Performance management in action: the Montana model

1. Performance management in action: the Montana model

2. Contrasting Big “QI”, Little “qi”, and Individual “qi” Topic Big ‘QI’ – organization-wide Little ‘qi’ – program/unit Individual ‘qi’ Improvement Quality Improvement Planning Evaluation of Quality Processes Quality Improvement Goals Daily work level focus Tied to yearly individual performance Performance of daily work Daily work Individual performance plans System focus Tied to the Strategic Plan Responsiveness to a community need Cut across all programs and activities Strategic Plan Specific project focus Program/unit level Performance of a process over time Delivery of a service Individual program/unit level plans

3. Continuous Quality Improvement System in Public Health Turning Point Baldrige QI Teams LSS MAPP MICRO Big ‘QI’ MACRO A P Little ‘qi’ C D Basic Tools of QI A P A P C D Individual ‘qi’ MESO C D INDIVIDUAL A S QFD Rapid Cycle C D Advance Tools of QI Daily Management

5. De-siloifying HIV MCH Preparedness STD Family Planning

6. Our Research Found Four Barriers to Strategic Implementation The Vision Barrier Only 5% of the work force understand the strategy The People Barrier The Management Barrier 9 of 10 companies fail to execute strategy Only 25% of managers have incentives linked to strategy 85% of executive teams spend less than one hour/ month discussing strategy 60% of organizations don’t link budgets to strategy The Resource Barrier Today’s Management Systems Were Designed to Meet The Needs of Stable Industrial Organizations That Were Changing Incrementally You Can’t Manage Strategy With a System Designed for Tactics

7. Four components of a performance management system Source: Turning Point Performance Management Collaborative, From Silos to Systems: Performance Management in Public Health (in press).

8. In a performance • management • system... • 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: Turning Point Performance Management Collaborative.

9. 6 Process Management Baldrige Criteria For Organizational Performance Excellence 2 Strategic Planning 5 Human Resource Focus 7 Business Results 1 Leadership 3 Customer & Market Focus 4 Information and Analysis

11. Montana’s Accreditationstrategy Using Systems to Comply Montana Department of Public Health and Human Services Public Health and Safety Division Lindsey Krywaruchka and Denny Haywood

12. Objectives • Integrated Management System Concept • PHAB Criteria and Systems • How To: Building a Performance Management System • Case Study: Chronic Disease and Health Promotion Bureau Take Home Message: Pursue accreditation by building systems

13. Integrated ManagementSystem A Fully Interconnected Unit

14. System • Outputs of one process are input to another. • Interaction and feedback between the parts. A set of interacting or interdependent processes. Pile of Sand Engine Not A System Is A System

15. Systematic • Must be defined, usually documented. • Consistently applied. • Build in opportunity for evaluation, improvement, and sharing. Approaches that are repeatable and use data and information so learning is possible.

16. Why Is Managing Systematically Important? • All work, including management, consists of linked processes forming a system, even if the system was not designed and is not understood. • Every system is perfectly aligned to achieve the results it creates. Process determines performance. • The results of an aligned system far exceed a system that fights against itself. • Integrated management systems ensure that performance excellence happens by design, not by chance.

17. PHSD Integrated Management System Are We On Track? Tasks – Dollars – Outcomes Define the Problems and Priorities Decide How To Attain Desired Outcomes Have We Attained High Level Outcomes? Why or Why Not? Plan Required Work Tasks & Resources Do The Work Allocate Dollars To Do Planned Work Build Capacity To Do Work

18. Integrated Management System Documents State Public Health Improvement Plan State Public Health Assessment PHS Division Strategic Plan Strategic Objectives & Metrics PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plans PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plans Program/ Activity Metrics PHS Division Budget

19. PHAB Criteria and Systems Potential Contradiction

20. Protocol – or – Two Examples • Some criteria call for: • Policy and procedures • Process • Protocol • Others call for: • Two examples Two isolated cases cannot ensure excellent performance happens every time! Systems and systematic approaches ensure quality the first time and every time.

