Identify Strategic Issues
Vision For Success
Formulate Strategies
Implement Strategies
Local Public Health System Assessment
Contextual Environment Assessment
90
Health Priority A situation or condition of
people which is considered undesirable, is likely
to exist in the future, and is measured as death,
disease, or disability.
Indirect Contributing Factors
Direct Contributing Factors
Risk Factors
Health Priority
91
Risk Factor A scientifically established factor
(determinant) that relates directly to the level
of a health problem.
Indirect Contributing Factors
Direct Contributing Factors
Risk Factors
Health Priority
92
Direct Contributing Factor A scientifically
established factor that directly affects the
level of a risk factor.
Indirect Contributing Factors
Direct Contributing Factors
Risk Factors
Health Priority
93
Indirect Contributing Factors A community
specific factor that directly affects the level
of the direct contributing factor.
Indirect Contributing Factors
Direct Contributing Factors
Risk Factors
Health Priority
94
Outcome Objective The level to which a health
problem (priority) should be reduced.
Indirect Contributing Factors
Direct Contributing Factors
Risk Factors
Health Priority
95
Indirect Contributing Factors
Direct Contributing Factors
Risk Factors
Health Priority
Impact Objective The level to which a risk
factor should be reduced.
96
Indirect Contributing Factors
Direct Contributing Factors
Risk Factors
Health Priority
Intervention Strategy Demonstrated to be
effective or used as national model and should
address an impact objective.
Impact Objective The level to which a risk
factor should be reduced.
97
Community Health Plan Worksheet
Health Problem
Outcome Objective
By 2004, reduce stroke deaths to no more than 70
per 100,000 (Baseline 1997 crude rate 76.5 per
100,000).
Cerebrovascular Disease (Stroke)
Risk Factor
Impact Objective
By 2002, reduce cigarette smoking to a prevalence
of no more than 24 percent among people aged 18
and older. (Baseline 1996 BRFS percentage 27.3).
Tobacco Use
Contributing Factors
Proven Intervention Strategies
Addiction Sedentary Lifestyle Hypertension Adverti
sing (Indirect)
Coalition will implement CDCs community-based
tobacco control program, focusing on delaying
initiation, cessation programs, and advertising
control.
Barriers
Resources Available
Limited number smokers seeking counseling. Media
messages promote smoking. Peer pressure.
Coalition will provide support to LHD with
in-kind donations, staff, and clinical counseling
space.
98
Community Health Plan
Description of the Health Problem, Risk Factors
and Contributing Factors
The problem is the high death rate associated
with cerebrovascular disease (county CR 76.5,
state CR 61.7 p/100,000 or 23 above state
rate). The major risk factor is cigarette
smoking and county has higher percentage of
smokers (27.6) , especially males (31) than
state (24, 28, respectively). Addiction
appears to be the chief contributing factor.
Corrective Actions
In order to effectively address this health
problem a multi-sited and multi- targeted
campaign is required to delay initiation of
smoking behavior, assist persons attempting to
quit, and provide counter advertising to tobacco
promotions.
Proposed Community Organizations
A coalition of community groups, including the
LHD, Cancer Society, Lung Association, General
Hospital, Teens Against Butts will collaborate
with in- kind donations, staff, and clinical
counseling space to assist in meeting objectives.
Evaluation Plan
Coalition will meet quarterly to assess progress
in achieving goals. Coalition will use the
evaluation tool developed by the CDC to determine
effectiveness of programming efforts. Surveys
will be conducted amongst coalition members to
ascertain stakeholder satisfaction with program.
99
Add Slides for Case Study A Here!
100
Components PresentIn This Example?

• Something needing improvement (is/is not)
  clearly identified
• Goals or targets for improvement (are/are not)
  established
• Appropriate measures of performance (are/are not)
  collected
• Reports of measurements (do/do not) reach the
  proper parties
• Information from measurements (are/are not) used
  to make improvements

101
Summary Case Study A
102
Case Study A to the Next Level

• Which PM components could be enhanced? How?
• For a companion effort at the state (or local)
  level, describe how the various PM components
  would be used.
• Have you been (are you now) involved in a similar
  effort? If so which PM components are in place?
  How could these be improved?

103
Part VCase Study B Workforce Development in a
State-Local PH Network
104
Public HealthWorkforce Development
1 Assess Competency Using Consistent Methods
and Tools 2 Enhance Specific Competencies Based
on Assessment 3 Verify Competent Performance in
Workplace via Human Resource Management 4
Recognize Competent Performance via System
Incentives such as Credentialing
Core Public Health Practice BT/ER Competencies
2
3
105
Case Study B
106
Case Study B
107
Case Study B
108
Case Study B
109
Case Study B
110
Case Study B
111
Components PresentIn This Example?

• Something needing improvement (is/is not)
  clearly identified
• Goals or targets for improvement (are/are not)
  established
• Appropriate measures of performance (are/are not)
  collected
• Reports of measurements (do/do not) reach the
  proper parties
• Information from measurements (are/are not) used
  to make improvements

112
Summary Case Study B
113
Case Study B to the Next Level

• Which PM components could be enhanced? How?
• For a companion effort at the state (or local)
  level, describe how the various PM components
  would be used.
• Have you been (are you now) involved in a similar
  effort? If so which PM components are in place?
  How could these be improved?