MarMason Consulting

1. Performance Management and QI Principles and StrategiesMinnesota’sDepartment of Health (MDH) and Community Health BoardsJanuary 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 MarMason Consulting

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 MarMason Consulting

4. 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 MarMason Consulting

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 MarMason Consulting

6. Performance Management Source: Turning Point Performance Management Collaborative, 2003. MarMason Consulting

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-Assessment) results • Program evaluation results • Monitoring of Indicators and Outcomes • Process and short-term outcomes • Health indicators and outcomes

9. Definition of Quality Improvement 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 A management process and set of disciplines that are coordinated to ensure that the organization consistently meets and exceeds customer requirements.

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 MarMason Consulting

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 MarMason Consulting

14. Levels of QI Integration MarMason Consulting

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 MarMason Consulting

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. Let’s Discuss! What is your experience with the four components of performance management in your Health Department? MarMason Consulting

18. QI Principles and Strategies MarMason Consulting

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? MarMason Consulting

20. Principles of Quality Management MarMason Consulting Know your stakeholders and what they need Focus on processes Use data for making decisions Use teamwork to improve work Make quality improvement continuous 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 MarMason Consulting

22. Department of Defense • Tri-Care • Prime National Institute of Health Governor / Legislature Office of the Superintendent of Public Instruction Office of the Insurance Commissioner • Department of Health • Chronic Disease & Risk Reduction • Diabetes Prevention & Control • Community & Rural Health • Community & Family Health • Maternal Support Srvcs • Women, Infants & Children • Licensing Boards • Dept. of Corrections • Prisons • Employment Security Department • Worksource • Dept. of Social & Human Services • Aging & Adult Services • Med. Asst. Admin • Division of Developmental Disabilities. • Mental Health Division Department of Labor & Industries Department of Veterans Affairs Local Governments State Board of Health • Health Care Authority • Public Employees Benefit Board • Basic Health Plan Local Health Jurisdictions Public Library System Public Hospital Districts Head Start Programs These are examples of partners in the public health system: Bold= Large agency or organization, Italics= Type of organization, not a specific entity, Regular= Specific organization or entity Bullets refer to examples of organizations and are not a comprehensive listing. Public Sector Map • School Boards • Public schools • BIA schools • Charter schools • Private faith based schools MarMason Consulting

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 part—some of the most complex processes are the result of creating a “work around” MarMason Consulting

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. We inspectrestaurants So that # of inspections Conditions in the restaurant don’t create unsafe food So that # of critical violations Public is sold food that is safe to eat So that % of critical violations corrected within 24 hours There are fewer incidents of foodborne illness rate of foodborne illness The Logic of Public Health MarMason Consulting

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 MarMason Consulting

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 Why’s • Matrix Diagram • Check Sheet • Bar Chart • Histogram • Pareto Chart • Control Chart • Run Chart [See Goal/QPC PH Memory Joggers] MarMason Consulting

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 MarMason Consulting

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? MarMason Consulting

33. Cause and Effect Diagram Test Location Client Don’t see benefit Inconvenient Don’t Want Test Too Public Fearful Poor HIV Testing Not Client Centered Not Respectful Not Offered Poor Experience Counseling Staff

34. Example of Fishbone MarMason Consulting

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 MarMason Consulting

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 MarMason Consulting

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 MarMason Consulting

38. Uptake of Vaccines Example (Kittitas, WA) MarMason Consulting

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 change’s sake MarMason Consulting

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 MarMason Consulting

41. PDSA Improvement Cycle Act Plan • What changes are to be made? • Next cycle? • Objective • Questions and predictions • Plan to carry out the cycle • (who, what, where, when) • Plan for data collection DOCUMENTATION OF CHANGE - MINUTES REVISE LOGIC MODEL LOGIC MODEL REVISE LOGIC MODEL Study Do • Complete the data analysis • Compare data to • predictions • Summarize lessons • Carry out the plan • Document problems and • unexpected observations • Begin analysis of the data DATA REPORT WORK PLAN MarMason Consulting

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 MarMason Consulting

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 MarMason Consulting

45. 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 MarMason Consulting

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 MarMason Consulting

47. Agency Level Performance Measures

48. MarMason Consulting

49. 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 MarMason Consulting

50. Some QI References • 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