PERFORMANCE MANAGEMENT
IN ACTION:
THE MONTANA MODEL
Contrasting Big “QI”, Little “qi”, and Individual “qi”
Topic
Big ‘QI’ – organization-wide Little ‘qi’ – program/unit
Individual ‘qi’
Improvement
System focus
Quality Improvement
Planning
Tied to the Strategic Plan Program/unit level
Evaluation of Quality
Responsiveness to a
community need
Performance of a process Performance of daily
work
over time
Processes
Cut across all programs
and activities
Delivery of a service
Daily work
Quality Improvement
Goals
Strategic Plan
Individual program/unit
level plans
Individual performance
plans
Specific project focus
Daily work level focus
Tied to yearly individual
performance
Continuous Quality Improvement System in Public Health
Turning
Point
Baldrige
QI
Teams
LSS
MAPP
MICRO
Big ‘QI’
MACRO
MESO
A
P
C
D
A
P
C
D
Basic Tools
of QI
Individual ‘qi’
A
P
C
D
INDIVIDUAL
QFD
Advance
Tools of QI
Little ‘qi’
A
S
C
D
Daily Management
Rapid
Cycle
De-siloifying
MCH
Preparedness
HIV
STD
Family Planning
Our Research Found Four Barriers to
Strategic Implementation
The Vision Barrier
Only 5% of the work force
understand the strategy
The People Barrier
Only 25% of managers have
incentives linked to strategy
The Management Barrier
9 of 10 companies
fail to execute
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
Four components of a performance management system
Source: Turning Point
Performance Management
Collaborative, From Silos to
Systems: Performance
Management in Public Health (in
press).
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.
Baldrige Criteria For Organizational
Performance Excellence
2
Strategic
Planning
5
Human
Resource Focus
7
Business
Results
1
Leadership
3
Customer &
Market Focus
6
Process
Management
4
Information and Analysis
Mission / Vision
Agency Strategic Plan
& Performance Report
Performance
Based Program
Budgeting
Measures
Quarterly
Performance
Report
State/Local
Performance
Standards
Healthy People
2000/2010 Benchmarks
CHD Quality
Improvement
Indicators
Performance
Management
System
County Health
Dept Plan
Program
Plans
Local and State
Needs
Assessments
Federal Grant
Requirements
MONTANA’S
ACCREDITATION
STRATEGY
Montana Department of Public Health and Human Services
Public Health and Safety Division
Lindsey Krywaruchka and Denny Haywood
Using
Systems to
Comply
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
12
INTEGRATED
MANAGEMENT
SYSTEM
Performance
Management
System
Support
A Fully
Interconnected
Unit
System
A set of interacting or interdependent processes.
 Outputs of one process are input to another.
 Interaction and feedback between the parts.
Pile of Sand
Engine
Not A System
Is A System
14
Systematic
Approaches that are repeatable and use data and
information so learning is possible.
 Must be defined, usually documented.
 Consistently applied.
 Build in opportunity for evaluation, improvement, and sharing.
15
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.
16
PHSD Integrated Management System
Are We On Track?
Tasks – Dollars – Outcomes
Define the Problems
and Priorities
Have We Attained
High Level Outcomes?
Why or Why Not?
Decide How To Attain
Desired Outcomes
Performance
Management
System
Do The Work
Plan Required
Work Tasks
& Resources
Allocate Dollars
To Do Planned Work
Support
Build Capacity To Do Work
17
Integrated Management System
Documents
State Public
Health
Improvement
Plan
State Public
Health
Assessment
Strategic
Objectives &
Metrics
PHSD
Program/
PHSD
Activity
Program/
PHSD
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
Plan
Operational
Activity
Plan
Operational
Plans
PHSD
Program/
PHSD
Activity
Program/
PHSD
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
Plan
Operational
Activity
Plan
Operational
Plans
Performance
Management
System
Program/
Activity
Metrics
PHS
Division
Strategic
Plan
PHS
Division
Budget
Support
18
PHAB CRITERIA AND
SYSTEMS
Performance
Management
System
Support
Potential
Contradiction
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.
20
“Systems” Terms Used In PHAB
Criteria










Systems
The criteria are good, but are more
Systematic
understandable when organized
as a system……
Standardized
Process
Protocol
Standard Operating Procedures
Comprehensive Planning
Strategic Planning
Operational Planning
Integrated
Performance
Management
System
Use PHAB Criteria To Build Systems
Resulting In
Performance Excellence
Support
21
PHAB Standards – Needs Assessment
 1 .1: Conduct collaborative process resulting in
Community Health Assessment.
 4.1: Engage with the
public health system and
community to identify and
address public health
problems.