21. “Systems” Terms Used In PHAB Criteria • Systems • Systematic • Standardized • Process • Protocol • Standard Operating Procedures • Comprehensive Planning • Strategic Planning • Operational Planning • Integrated The criteria are good, but are more understandable when organized as a system…… Use PHAB Criteria To Build Systems Resulting In Performance Excellence

22. PHAB Standards – Needs Assessment • 1.1: Conduct collaborative process resulting inCommunity Health Assessment. • 4.1: Engage with the public health system and community to identify and address public health problems. State Public Health Assessment

23. PHAB Standards – Strategic Planning • 5.2: Conduct comprehensive planning processresulting in State Health Improvement plan. • 5.3: Develop organizational strategic plan. • 4.2: Engage the community andgoverning entity in deliberating optionsand alternatives. • 7.2: Identify strategies to improveaccess to health care services. • 12.1.1 A: Provide mandated publichealth operations, programs,and services. • 12.2: Keep the governing entity informed of its public healthresponsibilities and its role in updatinglaws, rules, and regulations. State Public Health Improvement Plan PHS Division Strategic Plan

24. PHAB Standards – Operational Planning • 5.3: Implement organizational strategic plan. • 5.4: Maintain all hazards emergency operations plan. • 2.4: Maintain a plan, policies, and procedures for urgent and non-urgent communications. • 7.2: Implement strategies to improve access to healthcare services. • 11.1: Develop and maintainoperational infrastructure. • 11.1.1.A: Maintain operational policies and procedures. • 12.1.1 A: Provide mandatedpublic health operations, programs, and services. PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plans

25. PHAB Standards – Budget • 11.2: Establish effective financial management systems. • 11.2.3 A: Maintain financial management systems. • 11.2.4 A: Seek resources for infrastructure, processes, programs, and interventions. PHS Division Budget

26. PHAB Standards – Management Domain 2: Investigate Health Problems and Environmental Hazards • 2.1: Conduct timely investigations. • 2.2: Contain / mitigate health problems and hazards. • 2.3: Ensure expertise and capacity toinvestigate, contain, and mitigateproblems and hazards. PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plans Program/ Activity Metrics

27. PHAB Standards – Management Domain 3: Inform and Educate About Public Health Issues and Functions • 3.1: Provide health education and promotion policies, programs, processes, and interventions • 3.2: Provide information through multiplemethods to a variety of audiences. PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plans Program/ Activity Metrics

28. PHAB Standards – Management Domain 6: Enforce Public Health Laws • Standard 6.1: Review and update laws. • Standard 6.2: Educate about meaning, purpose, and benefits of laws and how to comply. • Standard 6.3: Monitor enforcementactivities and notify agencies. PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plans Program/ Activity Metrics

29. PHAB Standards – Evaluation • 1.3: Analyze public health data to identify problems, hazards, and factors affecting public health. • 1.4: Use data analysis to develop recommendations for policy, processes, programs, or interventions. • 5.1: Serve as resource forpolicies, practices,and capacity. • 7.1: Assess healthcareservice capacity and access. • 12.3: Engage the governing entity in the department’sobligations and responsibilities. Strategic Objectives & Metrics

30. PHAB Standards – Performance Management • Standard1.2: Maintain a system to collect, manage, analyze, and use public health condition and importance data. • Standard 9.1: Use a performance management system to monitor achievement of organizational objectives. • Standard 9.2: Develop and implementintegrated quality managementprocesses. • 12.3.3 A: Communicate with thegoverning entity about assessingand improving performance. Strategic Objectives & Metrics State Public Health Assessment State Public Health Improvement Plan PHS Division Strategic Plan PHS Division Budget PHSD Program/ Activity Operational Plans Program/ Activity Metrics Links all plans and measures.

31. PHAB Standards – Support • 8.1: Develop sufficient public health workers. • 8.2: Enable organizational and individual training and development. • 11.1: Develop and maintain organizational infrastructure. • 11.1.4 A: Maintain a human resource system. • 11.1.6 A: Provide infrastructure for dataanalysis, program management, and communication. • 11.1.7 A: Maintain facilities. • 10.1: Identify and use the best availableevidence in making decisions. • 10.2: Promote understandingand use of research results,evaluations, and evidence-basedpractices. PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plan PHSD Program/ Activity Operational Plans Program/ Activity Metrics

32. How To:Building a PerformanceManagement System Translating Strategy Into Action

33. Performance Management System Processes, information, and systems used by managers to: • Set strategy • Develop plans • Monitor execution • Forecast performance • Report results

34. Steps to Build • Construct Logic Model • Develop Work Plans • Establish Systematic Progress Review Tying the Integrated Management System together!

35. 1. Construct Logic Model • Desired Outcomes • Metrics • Linked in Chain of Cause-And-Effect • Translates Strategic Plan Strategies Into Actual Work Actions • Structure Integrates All Management Systems • Strategic Planning • Operational Planning • Budgeting and Accounting • Performance Management • Quality Improvement • Human Resources Management

36. Cancer Cardiovascular Disease Asthma Tobacco Prevention Core Activity (Project or Process) Diabetes Program Healthcare Provider Education School and Childcare Training Bureau MT Asthma Home Visiting Chronic Disease Asthma Care Monitoring System Subdividing Work Into More Manageable Pieces Makes a very complicated life much easier to manage!

