Section Overview2015

North Dakota Department of Health Performance Management and QI

NDDoH Performance Management SystemPerformance Management is a system

process which helps an organization achieve its mission and strategic goals through the active use of data Performance MeasurementStrategic PlanningAccreditationQuality Improvement

NDDoH PM Organizational StructurePerformance Management

Executive Committee(State Health Officer, Deputy

State Health Officer, Performance Management Director, Strategic Planning

Facilitator, State Epidemiologist

PM Steering Committee(Section Chiefs, HR Director, State Health Officer, Deputy State Health Officer, State

Epidemiologist and Accreditation Coordinator)

QI Council(Staff)

QI Project Teams(Cross-functional Staff Involved

in Selected Projects)

Accreditation Domain Teams(Cross-sectional Staff with

Focus in Domains 1-12)

Strategic Planning Committee(Department-wide Representatives)

Turning Point Model

Performance Standards

• Strategic Plan

• Accreditation

Performance Measurement• Measures based on

strategic goals and objectives

• Accreditation measures

Reporting ProgressAnnual Report• Objective

performance- April 15

• Strategy performance-

June 30

Quality Improvement

• Projects based on performance progress

NDDoH Performance Management System

Promote a State of Emergency Readinessand Response

Improve Access to and Deliveryof QualityHealth Care andWellness Services

Improve theHealth Status ofthe People ofNorth Dakota

Preserve andImprove theQuality of theEnvironment

DecreaseVaccine-Preventable Disease

Prevent and ReduceChronic Diseases andTheir Complications

Prevent and ReduceTobacco Use and SupportOther SubstanceAbuse Prevention

Preserve and ImproveAir Quality

EnsureSafe PublicDrinking Water

Manage Solid Waste

Prevent and ReduceIntentional andUnintentionalInjury

Achieve HealthyWeightsThroughoutthe Lifespan

Promote and MaintainStatewide EmergencyMedical Services

Enhance the Qualityof Health Care

Reduce Infectiousand Toxic Disease Rates

Improve Access to and Utilization ofHealth and WellnessServices

Improve HealthEquity

Preserve and Improve Surface and Ground Water Quality

Prepare Public Health and Medical Emergency Response Systems

Maintain HazardIdentificationSystems

Maintain EmergencyCommunication andAlerting Systems

Coordinate Public Health and Medical Emergency Response

CENTRAL CHALLENGE:Protect and Enhance the Health and Safety of All North Dakotans and the Environment in Which We Live

Ensure Safe Food and Lodging Services

Performance Measurement

StrategiesPerformance

Measure for Short term Outcome

More direct impact

ObjectivesPerformance Measure for Long Range Outcome

Intermediate Range Outcome

NDDoH Strategic and Business PlanStrategic Goals

Benefits of AccreditationBetter identify strengths and weaknesses

of the departmentDocument capacity of the department to

deliver core functions and 10 Essential Public Health Services

Stimulates transparencyImproves accountabilityImproves communicationImproves competitiveness for fundingStimulates QI and performance

management

Quality ImprovementThe use of deliberate and defined

improvement process such as the Plan-Do-Check-Act

Continuous and ongoing effort to achieve a measurable improvements in efficiency, effectiveness, performance, accountability, outcomes and other indicators.Quality assurance is a system to ensure a

process meets a desired level of quality and usually begins with a set of standards.

They Are Not the SameQuality Assurance

Quality Improvement

ReactiveWorks on problems after

they occurRegulatoryLed by managementPeriodic look-backResponds to a mandate

or crisis or fixed scheduleMeets a standard

(pass/fail)

Proactively selects a process to improve

Works on processes

Seeks to improveLed by staffContinuousExceeds

expectations

NDDoH Core Principles of QIDevelops a strong customer focusInvolves a team or includes team

knowledgeIdeas and changes come from all staff

involved and implemented by all staff involved

Ensures a process for improvementThere is an intended goal to improve or

changeIncludes ongoing measurement and

data driven decision making

Quality Improvement Projects“Big” QI

QI efforts targeted at the department-level“Small” QI

QI efforts targeted at the program or project level

Uses the Plan-Do-Check-Act method

Plan

DoCheck

Act

Plan Plan changes aimed at improvement, matched to root causes

Do Carry out changes; try first on small scale

Check See if you get the desired results

Act Make changes based on what you learned; spread success

Also called Plan-Do-Study-Act (PDSA), PDCA, PDCA Cycle, or Shewhart Cycle

Plan-Do-Check-Act

Plan

1. Identify and Prioritize Opportunities

2. Develop AIMStatement

3. Describe the CurrentProcess

4. Collect Data on Current Process

5. Identify All PossibleCauses

6. Identify PotentialImprovements

7. Develop Improvement Theory

8. Develop Action Plan

1. Implement theImprovement

Do

2. Collect and DocumentThe data

3. Document Problems,Observations, and Lessons

Learned

Check/Study

1. Reflect on the Analysis

Act

2. Document Problems,Observation, and Lessons learned

Adopt

Adapt

Abandon

Standardize

Do

Plan

Source: ABCs of the PDCA Cycle, G. Gorenflo and J. Moran, http://www.phf.org/pmqi/resources.htm

General Approach On How To Use The Basic Tools Of Quality Improvement

Issue ToConsider

Flow ChartExisting Process

Brainstorm& ConsolidateData Cause & Effect

Diagram – Greatest Concern

Use 5 Whys ToDrill Down ToRoot Causes

Gather DataOn Pain Points

Translate DataInto Information

• Pie Charts• Pareto Charts• Histograms• Scatter Plots, etc.

Flow ChartNew Process

Monitor New Process & Hold

The Gains

• Run Charts• Control Charts

Data ManagementStrategy

“As Is” State to “Should Be” State

“As Is” StateBrainstormingForce and Effect

Analyze Information andDevelop Solutions

Solution andEffect Diagram

Source: The Public Health Quality Improvement Handbook, R. Bialek, G. Duffy, J. Moran, Editors, Quality Press, © 2009, p.160

“AIM”viii

QI Project Selection and Implementation ProceduresDetermine whether the proposed project is

“Small QI or “Big” QIComplete the project proposal form to be

approved for implementation by the PM Executive Committee (submit to Londa)

Project teams will create an implementation planSubmit a monthly progress report to QI Council

(submit to Kelly)Submit final project results form to QI Council

(submit to Kelly)QI Council will assist in creating a storyboard

  Test #1 Test Test Test Test*

  March-April 2015 April- May 2015

April-May 2015

   

PLAN (Briefly describe the test, including the goal)

Determine whether blood pressure data can be collected through ND HIN

Determine number of individuals with uncontrolled blood pressure using ND HIN

Determine quality performance of providers and systems

   

DO (List observations from the test)

1. Determine data sharing agreements

2. Identify whether blood pressure readings are reported in electronic health records and linked to ND HIN

3. Identify what providers and systems are reporting blood pressure readings

4. Generate a report with all blood pressure readings for unduplicated individuals with date and time stamped, along with provider and system reporting

1.Analyze data generated from ND HIN

2. Define uncontrolled blood pressure standards as reported in ND HIN. Determine standard reading for uncontrolled and the number of readings/visits required at that reading

3. Generate report indicating the number of individuals meeting the standard definition

1. Define the quality measure of how the patient’s blood pressure is controlled

2. Generate a report a providers and systems meeting the quality measure and those that aren’t

   

STUDY (List what worked)          

STUDY (List what didn’t work)

         

ACT (Indicate whether you adopted, adapted, or abandoned the change you tested?; List next steps based on decision)

         

*Please add additional Test columns as necessary