Developing a Performance Excellence Council From Silos to Systems Daniel Jordan, PhD, ABPP Research Psychologist American Public Health Association Conference Monday, November 4, 2013: 8:30 AM-10:00 AM Ventura County Public Health A Division of the Ventura County Health Care Agency

An Aside

Inputs (Outputs) Policy/ Environment Changes Project Activities (Short-term) Access, Availability, Knowledge, Attitudes (Intermediate) Behavior Changes (Long-term) Health Outcomes Community Context (Impact) Chronic Disease Rates Funding Source Requirements CDC/CTG Engagement Model

CDC/CTG Engagement Model Inputs (Outputs) Policy/ Environment Changes Project Activities (Short-term) Access, Availability, Knowledge, Attitudes (Intermediate) Behavior Changes (Long-term) Health Outcomes Community Context (Impact) Chronic Disease Rates Funding Source Requirements  Daniel Jordan, PhD, ABPP This is a Downstream Medical Model

Inputs (Outputs) Policy/ Environment Changes Project Activities (Short-term) Access, Availability, Knowledge, Attitudes (Intermediate) Behavior & Environmental Changes (Long-term) Environmental Change & Health Outcomes Change Community Context (Impact) Chronic Disease Rates Funding Source Requirements Environmental/ Community Mobilization Model Inform, Educate, Empower, & Mobilize Communities Daniel Jordan, PhD, ABPP Upstream

Ventura County Public Health Acknowledgements Performance Excellence Council (PHAB Domain 9) Leads – Bev Hansen, Immunizations Program Manager, PEC Chair – Daniel Jordan, PhD, ABPP, Research Psychologist & Manager, Healthy Communities Team – Lauri Plunkett, Vital Records Manager, PEC Co-Chair Public Health Accreditation Leads – Rigoberto Vargas, MPA, VCPH Director – Steve Carroll, Emergency Medical Services Director – Patty Chan, Healthy Families Team Manager – Daniel Jordan, PhD, ABPP, Research Psychologist – Megan Steffy, RN, Director of Nursing and all of the staff members of Ventura County Public Health Daniel Jordan, PhD, ABPP,

Stimuli A long-standing Continuous Quality Improvement Committee – Functioned at an independent program level (siloed) – Projects designed and implemented by line managers and staff with little or no research design and evaluation experience APHA Domain 9 required a functioning, integrated Performance Management System County implemented Lean Six Sigma

Barriers Turning Point Foundation identified four major barriers to reducing silos and creating integrated performance management – Vision Barrier: Only 5% of the workforce understands the strategy – People Barrier: Only 25% of managers have incentives linked to strategy – Management Barrier: 85% of executive teams spend <1 hour per month discussing strategy – Resource Barrier: 60% of organizations don’t link budgets to strategy Source: Balance Scorecard Collaborative, ©2013 Daniel Jordan, PhD, ABPP,

More Barriers Categorical funding forces siloing: – Federal, State, Grant, Local support (e.g., County General fund) Changes in philosophy are siloing agencies from communities: – Inform, educate, empower, mobilize has become – Inform, educate and engage – communities as passive recipients of our “expertise” ©2013 Daniel Jordan, PhD, ABPP,

To What Extent Do We Do This? To What Extent do Our Staff Know This? Daniel Jordan, PhD, ABPP,

Inputs (Outputs) Policy/ Environment Changes Project Activities (Short-term) Access, Availability, Knowledge, Attitudes (Intermediate) Behavior Changes (Long-term) Health Outcomes Community Context (Impact) Chronic Disease Rates Funding Source Requirements CDC/CTG Engagement Model

CDC/CTG Engagement Model Inputs (Outputs) Policy/ Environment Changes Project Activities (Short-term) Access, Availability, Knowledge, Attitudes (Intermediate) Behavior Changes (Long-term) Health Outcomes Community Context (Impact) Chronic Disease Rates Funding Source Requirements  Daniel Jordan, PhD, ABPP This is a Downstream Medical Model

Inputs (Outputs) Policy/ Environment Changes Project Activities (Short-term) Access, Availability, Knowledge, Attitudes (Intermediate) Behavior & Environmental Changes (Long-term) Environmental Change & Health Outcomes Change Community Context (Impact) Chronic Disease Rates Funding Source Requirements Environmental/ Community Mobilization Model Inform, Educate, Empower, & Mobilize Communities Daniel Jordan, PhD, ABPP Upstream

Result of Barriers We’re all supposed to know and function out of a set of “Essential Services” that conceptually integrate public health philosophy, vision, mission, goals These essential services are to create a partnership with the communities we serve Activity: Compare your programs and services to the Ten Essential Services. Identify the extent of match. Daniel Jordan, PhD, ABPP,

