PERFORMANCE MANAGEMENT
AND QI PRINCIPLES AND
STRATEGIES
MINNESOTA’S DEPARTMENT OF HEALTH (MDH)
AND COMMUNITY HEALTH BOARDS
JANUARY 10, 2011
MarMason Consulting
Marni Mason BSN, MBA
2

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
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QI for Leadership Series
3
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Session # 1: Overview of Quality Improvement for Leadership
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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)
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Session # 3: Strategies and Methods for Continuous Quality
Improvement
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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
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Today’s Learning Objectives
4

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
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Performance Management
5
QI Methods
& Tools
Breakthrough
Collaborative
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Business
Process
Analysis
Performance Management
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Source: Turning Point
Performance
Management
Collaborative, 2003.
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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
Performance Measurement
Monitoring of
Performance
• Review of performance
(Accreditation/SelfAssessment) results
• Program evaluation
results
PERFORMANCE
MEASUREMENT
Monitoring
of Indicators and
Outcomes
• Process and short-term
outcomes
• Health indicators and
outcomes
Definition of Quality Improvement
A management process and set of
disciplines that are coordinated to ensure
that the organization consistently meets
and exceeds customer requirements.
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
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
QUALITY
IMPROVEMENT
PROCESS
Reporting Progress


REPORT
PROGRESS
Performance in standards
Indicators and outcomes
 Health
indicators
 Program evaluation data
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Regular data tracking, analysis and review
Basis for QI efforts
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Integration of QI into Agency Culture
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Multilevel Model of Integration*
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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
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Levels of QI Integration
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100
75
50
25
0
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Level 1- No
interest or
activities
Level 2Awareness,
interest and
one-time
projects
Level 3Multiple
teams and
QI tools,
but no
repetition
or
saturation
Level 4Speciic QI
model
integrated
into agency
management
structure
with
continuous
improvement
JPHMP Article Recommendations
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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
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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
Let’s Discuss!
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What is your
experience with the four
components of
performance
management in your
Health Department?
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QI Principles and Strategies
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The Quality Environment
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
Agency-wide commitment to
assessing and continuously
improving quality over time?
Decisions based on data?
 Agency achieving goals?

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Use data to decide on
improvement initiatives and to
know if the improvements are
successful?
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Principles of Quality Management
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1.
2.
3.
4.
5.
6.
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
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1. Know Your Stakeholders
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
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
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Public Sector Map
Department
of Defense
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National Institute of
Health
Office of the
Insurance
Commissioner
Dept. of Social &
Human Services
•Aging & Adult
Services
•Med. Asst. Admin
•Division of
Developmental
Disabilities.
•Mental Health
Division
Public Hospital
Districts
Department of
Health
•Chronic Disease &
Risk Reduction
•Diabetes
Prevention &
Control
•Community & Rural
Health
•Community &
Family Health
•Maternal Support
Srvcs
•Women, Infants &
Children
•Licensing Boards
Head Start
Programs
•Tri-Care
•Prime
Governor /
Legislature
Employment
Security
Department
•Worksource
Department of
Veterans
Affairs
Health Care
Authority
•Public
Employees
Benefit Board
•Basic Health
Plan
Office of the
Superintendent of
Public Instruction
Dept. of
Corrections
•Prisons
School Boards
•Public schools
•BIA schools
•Charter schools
•Private faith based
schools
State Board
of Health
Local Health
Jurisdictions
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
MarMasonBullets
Consulting
refer to examples of organizations and are not a comprehensive listing.
Department of
Labor &
Industries
Local
Governments
Public
Library
System
2. Focus on Work Process
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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”
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Measure processes that are:



Important and relevant to population
Control vs. Influence
High-risk
 Health

High-volume
 WIC,

Alerts, Drinking Water, CD Investigations
Food Safety, OSS, Immunizations
Problem-prone
 Emergency
Preparedness
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
The Logic of Public Health
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We inspect
restaurants
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
% of critical
violations corrected
within 24 hours
So that
There are fewer
incidents of
foodborne illness
rate of foodborne illness
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3. Use Data to Make Decisions
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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
Poll Question
How frequently do you/your organization use data
to target improvement efforts?
A. Rarely
B. Sometimes
C. Often
D. Always
Use Data to Make Decisions
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Conceptual Tools
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Affinity Diagram
Brainstorming
Process Flow Chart
Cause and Effect
Diagram (Fishbone)
Five Why’s
Matrix Diagram
Numerical Tools
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Check Sheet
Bar Chart
Histogram
Pareto Chart
Control Chart
Run Chart
[See Goal/QPC PH Memory Joggers]
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Power of Root Cause Analysis
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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.
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* The Public Health Quality Improvement Handbook,
page 22
Root Cause Analysis
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
Goal:
To find the real cause of a problem or issue
 Understand the impact to the organization
 Resolve it with a permanent fix
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We need to determine:
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what happened?
why it happened?
where it happened?
how to eliminate it?
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Cause and Effect Diagram
Test Location
Inconvenient
Too Public
Client
Don’t see
benefit
Don’t Want Test
Fearful
Poor
HIV Testing
Not Client
Centered
Not Offered
Counseling
Not Respectful
Poor Experience
Staff
Example of Fishbone
WIC Client Redemption of Farmer’s Market Coupons
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People
Access
Knowledge Deficit
Variety/Selection
Client has more
distractions in the summer
Limited WIC Providers
Locations
Preferences
Customer Service
Language
Personal
Hours
Cultural
WIC clients do
not redeem all of
the farmer’s
market coupons
Distribution
Small dollar value
Frequency
Timing
Limited supply
No change is given
Staff explanations of
Farmer’s Market option
Methods
Materials
Page 1
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4. Use Teamwork
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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
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Tips for Effective QI Teams
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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,
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Storming, Norming, Performing
Affinity Diagram*
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Why use it?
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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??
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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”
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*PH Memory Jogger page 12
Uptake of Vaccines Example (Kittitas,
WA)
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5. Make QI Continuous
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
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

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Improvement Model - PDSA Cycle
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The Plan Do Check/Study Act Cycle is a trial-andlearning 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
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PDSA Improvement Cycle
Act
• What changes are to
be made?
• Next cycle?
DOCUMENTATION OF
CHANGE - MINUTES
• Objective
• Questions and predictions
• Plan to carry out the cycle
(who, what, where, when)
• Plan for data collection
REVISE
LOGIC MODEL
LOGICLOGIC
MODEL
REVISE
MODEL
Study
Do
DATA REPORT
WORK PLAN
•Complete the data analysis
•Compare data to
predictions
•Summarize lessons
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Plan
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• Carry out the plan
• Document problems and
unexpected observations
• Begin analysis of the data
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
Make QI Continuous
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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
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Adopt or Adapt Model Practices
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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
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Describe your process (Logic Model or Flow Chart)
Study the exemplary practice process
Adopt or adapt as appropriate
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6. Demonstrate Leadership Commitment
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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
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QI Culture and QI Council
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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
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RCI/QI projects:

Quality planning is more appropriate than QI for some
projects with long-term outcomes
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Agency Level Performance Measures
Measure
Indicator
Improve immunization
rates
Increase the percentage of kindergarten enrollees
that are up to date on their immunizations upon
school entry from 86% to 92% by 2014.
Reduce tobacco use
Decrease the percentage of adult smokers to 16%
by 2014.
Reduce overweight &
obese populations
Reduce the rate of increase for adult obesity to 0%
by 2014.
Increase healthy physical
activity
Increase the percent of youth who are physically
active for at least 60 minutes per day from 16.8% to
18.5% by 2014.
Reduce substance abuse
Increase the number of adults receiving opiate
treatment service by 23% by 2014, to 800 patients.
Increase responsible
sexual behavior
Increase the percentage of sexual partners treated
for sexually transmitted diseases by 10% by 2014.
Responsibility
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Change vs. Improvement
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
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
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Some QI References
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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
What questions do you have?
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