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Performance Management and QI Principles and Strategies Minnesota

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Title: Performance Management and QI Principles and Strategies Minnesota


1
Performance Management and QI Principles and
StrategiesMinnesotas 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

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 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 TBD

4
Todays Learning Objectives
  • In todays 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

5
Performance Management
Performance Measurement
Lean Six Sigma
Public Health Indicators
Standards for Public Health
QI Plans Councils
QI Methods Tools
Breakthrough Collaborative
Self-Assessment or Accreditation
Business Process Analysis
6
Performance Management
Source Turning Point Performance Management
Collaborative, 2003.
7
Performance Standards
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

8
Performance Measurement
PERFORMANCE MEASUREMENT
  • Monitoring of Performance
  • Review of performance (Accreditation/Self-Assessme
    nt) results
  • Program evaluation results
  • Monitoring of Indicators and Outcomes
  • Process and short-term outcomes
  • Health indicators and outcomes

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.

QI Top management philosophy resulting in
complete organizational involvement 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
10
Quality Improvement Process
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

11
Reporting Progress
REPORT PROGRESS
  • Performance in standards
  • Indicators and outcomes
  • Health indicators
  • Program evaluation data
  • Regular data tracking, analysis and review
  • Basis for QI efforts

12
Integration of QI into Agency Culture
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

Bill Riley and Russell Brewer, Review and
Analysis of QI Techniques in Police Departments,
JPHMP Mar/April 2009
14
Levels of QI Integration
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

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
Lets Discuss!
  • What is your experience with the four components
    of performance management in your Health
    Department?

18
QI Principles and Strategies
19
The Quality Environment
  • 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
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

22
Public Sector Map
  • 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 partsome of the most complex processes are
    the result of creating a work around

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
27
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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

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
  • Conceptual Tools
  • Numerical Tools
  • Affinity Diagram
  • Brainstorming
  • Process Flow Chart
  • Cause and Effect Diagram (Fishbone)
  • Five Whys
  • Matrix Diagram
  • Check Sheet
  • Bar Chart
  • Histogram
  • Pareto Chart
  • Control Chart
  • Run Chart

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.

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?

33
Cause and Effect Diagram
Test Location
Client
Dont see benefit
Inconvenient
Dont Want Test
Fearful
Too Public
Poor HIV Testing
Not Client Centered
Not Respectful
Not Offered
Poor Experience
Counseling
Staff
34
Example of Fishbone
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

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

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

PH Memory Jogger page 12
38
Uptake of Vaccines Example (Kittitas, WA)
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
    changes sake

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

41
PDSA Improvement Cycle
REVISE LOGIC MODEL
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

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
  • Other industries
  • Describe your process (Logic Model or Flow Chart)
  • Study the exemplary practice process
  • Adopt or adapt as appropriate

45
6. Demonstrate Leadership Commitment
  • Build a QI culture in your agency
  • Connect the organizations 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

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

47
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.
48
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49
Change vs. Improvement
  • W. Edwards Deming stated Of all changes Ive
    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

50
Some QI References
  • Embracing Quality in Local Public Health
    Michigans 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_guideb
    ook.pdf
  • Mason M, Schmidt R, Gizzi C, Ramsey S. Taking
    Improvement Action Based on Performance Results
    Washington States Experience. Journal of Public
    Health Management and Practice. Jan/Feb 2010
    16(1) 24-31

51
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