Need A coordinated approach to managing an entire operation Development of skills and knowledge about the Ten Essential Services Shift from program measurement to a balanced and cohesive management model Shift from categorical to a scope targeting system-wide capacity, process and outcomes ©2013 Daniel Jordan, PhD, ABPP,

Strategy Create an integrated approach, vertical and horizontal, to improving and managing public health services performance Cross-develop public health skill sets by assigning staff to projects in domains “outside their comfort zones” Identify and train staff in broad skill sets so they can move about within the system and know our own resources Orient staff members to the meaning of public health as opposed to medical care Daniel Jordan, PhD, ABPP,

Performance Management System model from the Public Health Foundation (Turning Point) Source: Note: Distinctions between performance management, performance improvement, quality improvement, and similar phrases varies across authors and sources. The four categories used here are established as four components in a cycle of a comprehensive performance management system. Performance Management System Performance Standards —establish organizational or system performance standards, targets, [priorities,] and goals to improve public health practices. Performance Measures —develop, apply, and use performance measures to assess achievement of such standards. Reporting of Progress —document and report on progress in meeting standards and targets and sharing of such information through feedback. Quality Improvement Action — establish a program or process to manage change and achieve quality improvement in... policies, programs or infrastructure based on performance standards, measurements, and reports.” Performance Excellence Council Daniel Jordan, PhD, ABPP,

Siloed Plans and Processes Continuous Quality Improvement (CQI) Public Health Strategic Plan Public Health Accreditation Plan Public Health Budget & Plan Community Health Improvement Plan Daniel Jordan, PhD, ABPP,

Integrated Plans and Processes Continuous Quality Improvement (CQI) Public Health Strategic Plan Public Health Accreditation Plan Public Health Budget & Plan Community Health Improvement Plan Performance Management System/ Performance Excellence Council Daniel Jordan, PhD, ABPP,

Ventura County Performance Management System Performance Excellence Council Structure – #1 Daniel Jordan, PhD, ABPP,

Ventura County Performance Management System Performance Excellence Council Structure – #2 Daniel Jordan, PhD, ABPP,

Performance Management System Structural Alignment Administration & Management, Engage Governing Entity -Deployment Champions (Domain 11 & 12) – Assess, Monitor & Investigate (Domain 1 & 2) – Health Education & Promotion, Intervention (Domain 3) – Engage the Community (Domain 4) (Mobilize the Community, Essential Service 4) – Policy, Practice & Standards, Enforce Laws & Rules (Domain 5, 6, & 8) Public Health Accreditation Standards Essential Public Health Services National Public Health Performance Standards Program Strategic Plan, Health Improvement Plan, Business Plan – Capacity Development & Workforce Competency (Domain 7 & 8) – Assurance: Evaluation & Research (Domain 9 & 10) Daniel Jordan, PhD, ABPP,

Deployment Champions (Domains 11 & 12) Deployment champions (Lean Six Sigma terminology) are assigned by the Department Director. Identify value streams: current improvement or new development. Prioritize improvement and development projects with the Performance Excellence Council Chair and Co-Chairs. Review progress and take action on resulting reports and outcomes. Assure a balance in assignments of Team Leads and Members. If a special focus is established in one or more areas the Deployment Team may assign Leads and Members to assist across domains. Daniel Jordan, PhD, ABPP,

Public Health Performance Excellence Council Principles Integrate a performance improvement and management toolkit with the Ten Essential Services of Public Health. Identify, maintain, and improve community health, safety, and wellness. Continuously look for and act on excellence opportunities. Ongoing, integrated cycles of assessment, planning (DMEDI), and evaluation and process improvement (DMAIC) in a single structure, aligned with the County’s Service Excellence approach. Base strategies on measurable, knowledge-driven data. Conduct risk (threat and weakness) assessment. Workforce Competency: Staff members participate in all aspects of performance excellence. Mobilize the Community (Domain 4): As appropriate, community members and service recipients participate in identifying and responding to community health and wellness needs. Daniel Jordan, PhD, ABPP,

Basic Role Structure and Process Public Health Foundation PM System Stages Performance Standards Performance Measures Reporting of Progress Quality Improvement Deployment Champions Performance Excellence Council Leads & Coordination Domain Leads Project Participants: Staff, Stakeholders, Community Members, Clients Daniel Jordan, PhD, ABPP,