State Public
Health
Assessment
Performance
Management
System
Support
22
PHAB Standards – Strategic Planning
 5.2: Conduct comprehensive planning process
resulting in State Health Improvement plan.
 5.3: Develop organizational strategic plan.
 4.2: Engage the community and
governing entity in deliberating options
and alternatives.
 7.2: Identify strategies to improve
access to health care ser vices.
 12.1.1 A: Provide mandated public
health operations, programs,
and services.
 12.2: Keep the governing entity
informed of its public health
responsibilities and its role in updating
laws, rules, and regulations .
State Public
Health
Improvement
Plan
PHS
Division
Strategic
Plan
Performance
Management
System
Support
23
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
PHSD
Program/
PHSD
to improve access to health
Activity
Program/
PHSD
Operational
Activity
Program/
PHSD
care ser vices.
Plan
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
PHSD
Performance
 11 .1: Develop and maintain
Management
Plan
Operational
Activity
Program/
System
Plan
Operational
Activity
operational infrastructure.
Plan
Operational
Plans
 11.1.1.A: Maintain operational
policies and procedures.
 12.1.1 A: Provide mandated
public health operations, programs,
and services.
Support
24
PHAB Standards – Budget
 11 .2: Establish ef fective financial management systems.
 11.2.3 A: Maintain financial management systems.
 11.2.4 A: Seek resources for infrastructure, processes, programs, and
interventions.
Performance
Management
System
PHS
Division
Budget
Support
25
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 to
investigate, contain, and mitigate
problems and hazards.
PHSD
Program/
PHSD
Activity
Program/
PHSD
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
Plan
Operational
Activity
Plan
Operational
Plans
Program/
Activity
Metrics
Performance
Management
System
Support
26
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 multiple
methods to a variety of audiences.
PHSD
Program/
PHSD
Activity
Program/
PHSD
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
Plan
Operational
Activity
Plan
Operational
Plans
Program/
Activity
Metrics
Performance
Management
System
Support
27
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 enforcement
activities and notify agencies.
PHSD
Program/
PHSD
Activity
Program/
PHSD
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
Plan
Operational
Activity
Plan
Operational
Plans
Program/
Activity
Metrics
Performance
Management
System
Support
28
PHAB Standards – Evaluation
 1 .3: Analyze public health data to identify problems, hazards,
and factors af fecting public health.
 1 .4: Use data analysis to develop recommendations for
policy, processes, programs, or interventions.
 5.1: Serve as resource for
Strategic
Objectives &
policies, practices,
Metrics
and capacity.
 7.1: Assess healthcare
service capacity and access.
 12.3: Engage the governing
entity in the department’s
obligations and responsibilities.
Performance
Management
System
Support
29
PHAB Standards – Performance Management
 Standard1 .2: Maintain a system to collect, manage, analyze, and
use public health condition and impor tance data.
 Standard 9.1: Use a per formance management system to monitor
achievement of organizational objectives.
 Standard 9.2: Develop and implement
Strategic
integrated quality management
Objectives &
processes.
Metrics
 12.3.3 A: Communicate with the
governing entity about assessing
and improving performance.
State Public
Health
Assessment
State Public
Health
Improvement
Plan
PHS
Division
Strategic
Plan
PHS
Division
Budget
Links all plans and measures.
Performance
Management
System
PHSD
Program/
Activity
Operational
Plans
Program/
Activity
Metrics
Support
30
PHAB Standards – Support
 8.1: Develop suf ficient public health worker s.
 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 data
analysis, program management,
and communication.
 11.1.7 A: Maintain facilities.
PHSD
 10.1: Identify and use
Program/
PHSD
the best available
Activity
Program/
PHSD
Operational
Activity
Program/
PHSD
evidence in making
Plan
Operational
Activity
Program/
PHSD
Plan
Operational
Activity
Program/
PHSD
decisions.
Plan
Operational
Activity
Program/
Plan
Operational
Activity
 10.2: Promote under standing
Plan
Operational
and use of research results,
Plans
evaluations, and evidence -based
practices.
Performance
Management
System
Program/
Activity
Metrics
Support
31
HOW TO:
BUILDING A
PERFORMANCE
MANAGEMENT SYSTEM
Performance
Management
System
Support
Translating
Strategy Into
Action
Performance Management System
Processes, information, and systems used by managers to:





Set strategy
Develop plans
Monitor execution
Forecast per formance
Repor t results
Performance
Management
System
Support
33
Steps to Build
1.
2.
3.
Construct Logic Model
Develop Work Plans
Establish Systematic Progress Review
Tying the Integrated
Management System
together!
