Funding Source
The Role of Planning and
Quality Improvement Initiatives
In State Health Agencies
„
This research was conducted with
generous funding from the Robert Wood
Johnson Foundation and the Centers for
Disease Control and Prevention
Kusuma Madamala, PhD,MPH
Katie Sellers, DrPH
Michael Dickey, MPH,CHES
Brittany Petersen, MS
Ariel Holland
Jim Pearsol, MEd
Research Objective
Methods
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Explore the use of planning,
performance management and quality
improvement initiatives conducted by
State Public Health Agencies
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Survey Definition –
Performance Management
Includes ALL of the following: performance
standards, performance measures, reporting of
progress, and a quality improvement process
ASTHO conducted a web-based SPHA survey
(1st National Profile of SPHAs) between October and
December, 2007
Survey sent to 57 SPHA Senior Deputies
Telephone and email follow-up
Representatives from all 50 states and DC responded.
Response rate was 89.5%
No U.S. Territories responded
Analysis focused on questions related to SPHA planning,
performance management & quality improvement
initiatives
Survey Definition –
Performance Standards
Objective standards or guidelines that are used
to assess an organization’s performance;
standards may be set by benchmarking against
similar organizations, or based on national, state
or scientific guidelines
Survey Definition –
Performance Measures
Any quantitative measures or indicators of
capacities, processes, or outcomes relevant to
the assessment of an established performance
goal or objective
Survey Definition –
Quality Improvement
The 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.
Survey Definition –
Progress Reports
Documentation and reporting of progress in
meeting standards and targets and sharing such
information through feedback
Example: Health Improvement Plans
Performance Management &
Quality Improvement
Performance measurement and management
are critical to Quality Improvement, as a means
to understand reasons for variation or gaps in
performance and to test the impact of potential
improvements to the system
(Lotstein et al., 2008, Langley et al, 1996, Lighter and
Fair, 2004).
SPHA Performance Management
76% had a Performance Management process
16% (n =8) fully implemented department wide
30% (n =15) partially implemented department wide
10% (n=5) fully implemented specific programs
26% (n=13) partially implemented specific programs
SPHA Quality Improvement
82% report a QI process in place
Only 10% (n=5) fully implemented department wide
29% (n=15) partially implemented dept wide
22% (n=11) fully implemented for specific programs
33% (n=17) partially implemented for specific programs
Planning by SPHAs
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Planning by SPHAs
80% of SPHAs had a State Health Improvement Plan
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23.5% completed the plan in the last three years
57% completed the plan >three years ago
Comparison to LPHAs (NACCHO, 2005)
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59% had their state plan linked to at least one local
health improvement plan
Approximately half of respondents use planning tools
as a reference rather than implementing them directly
Of those states with SHIP, 68% developed the plan
using their state health assessment; 86% of LPHAs
had a CHIP based on a community health assessment
(NACCHO, 2005)
Type of Service
Clinical Practice Areas
Greater use of the performance management process in
clinical practice areas (i.e. MCH services, STD services,
TB services, and Family Planning services) than nonclinical practice areas (i.e. data and information systems,
financial systems, health status assessment, and health
facility regulation)
(p=.001)
Non-Clinical Practice Areas
Non-Clinical
Practice Areas
Performance
Measures
n (%)
Performance
Standards
n (%)
Progress
Reports
n (%)
Quality
Improvement
n (%)
Data & info
systems
35 (70%)
29 (58%)
31 (62%)
21 (42%)
Financial
systems
30 (60%)
25 (50%)
30 (60%)
17 (35%)
Health status
assessment
27 (54%)
23 (46%)
35 (70%)
17 (34%)
Health facility
regulation
33 (66%)
32 (64%)
33 (66%)
29 (58%)
Human
resource
development
32 (64%)
26 (51%)
33 (66%)
20 (40%)
Customer focus
& satisfaction
14 (28%)
16 (32%)
16 (32%)
18 (36%)
Management
practices
26 (52%)
20 (40%)
26 (52%)
19 (38%)
Note: Note: p-value compares 4 clinical vs. 4 chosen non-clinical practice areas. The 4 non-clinical practice areas were selected to balance the comparison
(compare an equal number of practice areas). The four areas were selected because they tend to be common practices for all SPHAs.
Clinical
Practice
Areas
Performance
Measures
n(%)
Performance
Standards
n (%)
Progress
Reports
n (%)
Quality
Improvement
n (%)
MCH
43 (86%)
34 (68%)
44 (88%)
31 (62%)
STD
43 (86%)
34 (68%)
42 (84%)
23 (46%)
TB
43 (86%)
35 (70%)
43 (86%)
26 (52%)
Family
Planning
37 (74%)
32 (64%)
41 (82%)
31 (62%)
Performance Standards &
Performance Measures
Greater use of reported performance measures than
performance standards across both clinical and nonclinical service areas (p=.002)
Less frequent use of QI compared to progress reports,
performance measures and performance standards
(p<.001)
Study Limitations
Conclusion
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Only U.S. States responded – No U.S. territories
responded.
Self report
Construct validity
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Practice and Policy Implications
1. Inform states efforts to ready themselves for
accreditation
2. Increase guidance in creating performance standards
and linking performance measures to those standards
3. Create organizational incentives for widespread PM
and QI, especially in non-clinical practice areas
References
Beitsch LM, Brooks RG, Grigg M, Menachemi N. Structure and functions of state public health
agencies. Am J Public Health. Jan 2006;96(1):167-172.
Lotstein D, Seid M, Ricci K, Leuschner K, Margolis P, Lurie N. Using quality improvement methods to
improve public health emergency preparedness: PREPARE for Pandemic Influenza. Health
Affairs. June 15, 2008 2008;27(5):328-339.
Langley GJ, Nolan KM, Norman CL, Provost LP, Nolan TW. The improvement guide: A practical
approach to enhancing organizational performance. New York: Jossey-Bass; 1996.
Lighter D, Fair D. Quality management in healthcare: Principles and methods. Boston: Jones and
Bartlett; 2004.
Mays GP, Halverson P, Miller CA. Assessing the performance of local public health systems: a survey
of state health agency efforts. J Public Health Manag Pract. Jul 1998;4(4):63-78.
National Association of City and County Health Officials. National Profile of Local Health Departments
2005.
Riley W, Brewer R. Review and analysis of quality improvement techniques in police departments:
Application for public health. Journal of Public Health Management and Practice. 2009;15(2):139149.
Comparison to Beitsch et al. (2006) and Mays et al.
(1998)
Fragmented use of PM and QI by SPHAs
Riley & Brewer (2009)recommendation. Most PM & QI
practiced at SPHAs is a project by project approach
without complete organizational involvement
Clinical practice areas implement QI more frequently
than non clinical practice areas (particularly
management areas)
Greater use of performance measures than performance
standards
Research Implications
1. Objective measures of PM and QI need to be
implemented
2. As increasing numbers of state and local health
agencies implement QI procedures, rigorous evaluation
of these QI initiatives will be critical