1. Overview of Performance Management Systems Pooja Verma, MPH Program Analyst Accreditation & QI NACCHO

2. Objectives Define performance management and related terms Identify the key steps in building a performance management system Provide tips and examples for developing performance measures Identify performance management resources

3. Defining Terminology

4. What is a performance management system? Source: Turning Point Performance Management Collaborative, 2003.

5. Performance Standards “Generally accepted, objective standards of measurement such as a rule or guideline against which an organization’s level of performance can be compared.” - Turning Point Management Collaborative, 2003 Public Health Standards: Public Health Accreditation Board (PHAB) National Public Health Performance Standards (CDC) 80% of clients rate health department services as “good” or “excellent.”

6. Performance Measures “A specific quantitative representation of a capacity, process, or outcome deemed relevant to assessment against a performance standard.” - Turning Point Management Collaborative, 2003 % of clients that rate health department services as “good” or “excellent.”

7. Reporting of Progress Reporting of Progress Includes performance against meeting standards and progress toward strategic goals and objectives Internal and external stakeholders Foundation for identifying QI efforts

8. Quality Improvement Quality Improvement The use of a deliberate and defined improvement process focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community. * * Definition developed by the Accreditation Coalition Workgroup and approved by the Accreditation Coalition on June 2009

10. What are the first steps in building a PM system? Establish a Performance Management Committee/Team Conduct a Performance Management self- assessment  Turning Point Self-Assessment Tool  Baldrige Performance Excellence Program Train staff!

11. Performance Measurement

12. Why is performance measurement important? Foundation for decision making Alignment of efforts with agency strategic direction Shift in focus from individuals/activities to results Meaningful feedback to employees Promotes learning and improvement culture *Adapted from MarMason Consulting

13. What do we measure in public health? Outcomes Efficiency Effectiveness Healthy People Processes 10 Essential Public Health Services Structures Information Technology Human Resources Fiscal Resources

14. Types of Performance Measures Capacity/Input: Human/capital resources Process/Output: Intermediate steps in developing product or providing service Short-Term Outcome: Immediate results of the product or service provided Long-Term Outcome: Intended, desired, or actual long-term results

15. Linking Performance Measures Input and Process (Program level) Short/ Intermediate term (Division level) Long-term (Organization level) Strategic Direction Monthly/Quarterly 1-2 years 2-3 years

16. Logic Model: Infant Mortality Performance Measures Input Process/ Output Short-term Outcome Intermediate Outcome Long- term Outcome - # of health educators - # of nurses - $$ for education materials, clinics, etc. - # of education classes - # of women in Pre-Natal Program - # Pre-natal clinics - % of women that understand risk factors - % of low income pregnant women w/access to Pre-natal care - % high risk pregnant women that smoke - % of high risk pregnant women with adequate nutrition - % premature births - % newborns w/low birth weight -Infant mortality rate

17. Considerations for Developing Performance Measures Do not select too many Feasibility of data collection Measurable over time Collectively represent major strategic goals and objectives Customer and stakeholder support

18. Frameworks for Performance Measurement Balanced Scorecard 1.Financial 2.Internal Business Processes 3.Learning and Growth 4.Customer Malcolm Baldrige National Quality Award Criteria: 1.Leadership 2.Strategic Planning 3.Customer Focus 4.Measurement and Analysis 5.Workforce/HR Focus 6.Operations Focus 7.Results

19. Developing Performance Measures What are you measuring? Who is the target population? What is your numerator? What is your denominator? What is your data source? Who is responsible? Rate of positive CT test at clinics Clients tested for Chlamydia # clients tested positive CT # of total CT tests at clinics DOH records Jane Doe

20. Establish Performance Targets/Benchmarks Use a method to establish thresholds for performance: Industry benchmarks (e.g. HP2020, County Health Rankings) Regulatory requirements Other health department’s data Past performance *Adapted from MarMason Consulting

21. SMART Objectives Decrease the rate of CT positivity at clinic sites from 8.1% to 6.5% by the end of 2013. Specific Measurable Attainable Relevant Time specific

22. Performance measure:The rate of Chlamydia (CT) positivity at provider clinic sites. Target population:People being tested for Chlamydia Numerator:Positive CT tests at clinic sites Denominator:All CT tests at clinic sites Which are you using—a target or benchmark? Target What is the target/benchmark?6.5% (goals based on past performance) SMART objective: Decrease the rate of CT positivity at clinic sites from 8.1% to 6.5% by the end of 2013. Source of data:DOH records Who will collect the information? Jim Smith How often will the data be analyzed and reported? quarterly Baseline measurement data and date(s): 2005: 10.1%2008: 8.6% 2006: 9.3%2009: 8.2% 2007: 10.5%2010: 8.1% Definitions and other comments: Provider clinics, Planned parenthood sites and others. *Adapted from MarMason Consulting