34
1. Construct Logic Model
 Desired Outcomes
 Metrics
 Linked in Chain of Cause - And-Ef fect
 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
35
Cancer
Healthcare
Provider
Education
Cardiovascular
Disease
School and
Childcare
Training
Asthma
MT Asthma
Home Visiting
Tobacco
Prevention
Asthma Care
Monitoring
System
Bureau
Chronic
Disease
Subdividing
Work Into More
Manageable
Pieces
Diabetes
Program
Core Activity
(Project or Process)
Makes a very complicated
life much easier to manage!
36
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
versus
Core Activity:
Asthma Home Visiting
Provider Education
School & Childcare Training
37
Linked Cascading Chain of Cause-And-Effect
Example
Desired
Outcomes
Chronic Disease
Bureau
Montanans with chronic
conditions manage their
disease and experience
fewer complications.
Diabetes Program
Individuals avoid
diabetes complications
and maintain quality
of life.
Asthma Program
Individuals experience
fewer asthma
symptoms such that
normal activity levels
are not hampered.
Cancer Program
Bureau Result
meets a Public
Need or Solves a
Public Problem
Fewer Montanans
experience late stage
cancer.
Collective
Intermediate
Results
Surveillance and Epidemiology
PH professionals are
promptly alerted
to the incidence of
asthma.
Provider Education
PCPs utilize the most
current and effective
evidence-based
asthma care practices.
School-Childcare Training
Montana schools
and child care
facilities properly
manage asthma.
Activity C Work Plan:
• Provide asthma
training to staff of 25
middle schools.
• Provide asthma
assessment training to
30 school nurses. 38
Linked Cascading Chain of Cause-And-Effect
Surveillance and Epidemiology
Diabetes Program
Example
Metrics
Chronic Disease
Bureau
Number of Montana
chronic disease
hospitalizations.
Number of individuals
per 100,000 population
who develop diabetes
monthly
Asthma Program
Number of asthma
hospitalizations per
10,000 population
monthly
Cancer Program
High level outcome
metric
Percent of Montanans
who are up-to-date
with colorectal cancer
screening.
Intermediate
outcome
metrics
Average number of days
from diagnosis to entry
into the asthma
database.
Provider Education
Number of healthcare
professionals receiving
spirometry diagnosis and
assessment training
School-Childcare Training
Number of school staff or
child care providers who
received training during
the past calendar year.
Detailed,
operational
and tactical
metrics
Activity C Work Plan:
• Provide asthma
training to staff of 25
middle schools.
• Provide asthma
assessment training to
30 school nurses. 39
Metrics Derived From Desired Outcomes
Example
Desired
Outcomes
Chronic Disease
Bureau
Montanans with chronic
conditions manage their
disease and experience
fewer complications.
Diabetes Program
Individuals avoid
diabetes complications
and maintain quality
of life.
Asthma Program
Individuals experience
fewer asthma
symptoms such that
normal activity levels
are not hampered.
Cancer Program
Fewer Montanans
experience late stage
cancer.
Surveillance and Epidemiology
PH professionals are
promptly alerted
to the incidence of
asthma.
Provider Education
PCPs utilize the most
current and effective
evidence-based
asthma care practices.
School-Childcare Training
Montana schools
and child care
facilities properly
manage asthma.
40
Metrics Derived From Desired Outcomes
Diabetes Program
Example
Metrics
Chronic Disease
Bureau
Number of Montana
chronic disease
hospitalizations.
Number of individuals
per 100,000 population
who develop diabetes
monthly
Asthma Program
Number of asthma
hospitalizations per
10,000 population
monthly
Cancer Program
Percent of Montanans
who are up-to-date
with colorectal cancer
screening.
Surveillance and Epidemiology
Average number of days
from diagnosis to entry
into the asthma
database.
Provider Education
Number of healthcare
professionals receiving
spirometry diagnosis and
assessment training
School-Childcare Training
Number of school staff or
child care providers who
received training during
the past calendar year.
41
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!
42
Defining Core Activities
What are the ideal end results of this program?
43
Defining Core Activities
What are the tasks that your program carries out to make those results happen?
44
Defining Core Activities
Silent brainstorming.
45
Defining Core Activities
Group tasks – part of same work function having same purpose.
46
Defining Core Activities
Debate clarifies values, purpose, and function.
47
Defining Core Activities
“affinity diagram”
Title of what is being done – Core Activity Name.
Program tasks grouped
by function / purpose.
