CLHO Accreditation Webinar Series: Webinar #5 Part II

1. CLHO Accreditation Webinar Series: Webinar #5 Part II Erin Mowlds, Program Manager for Local Accreditation Local Accreditation Webinar Series Coalition of Local Health Officials

2. Agenda • Domains 9-12 • NACCHO Summaries • NACCHO Considerations & Recommendations • Document Examples • Quality Improvement & Performance Management

3. Domain 9 Evaluate and continuously improve health department processes, programs, and interventions Domain 9 focuses on using and integrating performance improvement management and quality improvement practices and processes to continuously improve the public health department's practice, programs, and interventions.

4. Standard 9.1 Use a performance management system to improve organizational practice, processes, programs, and interventions • Engage staff at all organizational levels in establishing or updating a performance management (PM) system • Implement a PM system • Use a process to determine and report on achievement of goals, objectives, and measures set by the performance management system • Implement a systematic process for assessing customer satisfaction with health department services • Provide staff development opportunities regarding performance management

5. Standard 9.1 Continued Considerations: • LHDs may develop their own performance management (PM) system or use an existing model available to the public health community • Both a programmatic and an administrative area must show use of the PM system to monitor and evaluate achievement of goals and objectives • The use of the PM system need not result in improvement in processes, but documentation should include the results, opportunities for further improvement, and next steps • Staff development opportunities related to PM must target staff working directly on performance measure monitoring

6. Standard 9.2 Develop and implement quality improvement processes integrated into organizational practice, programs, processes, and interventions: • Establish a quality improvement (QI) program based on organizational policies and direction • Implement QI activities Considerations: • Staff involvement can be documented in QI projects or in QI team involvement

7. NACCHO Resources • http://www.naccho.org/topics/infrastructure/accreditation/statemap.cfm • http://www.naccho.org/topics/infrastructure/accreditation/quality.cfm

8. Domain 10 Contribute to and apply the evidence base of public health Domain 10 focuses on the role that health departments play in building and advancing the science of public health. Public health is strengthened when its practitioners continually add to the body of evidence for promising practices -- those practices that have the potential to become evidence-based over time. Health departments should employ evidence-based practices for increased effectiveness and credibility. Health departments also have important roles in developing new evidence. Health departments should apply innovation and creativity in providing public health services appropriate for the populations they serve.

9. Standard 10.1 Identify and use the best available evidence for making informed public health practice decisions • Identify and use applicable evidence-based and/or promising practices when implementing new or revised processes, programs, and/or interventions Considerations • One of the two examples of using evidence-based practices must be from a chronic disease program

10. Standard 10.2 Promote understanding and use of the current body of research results, evaluations, and evidence-based practices with appropriate audiences • Ensure human subjects are protected when the health department is involved in or supports research activity • Maintain access to expertise to analyze current research and its public health implications • Communicate research findings, including public health implications Considerations • If an LHD does not have its own IRB policies, it should have a copy of the IRB approval from the institution where the IRB review was done • Access to research experts must be formalized (MOU, MOA, contract, etc) if it is not within the agency

11. NACCHO Example Documentation • 10-2-1-A-IRB-guidelines • 10-2-3-A-disease-prevention-article

12. Domain 11 Maintain Administrative and Management Capacity Domain 11 focuses on health department management and administration capacity. Health department leaders and staff must be knowledgeable about the structure, organization, and financing of their public health department and other agencies and organizations that provide public health services. Health departments must have a well-managed human resources system, be competent in general financial management, and be knowledgeable about public health authorities and mandates. 

13. Standard 11.1 Develop and maintain an operational infrastructure to support the performance of public health functions • Maintain policies and procedures regarding health department operations, review policies and procedures regularly, and make them accessible to staff • Maintain written policies regarding confidentiality, including applicable HIPAA requirements • Maintain socially, culturally, and linguistically appropriate approaches in health department processes, programs, and interventions relevant to the population served

14. Standard 11.1 Continued Develop and maintain an operational infrastructure to support the performance of public health functions • Maintain a human resources system • Implement and adhere to the health department's human resources policies and procedures • Use information systems that support the health department mission and workforce by providing infrastructure for data collection/analysis, program management, and communication • Maintain facilities that are clean, safe, accessible, and secure

15. Standard 11.1 Considerations: • Only the most recent versions of policies are acceptable • Policies can be electronic or in hard-copy-format • Culturally/Linguistically appropriate program examples need to include social marketing methods

16. Standard 11.2 Establish effective financial management systems: • Comply with external requirements for the receipt of program funding • Maintain written agreements with entities providing processes, programs, and/or interventions delegated or purchased by the public health department • Maintain financial management systems • Seek resources to support agency infrastructure and processes, programs, and interventions