23. Linking Performance Measures: Example Improve quality of life among Diabetics Decrease morbidity rates of Diabetes patients by 20% by 2014. Performance Measures Intermediate Outcome -% of patients w/adequate blood glucose Short-Term Outcome -# of patients seen by provider Process/Output - Length of time b/w request of service and meeting w/provider Input/Capacity - # of service providers on staff Impact

24. Linking Performance Measures: Example Reduce childhood obesity Decrease % of obese/overweight youth to 25% by 2014. Performance Measures Intermediate Outcome - % of low income children w/60 mins of moderately active daily Short-Term Outcome - % of low income children that access parks/playgrounds Process/Output - # parks/playgrounds in low income neighborhoods Input/Capacity - $$/partnerships for new playgrounds/green space Impact

25. Collecting & Storing Data Database, Spreadsheets o Excel o Access Performance Management Software o My Strategic Plan, M3 Planning o Results Scorecard, Results Leadership Group

26. Example Performance Dashboard ObjectivePerformance Measure Baseline (2010) Baseline (2011) Current Status Target Infant Mortality Decrease % of women who smoke during pregnancy enrolled in Pre-Natal Partnership Program (PNPP) % of women who smoke during pregnancy in PNPP 32%28%25%20% Increase % of low income women who receive prenatal care in the 1 st four months of pregnancy % low income women receiving prenatal care w/in 1 st four months of pregnancy 85%87%92%90% Immunizations Increase % of 19-35 mo. olds adequately immunized % of 19-35 month old children adequately immunized 59%60%66%75%

27. Turning Data Into Knowledge: Data Analysis Questions to consider: How does actual performance compare to a standard or target? Is corrective action necessary? Are new goals, objectives, or measures necessary? How have existing conditions changed?

28. Analysis Tools Analyze Measurement DataIdentify Root Causes Run chart Statistical analysis Control chart Matrices Flow chart Scatter plots Decision tree Affinity diagram Brainstorming Fishbone Histogram Pareto chart Story boarding 5-whys technique

29. Reporting Structure Frequency o Program measures – monthly/quarterly o Division measures – semiannual/annual o Department measures – every 2-3 years Communicate to: o Management o PM team and/or QI Council o Board of health o Staff

30. Reporting and Presenting Questions to consider: Who is the audience? What is the intended use of the information? What is the basic message to be communicated? What is the presentation format? (brochure, oral presentation, report, etc.)

31. Quality Improvement

32. Performance Management Process 1.Select performance measures 2.Collect data 3.Store data 4.Analyze data 5.Report and present findings 6.Apply knowledge

33. “Maybe I’m lucky to be going so slowly, because I may be going in the wrong direction.” ~ Anonymous

34. Performance Management Resources Performance Management Self-Assessment Tool: http://www.collaborativeleadership.org/pages/pdfs/CL_self- assessments_lores.pdf http://www.collaborativeleadership.org/pages/pdfs/CL_self- assessments_lores.pdf Turning Point Resources: http://www.turningpointprogram.org/Pages/perfmgt.html http://www.turningpointprogram.org/Pages/perfmgt.html PHF’s Performance Management & QI Website: http://www.phf.org/focusareas/PMQI/Pages/default.aspx http://www.phf.org/focusareas/PMQI/Pages/default.aspx Public Health Performance Management Centers for Excellence: http://www.doh.wa.gov/PHIP/perfmgtcenters/index.htm http://www.doh.wa.gov/PHIP/perfmgtcenters/index.htm Developing, Monitoring, and Using Performance Measures: http://www.doh.wa.gov/PHIP/perfmgtcenters/modules/Year2/11-09- 11_PerfMeas_public_main.htm http://www.doh.wa.gov/PHIP/perfmgtcenters/modules/Year2/11-09- 11_PerfMeas_public_main.htm

35. References Turning Point Performance Management Collaborative: http://www.turningpointprogram.org/Pages/perfmgt.html http://www.turningpointprogram.org/Pages/perfmgt.html Public Health Performance Management Centers for Excellence: http://www.doh.wa.gov/PHIP/perfmgtcenters/index.htm http://www.doh.wa.gov/PHIP/perfmgtcenters/index.htm The Performance Based Management Handbook, U.S. Dept. of Energy: http://www.doh.wa.gov/PHIP/perfmgtcenters/index.htm http://www.doh.wa.gov/PHIP/perfmgtcenters/index.htm The Quality Improvement Handbook: http://bookstore.phf.org/product_info.php?products_id=660 http://bookstore.phf.org/product_info.php?products_id=660

36. Thank You! Pooja Verma Accreditation & QI NACCHO (202) 507-4206 pverma@naccho.org www.naccho.org/QI