48
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
49
Logic Model & Work Plan Development
Brainstorm
Session Tasks
One
3 hr
Identify Core
Activities
Logic Model
Training
Refine Program
Session Logic Model
Two
2-3 hr
Work Plan
Training
Select Core
Activity to
Develop First
Work Plan
Develop
Program Logic
Model
Prepare First
On Own Work Plan
Time Independently
Learning
Session Exercise:
Three Review First
Work Plan
1 hr
Complete
Other Work
Plans
Independently
50
3. Establish Systematic Progress
Review
 Compare Current Progress to Work Plan
 Program/Activity Manager Reviews Monthly
 Bureau Chief Reviews Quarterly
 HealthStat: Division Administrator Reviews Every 6 Months
 Similar to CitiStat, CompStat
CRITICAL to Keep System Alive
51
Why regular Progress Review
Meetings?
 Systematically, take a “time out” to communicate and jointly
evaluate progress with management.
 Conduct problem solving about problems or “road blocks”
encountered.
 Anticipate road blocks on the immediate horizon.
 Develop plans and take proactive corrective actions to get the
Activity back on schedule or keep it on schedule, including
resource allocation. – Initiate QI Corrective Action Procedure
 Address “road blocks” or problems early before they become
crises
52
Structured Progress Review Meeting
 Are we there yet?
 Review metrics and work progress
 Did we do what we said we
were going to do?
 Did it work?
 Discuss what worked, what didn’t,
and why
Governor Gregoire
State of Washington GMAP
 What do we need to do dif ferently?
 Develop action plans to remove “road blocks” or solve problems
 Revise the work plan as needed
 Initiate QI “Corrective Action” procedure
53
Monthly
Review –
Program
Manager
Monthly
Review –
Program
Manager
Dec
Quarterly
Review –
Bureau
Chief
Jan
Nov
Performance
Management
System
Monthly
Review –
Program
Manager
Feb
Support
Quarterly
Review –
Bureau
Chief
Mar
Systematic and
Oct
Monthly
Review –
Program
Manager
Continuous Cycle of
Program / Core Activity
Progress Reviews
Monthly
Review –
Program
Manager
Apr Quarterly
Review –
Sep
Bureau
Chief
May
Aug
Monthly
Review –
Program
Manager
Jul
Quarterly
Review –
Bureau
Chief
Jun
Monthly
Review –
Program
Manager
Monthly
Review –
Program
Manager
54
CASE STUDY:
CHRONIC DISEASE
BUREAU
Performance
Management
System
Support
Beginning
From A
Blank Canvas
Eating the Elephant…
 Leadership Team Of fsite Meeting Dec 2011
 Began pilot with one program
 Dec 2011  Jan 2012
 Carefully selected most supportive people
 Already think and manage this way
 Developed two internal experts
 CDC Coordinated Chronic Disease Prevention and Health Promotion
 Initiated one or two programs per week
 Feb  May 2012
 Bureau Chief set deadline
 12 Programs and circa 65 Core Activities
56
57
58
Logic Model Poster
59
Next Steps
 Complete Work Plan Database
Development and Rollout
 Complete Work Plans
in All Bureaus
 Initiate HealthStat
Progress Reviews
in All Bureaus
60
SUMMARY
AND
CONCLUSIONS
Performance
Management
System
Support
PHSD Performance Management
System Components
PHSD Strategies and Objectives
Work Plan Metrics and Targets
Work Plan Action Plan
Work Plan Budget
and Expenditures
 Program/Bureau/Division
Logic Model
 SharePoint Database of
Metrics and Work Plans
 Regular Progress Reviews




 QI Project Initiation
Performance
Management
System
Support
62
Take Home Message
 Organizational performance excellence relies on systems
thinking
 seeing the organization as one fully interconnected unit
 Build management systems to comply with PHAB
 Building Performance Management System:
1.
2.
3.
Construct Logic Model – Identify Activities
Develop Work Plans
Establish Regular-Systematic
Progress Reviews
Performance
Management
System
Support
63
Montana PHSD Integrated Management System
Additional Resources
 Baldrige Criteria for
Performance Excellence
 http://www.nist.gov/baldrige/
 Government Management Accountability and Performance
(GMAP)
 http://www.accountability.wa.gov/
 City of Baltimore – CitiStat
 http://www.baltimorecity.gov/
Government/AgenciesDepartments/
CitiStat.aspx
Lindsey Krywaruchka – LKrywaruchka@mt.gov
Denny Haywood – DHaywood@mt.gov
64
THANK YOU
This presentation was supported by funds made available
from the Centers for Disease Control and Prevention,
Office for State, Tribal, Local and Territorial Support,
under CD10-1011 Strengthening Public Health
Infrastructure for Improved Health Outcomes
Lindsey Krywaruchka—lkrywaruchka@mt.gov
Denny Haywood—dhaywood@mt.gov
65