17. Standard 11.2 Continued Considerations: • Fiscal audit reports must be for the previous two years • MOU agreements must be current (ie updated or executed within the last two years), must contain financial provisions, and must be still in effect • A budget can be approved by the local governing entity or the body with approval authority (ie governors office for centralized states)

18. NACCHO Example Documentation • 11-1-1-A-employee-policy-manual • 11-1-1-A-health-district-by-laws • 11-1-1-A-organizational-chart • 11-1-1-A-proof-of-review-and-process-fo-revision • 11-1-1-A-staff-access-to-policy • 11-1-4-A-employee-handbook-and-policies • 11-1-4-A-employee-policy-manual • 11-1-4-A-employee-handbook • 11-2-1-A-audited-financial-statement • 11-2-4-A-editorial-on-tobacco-taxes

19. Domain 12 Maintain capacity to engage the public health governing entity Domain 12 focuses on the health department's capacity to support and engage its governing entity in maintaining the governmental public health infrastructure for the jurisdiction served. Governing entities play an important role in the function of many public health departments. Governing entities both directly and indirectly influence the direction of a health department and should play a key role in accreditation efforts. However, much variation exists regarding the structure, definition, roles, and responsibilities of governing entities.

20. Domain 12 Continued A governing entity, as it relates to the accreditation process, should meet the following criteria: • It is an official part of Tribal, state, regional, or local government; • It has primary responsibility for policy-making and/or governing a Tribal, state, or local, health department; • It advises, advocates, or consults with the health department on matters related to resources, policy making, legal authority, collaboration, and/or improvement activities; • It is the point of accountability for the health department; • In the case of shared governance (more than one entity provides governance functions to the health department), the governing entity, for accreditation purposes, is the Tribal, state, regional, or local entity that, in the judgment of the health department being accredited or PHAB site reviewers, has the primary responsibility for supporting the applicant health department in achieving accreditation.

21. Standard 12.1 Maintain current operational definitions and statements of public health roles, responsibilities, and authorities: • Provide mandated public health operations, programs, and services • Maintain current operational definitions and/or statements of the public health governing entity's roles and responsibilities Considerations: • While the entirety of applicable laws and regulations need not be submitted as documentation, they must be available for the site visit review team

22. Standard 12.2 Provide information to the governing entity regarding public health and the official responsibilities of the health department and of the governing entity • Communicate with the governing entity regarding the responsibilities of the public health department • Communicate with the governing entity regarding the responsibilities of the governing entity Considerations: • Documentation formats can vary depending on the governance model of the health department • One example documentation can meet both measures in this standard as long as it clearly shows communication with the governing entity about the responsibilities of of the health department and of the governing entity

23. Standard 12.3 Encourage the governing entity's engagement in the public health department's overall obligations and responsibilities • Provide the governing entity with information about important public health issues facing the health department and/or the recent actions of the health department • Track actions taken by the governing entity • Communicate with the governing entity about accessing and improving the performance of the health department Considerations: • Communication with the governing entity can be formal (ie meeting minutes, reports) or informal (ie e-mails, memos, records of conversations)

24. NACCHO Example Documentation • 12-3-1-A-BOH-meeting-minutes

25. Performance Management • Performance managementis “the use of performance measurement information to help set agreed-upon performance goals, allocate and prioritize resources, inform managers to either confirm or change current policy or program directions to meet those goals, and report on the success in meeting those goals

26. Performance Management Systems Performance management includes the following components: • Performance standards—establishment of organizational or system performance standards, targets, and goals to improve public health practices. • Performance measures—development, application, and use of performance measures to assess achievement of such standards. • Reporting of progress—documentation and reporting of progress in meeting standards and targets and sharing of such information through feedback. • Quality improvement—establishment of a program or process to manage change and achieve quality improvement in public health policies, programs or infrastructure based on performance standards, measurements, and reports. A performance management system is the continuous use of all the above practices so that they are integrated into an agency’s core operations (see inset at right). Performance management can be carried out at multiple levels, including the program, organization, community, and state levels.

27. “Refreshed” Turning Point Framework

28. Benefits of Performance Management System Some of the ways performance management can positively influence a public health agency, include: • Better return on dollars invested in health; • Greater accountability for funding and increases in the public’s trust; • Reduced duplication of efforts; • Better understanding of public health accomplishments and priorities among employees, partners, and the public; • Increased sense of cooperation and teamwork; • Increased emphasis on quality, rather than quantity; and • Improved problem solving.

