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Performance Improvementin Public HealthLos Angeles CountyDepartment of Public HealthDivision of Quality ImprovementPLANDOACTSTUDY

Presentation ObjectivesReview the DPH approach to QualityImprovement (QI) and PerformanceImprovement (PI) Describe the goals and activities ofthe department-wide PI Team Discuss current DPH PI efforts

DPH Quality Improvement Division Includes— Office of the Medical Director(Quality Improvement)Organizational Development andTrainingNursing AdministrationHealth Education AdministrationPublic Health InvestigationPhysician AdministrationOral HealthQuality Professional PracticeScience ReviewService Quality (deferred)

What is PerformanceImprovement?Performance Improvement is a continuousprocess where information and data from anagreed upon set of performance goals andmeasures are reviewed to:1.2.3.Inform managers on the effectiveness of current effortsReport on successes in meeting program goalsPrioritize department resources

The “4 Ts” of QI/PI Training Technical Tools TrackingAssistance

Overview of Performance Improvement (general concepts)Planning for and Measuring PerformanceThe 4-Step Model for ImprovementUsing Logic Models and Process MapsPreparing for Public Health Department gMandatesData TrendsProgress ReviewsAnnual Quality ReportKey Indicators of Health ReportAccreditationToolsTechnicalAssistanceMeasure Selection and UpdatesLong-Term Standard/Target SettingDeveloping Data Collection SystemsGraphs and GIS MapsPlan-Do-Study-Act (PDSA) ModelResults Accountability Principles (modified for Public Health)Structure-Process-Outcome ApproachHealthy People 2010/2020Action Plan Development

PerformanceImprovementTeam

Performance Improvement Team:Overall Goal Create PI processes andtools that: awareness of the linkbetween key strategies andrelated outcomesImprove departmentmanagement and businessdecisions accountability to internaland external partnersPLANDOACTSTUDY

Performance Improvement Team:2010 Goals Adopt a department-wide approach toperformance improvement that is integratedwith the DPH Strategic Plan and track progressAssess data sharing capacity between programsand plan for a centralized reporting systemCreate educational workshops for performanceimprovement training needs across thedepartment

Tool #1PDSA ModelPLANDOACTSTUDY

Tool #2Results AccountabilityPOPULATION INDICATORS(measures of population-levelhealth outcomes)ANDPERFORMANCE MEASURES(measures of programeffort and output)Public HealthMeasures

Tool #3Structure-Process-Outcome Structure – “Conditions” under which public healthservices are provided to include material resources,human resources, and organizational characteristicsProcess – “Activities” that constitute and supportthe delivery of public health servicesOutcome – “Changes” (desirable or undesirable) inindividuals and populations that result from thedelivery of public health servicesAdapted from: Avedis Donabedian. An introduction to quality assurance in health care.Oxford University Press, 2003: pp. 46-47.

DPH PerformanceImprovement Efforts

Multiple DPH PerformanceImprovement EffortsStructureCounty LevelDepartment LevelProgram/SPA LevelProcessOutcomeShort-TermLong-TermPerformance Counts!Operational MeasuresIndicatorsPublic HealthReport Card“Key Indicators of Health”andOther ReportsPublic Health MeasuresPerformance MeasuresPopulation Indicators

Integration of Efforts 1.2.3.National EffortsHealthy People 2010/2020Accreditation of LHDCDC Guidelines orPerformance Measures 1.2. 1.2. 1.2.State EffortsPerformance MeasuresMandates and RegulationsCounty EffortsPerformance Counts!County Progress ReportDepartment EffortsPublic Health MeasuresPublic Health Report Card

PI—Key Indicators of HealthReport Report is based on resultsfrom several surveys thatprovide local-level dataHealthy People 2010targets are used as thecomparison or“Standard” value toachieveShows results bygeographic anddemographic criteria

PI—Public Health Report Card

PI—Public Health Report Card

PI-Public Health Measures Los Angeles County Public Health approachnamed the Public Health MeasuresBased on the Results Accountability Framework*Emphasis on program-level performance linkedto “shared” population-level health outcomesIntegrated with Healthy People 2010,NACCHO/Accreditation Standards, theCommunity and Clinical Guides, grant metricsand guidelines*Friedman, Mark. “Trying Hard is not Good Enough: How toProduce Measurable Improvements for Customers and Communities.”2005. Trafford Publishing. Victoria, BC, Canada. www.raguide.org

Public Health Measures Championed as a QI effort in 200240 Public Health units identified “populationhealth indicators” linked to programperformance measures to follow over timeHealthy People 2010 objectives often identifiedand used as the “Standard” to achieve over time

Public Health MeasuresPOPULATION INDICATORS(measures of population-levelhealth outcomes)ANDPERFORMANCE MEASURES(measures of programeffort and output)Public HealthMeasures

Public Health MeasuresPopulation HealthProgram Goal 1IndicatorStrategy 1Goal 1Measure 1IndicatorStrategy 2Goal 2Measure 2NACCHOStandardsFederal, State,or Community GuideClinical GuideOther Sources

Example: Immunization ProgramPopulation Goal To reduce morbidity and mortality from vaccine-preventablediseases by improving immunization levelsPopulation IndicatorPercentage of children, ages 19-35 months, who are fully immunized with oneof the series of the Advisory Committee on Immunization Practices (ACIP)recommended vaccinesEffective, Evidence-Based Strategies (selected subset)1. Change provider behavior through systems change—Provider recall/remindersystems in clinics2. Change provider behavior through education—multi-component interventionswith education3. Increase demand and access to immunizations—reduce out-of-pocket costsProgram Performance Goal (NACCHO Standard 9)Performance MeasurePercent of Immunization Program public and nonprofit clinic partners whoroutinely meet the Standards for Pediatric Immunization Practices for provider andclient recall/reminder systems