37. Core Activity Definition • A discrete unit of work with a common purpose • One-Time Project or Continual Work Process • Budgetary unit (derived from activity based costing) • Requires a Work Plan (Operational Plan) • Building blocks of Logic Model Program: Asthma Core Activity: Asthma Home Visiting Provider Education School & Childcare Training versus

38. Activity C Work Plan: • Provide asthma training to staff of 25 middle schools. • Provide asthma assessment training to 30 school nurses. Linked Cascading Chain of Cause-And-Effect Surveillance and Epidemiology Diabetes Program Example Desired Outcomes Individuals avoid diabetes complications and maintain quality of life. PH professionals are promptly alerted to the incidence of asthma. Provider Education Chronic Disease Bureau Asthma Program PCPs utilize the most current and effective evidence-based asthma care practices. Individuals experience fewer asthma symptoms such that normal activity levels are not hampered. Montanans with chronic conditions manage their disease and experience fewer complications. School-Childcare Training Montana schools and child care facilities properly manage asthma. Cancer Program Fewer Montanans experience late stage cancer. Bureau Result meets a Public Need or Solves a Public Problem Collective Intermediate Results

39. Linked Cascading Chain of Cause-And-Effect Surveillance and Epidemiology Diabetes Program Average number of days from diagnosis to entry into the asthma database. Number of individuals per 100,000 population who develop diabetes monthly Example Metrics Provider Education Chronic Disease Bureau Asthma Program Number of healthcare professionals receiving spirometry diagnosis and assessment training Number of asthma hospitalizations per 10,000 population monthly Number of Montana chronic disease hospitalizations. School-Childcare Training Number of school staff or child care providers who received training during the past calendar year. Cancer Program Percent of Montanans who are up-to-date with colorectal cancer screening. High level outcome metric • Activity C Work Plan: • Provide asthma training to staff of 25 middle schools. • Provide asthma assessment training to 30 school nurses. Detailed, operational and tactical metrics Intermediate outcome metrics

40. Metrics Derived From Desired Outcomes Surveillance and Epidemiology Diabetes Program Example Desired Outcomes Individuals avoid diabetes complications and maintain quality of life. PH professionals are promptly alerted to the incidence of asthma. Provider Education Chronic Disease Bureau Asthma Program PCPs utilize the most current and effective evidence-based asthma care practices. Individuals experience fewer asthma symptoms such that normal activity levels are not hampered. Montanans with chronic conditions manage their disease and experience fewer complications. School-Childcare Training Montana schools and child care facilities properly manage asthma. Cancer Program Fewer Montanans experience late stage cancer.

41. Metrics Derived From Desired Outcomes Surveillance and Epidemiology Diabetes Program Average number of days from diagnosis to entry into the asthma database. Number of individuals per 100,000 population who develop diabetes monthly Example Metrics Provider Education Chronic Disease Bureau Asthma Program Number of healthcare professionals receiving spirometry diagnosis and assessment training Number of asthma hospitalizations per 10,000 population monthly Number of Montana chronic disease hospitalizations. School-Childcare Training Number of school staff or child care providers who received training during the past calendar year. Cancer Program Percent of Montanans who are up-to-date with colorectal cancer screening.

42. How to Identify Core Activities Facilitated Team Work Sessions • All persons who do the work • Brainstorm tasks performed by the program. • Group tasks – part of same work function having same purpose • Label columns by what is being done • Performance Management focuses on what not who!

43. Defining Core Activities What are the ideal end results of this program?

44. Defining Core Activities What are the tasks that your program carries out to make those results happen?

45. Defining Core Activities Silent brainstorming.

46. Defining Core Activities Group tasks – part of same work function having same purpose.

47. Defining Core Activities Debate clarifies values, purpose, and function.

48. Defining Core Activities “affinity diagram” Title of what is being done – Core Activity Name. Program tasks grouped by function / purpose.

49. 2. Develop Work Plans For Each Activity • Mission – Services and Product Provided to Whom • Desired Outcomes • Strategic Plan Goals, Strategies, Objectives • Intermediate Outcome Metrics • Process Metrics • Action Plan • Budget Montana Giardiasis Surveillance 1987 - 2009

50. Logic Model & Work Plan Development Develop Program Logic Model Brainstorm Tasks Logic Model Training Identify Core Activities Session One 3 hr Refine Program Logic Model Work Plan Training Select Core Activity to Develop First Work Plan Session Two 2-3 hr Prepare First Work Plan Independently On Own Time Learning Exercise: Review First Work Plan Complete Other Work Plans Independently Session Three 1 hr