29. Quadrant Details • Quality Improvement • Use data for decisions to improve policies, programs, outcomes • Manage changes • Create a learning organization • Reporting of Progress • Analyze and interpret data • Report results broadly • Develop a regular reporting cycle • Performance Standards • Identify relevant standards • Select indicators • Set goals and targets • Communicate Expectations • Performance Measures • Refine indicators • Define measures • Develop data systems • Collect data

30. Effective Performance Management MarMason Consulting • Establishing and implementing performance management systems helps state agencies: • Align agency plans to reduce duplication and increase efficiency and effectiveness • Prioritize planning and improvement efforts • Address accreditation requirements • Demonstrate the results of PH programs and services through performance measurement and reporting

31. Performance Measurement 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 and social determinant indicators MarMason Consulting

32. Performance Management Self Assessment Tool • http://www.turningpointprogram.org/toolkit/content/pmassess.htm

33. What is Quality Improvement? • QI is the use of a deliberate and defined process, such as Plan-Do-Check-Act, which is 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 services or processes which achieve equity and improve the health of the community. Developed by the Accreditation Coalition Workgroup and approved by the Accreditation Coalition in June 2009

34. Why Quality Improvement? • Foundation of Accreditation • Focuses on efficiency and effectiveness • Demonstrates commitment to high quality services • Shows that we are good at what we do and always improving

35. QI in the context of accreditation QI is an important component of accreditation and of an effective, efficient HD Domain 9, interwoven throughout Increased leadership buy-in “Big” QI and “Small” QI Re-accreditation improve improve Accreditation improve Improving the public’s health through continuous Quality Improvement

36. Definition of Quality Improvement QI Top management philosophy resulting in complete organizational involvement qi Conduct of improving a process at the micro system level Bill Riley and Russell Brewer, Review and Analysis of QI Techniques in Police Departments, JPHMP Mar/April 2009 MarMason Consulting A management process and set of disciplines that are coordinated to ensure that the organization consistently meets and exceeds customer requirements.

37. Applying QI:Plan Do Check Act • 4 phase cycle • Plan: Understand Problem • Do: Develop Potential Solutions • Check: Testing Solutions • Act: Analyzing Results

38. PLAN • Most critical step • Investigate and fully understand the situation • Identify all opportunities for QI and prioritize them • Ideas for QI come from all levels– staff have opportunity for getting ideas heard and acted upon. • Problem Statement • Aim Statement • Where are we now? • Develop an action Plan

39. Root Cause Analysis Tools • Five Why Processes: Assists teams in driving to the root cause of a problem by thoroughly understanding the problem where it occurs. • Fishbone Diagram: Equipment People What’s the Problem Materials Methods

40. DO • Implement the improvement • Document Everything • Problems • Unexpected observations • Lessons learned • Knowledge gained

41. CHECK • Analyze effect of improvement plan • Was improvement achieved? • Document everything • Lessons learned • Knowledge gained • Any surprising results that emerged

42. ACT • Act upon what was learned: • ADOPT: Celebrate and standardize • ADAPT: Adjust and repeat • ABANDON: Start Over • Once you have adopted, monitor and hold the gains

44. Accreditation and process improvement • 9.1.5 Evaluate the effectiveness of processes, programs, and interventions and identify needs for improvement. • Intent of this measure: key processes and all programs and interventions of the agency are evaluated and monitoring data is used to identify areas and methods for improvement.

45. LEAN • LEAN is an improvement process that focuses on what the client wants/ needs and develops a process that delivers that as efficiently as possible • Aimed at maximizing value, reducing waste and incidental work • In LEAN: • Assess your current state • Remove waste • Smooth out the process • Test it out

46. Gathering data • Family Planning client process • Total cycle time (client check-in to client check-out) = 120 minutes • Check-in process = 10 minutes • Provider visit = 60 minutes • Check-out process = 10 minutes • Where do the extra 40 minutes go?

47. Why focus on process? • Nearly every tangible output, service, or product is the result of a series of system processes. • Most process improvement opportunities are within the process itself. • Processes can be mapped, measured, and managed to ensure consistent, positive results.

48. Activities Output Input Clean Teeth Brush Teeth Birth control method Client visit How do processes work? • Outcome Family planning client • Lower teen pregnancy rate • Good breath • Fewer Cavities Toothpaste

49. Levels Of A Process BusinessDevelopment Core Functional Departments Business Process (“Strategic”) Sales Underwriting Contracting Customer Service BusinessProcesses Sub-process Supplier Customer High Level Process Map Terms Terms Docs Negotiate Close Underwriters (ext.) Customers (int.) Cust. Service Dept. Detailed Sub-Process Map Tasks Procedures

50. Levels Of A Process BusinessDevelopment Core Functional Departments Business Process (“Strategic”) Sales Underwriting Contracting Customer Service BusinessProcesses Sub-process Supplier Customer High Level Process Map Terms Terms Docs Negotiate Close Underwriters (ext.) Customers (int.) Cust. Service Dept. Detailed Sub-Process Map Tasks Procedures