Summary The Quality Improvement Division has 4 functionalareas in which it focuses its effortsPerformance Improvement is the area that linksstrategic planning and outcome measurement to ensureprogram successTools include PDSA, “Results Accountability”, andStructure-Process-OutcomeThe Performance Improvement Team assists thedepartment in developing new tools and processes tointegrate performance improvement efforts acrossNational, State, County, and Department levels

Applying PerformanceImprovement to DailyOperationsPLANDOACTSTUDY

Presentation Objectives Understand how strategic planning goals andobjectives can be translated into measurement ofpopulation-level outcomes and daily operationsDescribe key components of the PDSA modelProvide an interactive learning session to helpyou develop a strong PI effort in your Programor SPA

The PDSA Model PLANConnect and link goals tomeasurable outcomesDOImplement evidence-basedactivities tracked with datacollectionSTUDYEvaluate progress towardstandards/long-term targetsACTRespond to what results tell usPLANDOACTSTUDY

PDSA ModelLink Goals to MeasurableOutcomes Determine prioritiesand goals Select PopulationIndicators andPerformance Measures Set standards/long-term targetsRespond to whatthe results tell usImplement evidencebased interventions andrespond to mandatesPLANDOACTSTUDYEvaluate progress towardPopulation Indicator andPerformance Measure standards

Determine Priorities and Goals1.2.What are the prioritypublic health issues inLos Angeles County?What are the behaviorsand outcomes relatedto these issues that wewant for people wholive in LA County?SPA/ProgramStrategic PlanDPH Strategic PlanCounty Strategic Plan

Linking Indicators and Measures3. How can we measure these conditions?POPULATION INDICATORS(measures of population-levelhealth outcomes and behaviors)ANDPERFORMANCE MEASURES(measures of programeffort and output)Public HealthMeasures

Population Indicators Longer life spanIncreased quality of lifeIncreased health equityLess diseaseLess premature deathHealthier choicesSafer environmentHealthier homesPOPULATION-LEVELHEALTH OUTCOMES& BEHAVIORS

Population Indicators Percent of students who had at least one drinkof alcohol in the past 30 daysRate of foodborne illness hospitalizations eachyear (per 100,000)Percentage of children covered by healthinsuranceDeath rate from colorectal cancer

Resources Healthy People 2010http://www.healthypeople.gov/ DPH Key Indicators of Health Report Other Indicator ReportsOlder Americans: Key Indicators of Well-Being American Children: Key Indicators of Well-Being

Performance Measures1.2.3.4.5.Who are our clients?Which services do weprovide to our clients?What evidence-basedstrategies will lead topositive change in ourclients?How can we measure ifour clients are better off?How can we measure ifwe are delivering serviceswell?QuantityInput /EffortQualityHowHow WellMuch Did Did WeWe Do? Do It? (%)(#)OutputHowQuality of/ EffectMuchChange?Change?(%)(#)

Performance Measures Policies CreatedPeople InformedPartners EngagedSurveillance PerformedInvestigations CompletedIncreased Access to ServicesClient satisfactionMEASURES OFPROGRAMEFFORT & OUTPUT

Performance Measures Percent of outbreaks (excluding scabies)investigated within standard timeframePercentage of children under 6 years whoparticipate in fully operational population-based[immunization] registriesNumber of cities that adopted a policy thatprohibits smoking in outdoor areas

Performance Measures Framework3 Core Functions (1988)AssessmentPublic HealthMission1. Protect Health2. Prevent Disease3. Promote Health &Well-Being10 EssentialServices (1994)Policy DevelopmentAssurance10 Standards for LocalHealth Departments(NACCHO, 2005)11 Domains for Local PublicHealth Accreditation(PHAB, 2009)

NACCHO Standards Monitor health status of the communityProtect people from health hazardsGive people information to make healthy choicesEngage the community to solve health problemsDevelop and advocate for public health policiesEnforce laws and regulationsHelp people receive health servicesMaintain a competent public health workforceEvaluate and improve programsContribute to and apply public health researchCore Business Functions (DPH re/accreditation/opdef.cfm

Ideal PIs/PMs Prioritization Criteria1)2)3)Evidence CriteriaEvidence CriteriaData CriteriaOther RationaleData CriteriaOther RationaleIDEAL INDICATOR OR MEASURE

Strategic Plan ProgressReporting Template

2010 Annual Performance Report Internal report of selected Population Indicatorsand Performance MeasuresIncludes:Traditional Report Card results NEW Program Performance Snapshots In-Person Progress Review with Dr. Fielding

Questions?PLANDOACTSTUDY

Small Group ExerciseYou are the Director of the Chronic Disease Divisionat your local County Department of Public Health.The Health Officer is championing interventionsthat will decrease obesity throughout the County.She wants you to create a set of priority objectivesand performance metrics based on the bestscience. Your objectives and metrics will be usedto engage stakeholders, pursue fundingopportunities, and assess overall effectiveness andefficiency of your prioritized interventions.

Performance ImprovementPDSA ModelLink Goals to MeasurableOutcomes Determine prioritiesand goals Select PopulationIndicators andPerformance Measures Set standards/long-term targetsRespond to whatthe results tell usImplement evidencebased interventions andrespond to mandatesPLANDOACTSTUDYEvaluate progress towardPopulation Indicator andPerformance Measure standards

Rapid-Cycle PDSA Projects

Example: Telephone Hotline ActivationVirginia Department of Public HealthTrigger:Threat topublic healthor emergencyRequesthotlineSet upcall centerAuthorizeactivationDevelopmessagesRecruitand veaccurateinformation