Quality Improvement, Performance Management, and Accreditation

1. Quality Improvement, Performance Management, and Accreditation Ron Chapman, MD, MPH Director and State Health Officer California Department of Public Health

2. What is the System? • 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.

3. Systems Run Our lives • People create systems: • “Each system is perfectly designed to serve the purpose for what is was intended.” • Peopleare not the system. • Need to analyze and improve the system.

4. Performance Management Actively use performance data to improve the public’s 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.

5. Quality Improvement 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.

6. The Tools • 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!

7. Quality Improvement Methods • 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

8. QI Expectations • 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.

9. What Performance Management and QI Are Not • Not a replacement for: • Leadership skills • Functional teams (team building) • Governance

10. QI Example: Contracts • 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%

11. Understand problem • Discussed Issues with DGS • Contacted another Departments Contract Units • How do they do business?

12. Reasons for the problem (Root Causes) • 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

13. Possible Solutions to the Problem • 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

14. Plan to Measure • 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

15. Implement solution & collect data for evaluation • 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

16. Analyze data and develop conclusions • 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

17. Results • Of last 900 contracts only 4 were returned from DGS=99.5% approval rate. • FY 10-11 completed about 300 contracts. FY 11-12 completed over 900 contracts. Productivity tripled! • Some program contracts given delegated authority from DGS. • Customers have noted improved contracting process.

19. Office of Quality Performance and Accreditation (OQPA) • Established July 2012. • 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.

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

21. National Accreditation Program • 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.

22. Domain 9 • 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.