Quality Improvement, Performance Management,

and AccreditationRon Chapman, MD, MPH

Director and State Health OfficerCalifornia Department of 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.

National Accreditation Program

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.

Domain 9

• 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.

What is the System?

• 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.

Systems Run Our lives

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.

Performance Management

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.

Quality Improvement

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!

The Tools

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

Quality Improvement Methods

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.

QI Expectations

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

What Performance Management and QI Are Not

Childhood Immunizations 1993 Congestive Heart Failure 1995 Childhood Asthma 2002 Solano County 2004-2010 CDPH Contracts 2012

QI Examples

Problem: Contracts are not being executed timely (3,000 contracts in CDPH)

Baseline Data:◦ DGS routinely rejected 60 – 70 % of contracts◦ Review all of the DGS Rejections for past year

Unclear and/or Poor Scope of Work and Budget 75% Conflicting Exhibits – 25%

Contracts

Discussed Issues with DGS

Contacted another Departments Contract Units◦ How do they do business?

Understand problem

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

Reasons for the problem (Root Causes)

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

Possible Solutions to the Problem

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

Plan to Measure

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

Implement solution & collect data for evaluation

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

Analyze data and develop conclusions

Of last 600 contracts only 2 were returned from DGS.

Some programs given streamlined contract authority from DGS.

Customers have noted improved contracting process.

Results