Deployment Champions Revised: 6/5/14 Performance Excellence Council (PEC) Chairs PEC Staff Coordinator Performance Excellence Council (PEC) Chairs PEC Staff Coordinator Public Health Managers, Staff Members, Coalitions, or Community Members, etc. Public Health Managers, Staff Members, Coalitions, or Community Members, etc. Set Priorities, Performance Standards, Goals and Objectives, Communicate Expectations Develop Strategic Plan, benchmarks,¹ Performance Management proposals, prioritize and coordinate resources Set Priorities, Performance Standards, Goals and Objectives, Communicate Expectations Develop Strategic Plan, benchmarks,¹ Performance Management proposals, prioritize and coordinate resources Set Performance Standards: Oversee project proposals, identify resources to implement projects Coordinate Performance Standards & Measurement, analyses, recommendations from Core Function Team Leads at least annually, collect, coordinate, Report Progress² Coordinate, track, and compile Performance Management projects, support PEC Chairs Set Performance Standards: Oversee project proposals, identify resources to implement projects Coordinate Performance Standards & Measurement, analyses, recommendations from Core Function Team Leads at least annually, collect, coordinate, Report Progress² Coordinate, track, and compile Performance Management projects, support PEC Chairs Engage Staff & Community: Provide Process Improvement feedback to PEC Chairs; seek aid to implement process improvements Refine Goals and Targets for program-level improvement projects, request aid from PEC Leads Engage Staff & Community: Provide Process Improvement feedback to PEC Chairs; seek aid to implement process improvements Refine Goals and Targets for program-level improvement projects, request aid from PEC Leads Assess and assign Performance Management proposals; refine measures, develop projects and charters⁴ Assess and assign Performance Management proposals; refine measures, develop projects and charters⁴ Performance Standards: Review and Approve Performance Management project proposals, forward approved projects to PEC Chairs Bi-Monthly Council/ Team Meeting: Report Progress, Coordinate Projects; Assign projects to Team Leads, Identify participants CQI Process: Implement recommendations, track results, provide feedback CQI Report Progress: Quarterly Feedback to Deployment Champions, Team Leads, Staff, Coalitions, and Community, recommend performance management improvements CQI Oversight: Review updates, provide feedback, re-prioritize benchmarks; Use data to improve policies, programs & outcomes, create management changes & a learning organization Ventura County Public Health Coordinate and implement performance standards: Work with Team Leads - refine indicators, data systems for plans³ based on goals and targets Performance Management System and Quality Improvement Procedures: Submit suggestions and proposals to 1.Benchmarks may be based on Healthy People 2020, County Health Rankings, County and State indicators, Census products, syndromic surveillance, program data, budgeting, etc. 2.This applies to the Strategic Plan, Business Plan, Community Health Improvement Plan, COOP, etc. The PHAB/PEC Coordinator focuses on PHAB-related issues to assure accreditation compliance. 3.PEC Chairs assure Performance Measurement charters are developed from priorities set by the Deployment Champions. They assign projects to Team Leads, PH Managers or staff members as appropriate. This includes refining proposed projects, indicators and measures and collecting data. 4.This performance management structure and process is based on: Ventura County Public Health Performance Management System/Performance Excellence Council Process Decide on, prioritize and assign Performance Standards & PEC Council Leads Recommendations Review Progress Reports, make recommendations for change Report PEC/PHAB Project Progress to PEC Leads; Report to funding sources, etc. Three Core Function Teams (Assessment, Policy Development, Assurance) Performance Standards: Propose Performance Improvements; request aid to implement projects Performance Measurement: Perform SWOT analyses; Report Progress² recommendations at least annually for each Domain Performance Standards: Propose Performance Improvements; request aid to implement projects Performance Measurement: Perform SWOT analyses; Report Progress² recommendations at least annually for each Domain Work with PEC Chairs to refine indicators, develop data systems for plans³ based on goal and target benchmarks Performance Management System Roles Summary Responsibilities Performance Standards Measurement Progress Reporting CQI Activities Oversee Performance Measurement Projects: Project Data System, Collect Data, Implement Strategic Plan Objectives, Event Charters, or Just- Do-Its, Report Progress, Analyze Data Report Project Progress and Results to PEC Leads, make recommendations Propose Projects to PEC Chairs and assure coordination across all active projects CQI Process: report results and make recommendations to PEC Leads performance improvements Conduct Program-Level Performance Measurement: Implement ongoing improvement projects, collect and analyze data Daniel Jordan, PhD, ABPP,

Results to Date This structure was used to develop Domain 9 of the PHAB accreditation proposal and received high praise from the PHAB Site Visit Team The PEC structure and process is being used to deploy improvement projects that have been identified through the PHAB accreditation process Daniel Jordan, PhD, ABPP,

Results to Date Staff members are much more well-versed in public health essential services, and have more awareness of the range of public health services in our County To date 27 projects have been suggested by staff and stakeholders Four performance management projects have been deployed (we first had to get through PHAB) Daniel Jordan, PhD, ABPP,

Summary: Creating a Performance Improvement and Management Culture This shift to integration creates a new culture of performance improvement and management Managers and staff have to think, and work, outside their own siloes Projects can have broader utility than just within individual programs Programs can call on outside resources Daniel Jordan, PhD, ABPP,