SHASTA HUB LEARNING SUMMIT MARCH 8, 2016 LINKING THE CHIP, STRATEGIC PLAN, & QI Tamara Maciel Bannan, MPH Director, QI On-TAP

OVERVIEW Review performance management and QI Understand how to use a modified logic model to link long-term measures with program performance measures Discuss how to reflect these linkages within the PHAB required plans Learn how using the data helps to identify quality improvement projects

Performance Management System Quality Improvement Community Health Improvement Plan Strategic Plan KEY ELEMENTS & DOCUMENTS FOR ACCREDITATION

PHAB’S DEFINITION OF A PERFORMANCE MANAGEMENT SYSTEM Published in the PHAB Acronyms and Glossary of Terms Version 1.5 A fully functioning performance management system that is completely integrated into health department daily practice at all levels includes: 1)Setting organizational objectives across all levels of the department, 2)Identifying indicators to measure progress toward achieving objectives on a regular basis, 3)Identifying responsibility for monitoring progress and reporting, and 4)Identifying areas where achieving objectives requires focused quality improvement processes.

“If you don’t know where you are going, how are you gonna’ know when you get there?” Yogi Berra

DISCUSSION Who has a standardized way to collect, track, and report performance data? What type of system are you using? What measures do you track?

ROAD TRIP EXAMPLE You need to be in Atlanta, Georgia by March 30 th. What are some of the things that you need to know? Number of miles Gallons of gasoline / gas mileage Cost Number of stops Total travel time Time since last tune up What do these look like?

TWO TYPES OF MEASURES LONG-TERM OUTCOMES (measures of population-level health outcomes, behaviors, and environments – CHIP goals) PERFORMANCE MEASURES (measures of program effort and output) and

LONG-TERM OUTCOME MEASURES Also known as health indicators or health outcomes Are about whole populations Are about people’s lives independent of receiving services Are proxies for the well-being of whole populations

EXAMPLES OF LONG-TERM OUTCOMES They might be the same indicators used for the Community Health Status Assessment Percent of students who had at least one drink of alcohol in the past 30 days Rate of foodborne illness hospitalizations each year (per 100,000) Rate of serious psychological distress in the past year (per 100,000) Rate of colorectal cancer deaths (per 100,000 population) Percent of population using tobacco Percent of children with a BMI > 25.0

PROGRAM PERFORMANCE MEASURES Are about client populations Are usually about people who receive services Are a known group of people who get service and conditions for this group can often be accurately measured

EXAMPLES OF PERFORMANCE MEASURES Percent of outbreaks investigated within standard timeframe Percent knowledge gained following an educational session Number of schools offering joint-use agreements to allow the public to use the recreational facilities Rate of readmission (hospital or psychiatric care facility)

Population Goal To reduce morbidity and mortality from vaccine-preventable diseases by improving immunization levels Population Indicator Percentage of children, ages months, who are fully immunized with one of the series of the Advisory Committee on Immunization Practices (ACIP) recommended vaccines Effective, Evidence-Based Strategies (selected subset) 1.Change provider behavior through systems change—Provider recall/reminder systems in clinics 2.Change provider behavior through education—multi-component interventions with education 3.Increase demand and access to immunizations—reduce out-of-pocket costs Program Performance Goal (NACCHO Standard 9) Performance Measure Percent of Immunization Program public and nonprofit clinic partners who routinely meet the Standards for Pediatric Immunization Practices for provider and client recall/reminder systems EXAMPLE: IMMUNIZATION PROGRAM

PERFORMANCE MEASURES QuantityQuality Input / Effort How Much Did We Do? (#) How Well Did We Do It? (%) Output / Effect How Much Change? (#) Quality of Change? (%) Based on the Results Accountability Framework

SHARING INFORMATION WITH LOGIC MODELS

DISCUSSION Who has used a logic model? Does anyone have a funder that requires them? How did you use it?

WHAT IS A LOGIC MODEL?  A simplified picture of a program, initiative, or intervention that displays the connections between resources, activities and outcomes  It serves as a framework and a process for planning to bridge the gap between where you are and where you want to be

WHY USE A LOGIC MODEL?  They could be required by funders and other organizations  Illustrate how programs are linked to organizational strategic goals and objectives

WHEN DO I USE A LOGIC MODEL?  Program Planning - A logic model serves as a framework and a process for planning to bridge the gap between where you are and where you want to be  Program Management - A logic model is used to explain, track and monitor operations, processes and functions as part of operational excellence  Evaluation - It helps determine when and what to evaluate so that evaluation resources are used effectively and efficiently. A logic model helps us focus on appropriate process and outcome measures.  Communications - A simple, clear graphic representation helps communicate about a program or initiative, whether it be with/to program staff, those funding the programs, or other key stakeholders

WHAT ARE THE COMPONENTS OF A LOGIC MODEL? In its simplest form, a logic model looks like this: InputsOutputs Outcomes - Impact What is investedWhat is done Results

WHAT ARE THE COMPONENTS OF A LOGIC MODEL?  Inputs – the resources that go into a program  Outputs – the activities the program undertakes  Outcomes – the changes or benefits that result The logic model describes the sequence of events believed to bring about benefits or change over time. It portrays the chain of reasoning, that links investments to results. A logic model is a systems model that shows the connection of interdependent parts that together make up the whole. As with systems thinking, we know that a total program is greater than the sum of the individual parts.

