Ron Chapman, MD, MPH Director and State Health Officer California Department of Public Health

Pipes where demand for services goes in one end and a service/product comes out the other end. History and a series of decisions makes the pipes long and tortuous. The pipes need to be straightened and shortened.

People create systems: – Each system is perfectly designed to serve the purpose for what is was intended. People are not the system. Need to analyze and improve the system.

Actively use performance data to improve the publics health. Strategic use of performance measures and standards to establish performance targets and goals. Performance management practices can also be used to: prioritize and allocate resources; inform managers about needed adjustments or changes in policy or program directions to meet goals; frame reports on the success meeting performance goals.

Quality improvement (QI) in public health is the use of a deliberate and defined process which is focused on activities that are responsive to community needs and improving population health. QI is a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, and outcomes of services and processes which achieve equity and improve the health of the community. Defining Quality Improvement in Public Health. Journal of Public Health Management and Practice, Jan/Feb 2010.

QI is a set of tools to help people understand, analyze, and transform systems. Need to tear apart the house to see the pipes. QI principles Systems and customer focus Evidence-based and data driven Shared decision making Multidisciplinary process (many eyes!) Continuous!

Continuous Quality Improvement (CQI) AKA Plan- Do-Check-Act (PDCA) or Plan-Do-Study-Act (PDSA) Baldrige Performance or Balanced Scorecard ISO 9000 Lean Six Sigma Total Quality Management Turning Point Performance Management Framework Kaizen

People will learn and use the tools to analyze and transform systems. People will be empowered to use these tools and to make the systems changes. The system will be changed to provide better and faster services for our customers. Process will not be sacrificed for product.

Not a replacement for: Leadership skills Functional teams (team building) Governance

Problem: Contracts are not being executed timely (3,000 contracts in CDPH) Baseline Data: DGS routinely rejected 60 – 70 % of contracts Analyze all of the DGS Rejections for past year Unclear and/or Poor Scope of Work and Budget 75% Conflicting Exhibits – 25%

Discussed Issues with DGS Contacted another Departments Contract Units How do they do business?

Major root causes identified No Inventory of contracts No data source of contract activities that could provide guidance CMU Managers were not available to staff and review contracts to send to DGS; time spent in meetings with program Lack of contract knowledge both internally and externally Performance measure requiring CMU review in 15 days placed focus on quantity, not quality

No Inventory of contracts Inventory Contracts and develop meaningful reports CMU Managers were not available to staff and review contracts to send to DGS CMU Managers need to be available to provide guidance to CMU staff Lack of contract knowledge both internally and externally Training Program for CDPH Staff involved with Contracts CMU Performance measure focused on quantity, not quality Focus on quality not quantity

Monitored DGS rejection rate of contracts Measured % of contracts approved by DGS in first submission Monitored if contracts moved through process CMU Manager available to provide Quality Control Feedback to CMU staff more valuable and efficient

Better Use of Information Technology Develop processes to ensure: All contract information accurately entered into CAPS Staff Training Classes developed for program staff and CMU staff Streamline Contracting Process Increased use of DGS established templates Updating Exhibit language to remove conflicts

Ongoing inventory and clean up of CAPS Ability to generate contract status reports CMU Managers and shift in responsibilities Managers available to CMU & Program staff to provide guidance Ongoing training for CMU and program staff Series of classes covering contracts and procurements Eliminated redundant review of approved contracts Saved approximately 2-3 hours of contract processing time Philosophical shift from just send to DGS to do it right Executive management support is key to promote shift in attitude

Of last 900 contracts only 4 were returned from DGS=99.5% approval rate. FY completed about 300 contracts. FY completed over 900 contracts. Productivity tripled! Some program contracts given delegated authority from DGS. Customers have noted improved contracting process.

Established July Deputy Director reporting to CDPH Director. Staff integrated from across CDPH. CQI training for executives & teams July-Sept. CQI Academy to train all 3,800 employees. Disseminate to local public health.

OQPA will: Track strategic objectives. Support leadership development. Provide leadership and structure for successful accreditation. Collaborate and coordinate with local public health.

The goal of the national public health accreditation program is to improve and protect the health of the public by advancing the quality and performance of state, local, territorial and tribal health departments. Accreditation will drive public health departments to continuously improve the quality of the services they deliver to the community.

Evaluate and continuously improve health department processes, programs, and interventions. Standard 9.1: Use a performance management system to monitor achievement of organizational objectives. Measure: Engage staff at all organizational levels in establishing or updating a performance management system.