HUNGRYHUNGRY Feel better Get food Eat food EVERYDAY EXAMPLE

AN EXPANDED SIMPLE LOGIC MODEL InputsOutputs Outcomes – Impact What is investedWhat is doneResults Pro- gram Invest- ments Partici- pation Activi- ties Med. Term Short Term Long Term

Long-term Outcome1 Outcome 2 Short-term Outcome 1 Outcome 2 Medium- term Outcome 1 Outcome 2 Impact Activities or Effort Measure 1 Measure 2 Program Output Measure 1 Measure 2 Program Performance How much did we do? How well did we do it? How much change? What is the quality of the change? LINKING INDICATORS & MEASURES: MODIFYING THE LOGIC MODEL Is anyone better off? Have we improved the health of the community?

Performance Management System Quality Improvement Community Health Improvement Plan Strategic Plan KEY ELEMENTS & DOCUMENTS FOR ACCREDITATION

DISCUSSION Has anyone completed formal training in QI? Which method? Has anyone completed a QI project?

LINKED MEASURES Population Indicators (measures of population-level long-term health outcomes) Program Performance Measures (existing measures of program effort and outputs) AND QI Project Measures -pull from existing PMs - write new PMs

PUBLIC HEALTH PERFORMANCE MANAGEMENT SYSTEM Source: Turning Point

BACK TO OUR ROAD TRIP LET’S SAY WE MISSED OUR ARRIVAL DATE BY ONE DAY

Continuing to get the work done Looking for ways to improve it Requiring balance JUGGLING & DESIGNING

DISCUSSION Has anyone used any of NACCHO’s Culture of Quality Assessment tools? (the Roadmap or the SAT) Thoughts?

+ THE CONTINUOUS IMPROVEMENT PHASE OF A PROCESS IS HOW YOU MAKE A CHANGE IN DIRECTION. THE CHANGE IS NECESSARY BECAUSE THE PROCESS OUTPUT IS DETERIORATING OR CUSTOMER NEEDS HAVE CHANGED. Continuous Quality Improvement

Overview of the Deming’s Model for Improvement QI On-TAP Three Key Questions  What are we trying to accomplish?  How will we know the change is an improvement?  What changes can we make that will result in improvement? Usually written in a format called an Aim Statement

Once a hypothesis is supported or negated, executing the cycle again will extend what you have learned.

WHEN TO USE PDCA  It can be used to assist in meeting accreditation standards.  It can be used on an organization-wide basis to increase organizational capacity or to implement community-wide efforts to improve the public health system.  It is a model for continuous improvement.  It can be used when developing a new or improved design of a process, product, or service.  It can be used when planning data collection and analysis to verify and prioritize problems or root causes.  It can be used when implementing change.

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

Performance Management System Quality Improvement Community Health Improvement Plan Strategic Plan KEY ELEMENTS & DOCUMENTS FOR ACCREDITATION

Community Health Improvement Plan Conduct a comprehensive planning process resulting in a community health improvement plan Community Health Assessment Participate in or conduct a collaborative process resulting in a community health assessment Strategic Plan Develop and implement a health department organizational strategic plan Public Health Accreditation Application Pre-requisite Documents Performance Standards - Identify relevant standards - Select indicators - Set goals & targets - Communicate expectations Performance Measurement - Refine indicators - Define measures - Develop or enhance data systems - Collect data Performance Reporting - Analyze & interpret data - Report results broadly - Develop a regular reporting cycle Concepts of performance management and quality improvement are incorporated throughout PHAB’s standards and measures Quality Improvement - Use data for decisions to improve policies, programs, and outcomes

INSERT AN EXAMPLE

QUESTIONS? DETERMINING THE NEXT STEP ON YOUR PM/QI JOURNEY

AUDIENCE FEEDBACK AND DISCUSSION Were these webinars useful? What did you like about them? What could be improved? What type of support will you need to continue your accreditation journey?

RESOURCES Results-based Accountability Logic Models and more on Logic Models Logic Models NACCHO’s Roadmap to a Culture of Quality NACCHO’s Roadmap NACCHO’s QI Self-assessment Tool Turning Point Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook California Performance Improvement Management (Cal-PIM) Network California Performance Improvement Management (Cal-PIM) Network