Performance Management System Workplan (Indicator 1.2)

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1 Performance Management System Workplan (Indicator 1.2) I. Policy Statement: The Branch-Hillsdale-St. Joseph Community Health Agency has adopted a performance management system approach to its services as a method to improve the effectiveness of its programs, the efficiencies of its operations, the satisfaction of its customers and the engagement of its staff. The performance management approach will incorporate four key components, which include: Performance Standards Performance Measures Report of Progress Quality Improvement Projects II. Background: The Performance Management System Plan has been developed in response to the Branch-Hillsdale-St. Joseph Community Health Agency s Strategic Plan which identified the following goals and objectives as part of its Strategic Priority 1: Strategic Priority 1: Support and enhance the Agency s infrastructure to maximize its performance as a public health organization of excellence. Goal 1: Improve workforce development and strengthen systems and organizational capacities that support the workforce. Obj. 1.1 Obj. 1.2 Obj. 1.3 Obj Obj. 1.5 Obj. 1.6 By September 30, 2015, develop standardized policies, procedures and training materials for hiring and orientating employees to public health and the agency services. By September 30, 2015, develop and implement a succession plan for key organizational positions. By December 31, 2015, increase capacity of existing workforce. By December 31, 2016, identify and maintain a system for tracking and evaluating workforce needs and assure that 75% of employees have received required and program-specific training. By September 30, 2017, there will be a 25% improvement in staff engagement as measured through key workplace satisfaction indicators. By December 31, 2018, institute and maintain a performance management system that links to the Agency s planning processes. Goal 2: Obj. 2.1 Maximize business efficiencies and effectiveness through the use of technology. By December 31, 2015, identify strategies that lead to improvements in insurance billing. 1 P a g e

2 Obj. 2.2 Obj. 2.3 Obj. 2.4 Obj. 2.5 By December 31, 2015, examine current methods for accepting client payments using debit and credit cards and determine if improvements are needed. By May 31, 2016, purchase, install and maintain a new accounting system to replace the current accounting system. By September 30, 2017, utilize an Electronic Health Record for 100% of applicable customer services. By September 30, 2017, develop and maintain an Information Technology plan which will be used to guide the ongoing development and evolution of technology in support of the Agency s programs and its strategic directions. Goal 3: Increase the Agency s capacity for conducting continuous quality improvement (CQI) and assurance activities. Obj. 3.1 Obj. 3.2 Obj. 3.3 Obj. 3.4 By December 31, 2015, provide CQI training on an annual basis to at least 75% of Agency employees. By December 31, 2015, implement and maintain a mandate/contract compliance process which will help to assure that the Agency is in compliance with all requirement mandated, contractual and program requirements. By December , every Agency program will incorporate, monitor and report on quality improvement outcomes to the administration. By September 30, 2017, the Agency will develop a Quality Improvement Report which it will issue to the community and the Board of Health. Through the development and implementation of this performance management plan which will improve its data collection infrastructure and enhance its utilization of quality Improvement methods, the Agency will maximize its performance as a public health organization of excellence. III. Performance Management System Approach and Timeline: Phase 1: Self- Assessment (to be completed by March 30, 2015) The Agency will utilize the Turning Point Performance Management Self-Assessment Tool. The purpose of the assessment is to assist the Agency in identifying both strengths and weaknesses and to help it identify areas for improvement. This assessment will be completed by the Quality Improvement Team (QI Team), which consists of the Administrative Team, along with key staff members (i.e., front line staff, IT staff, etc.) annually. This 12 person team will review the results of the assessment and based upon these results identify a course of action for the next phase: Standards Review. Phase 2: Standards Review (by April 30, 2015) Once the assessment is completed, the Quality Improvement Team will identify relevant standards from the following sources: 2 P a g e

3 Healthy People 2020 National Prevention Strategy National Public Health Performance Standards Program Michigan Local Public Health Accreditation Minimum Program Requirements CDC Principles of Community Engagement CDC Public Health Preparedness Capabilities, National Standards for State and Local Planning Community Guide Minnesota Department of Health Based upon the standards reviewed, the committee will select key standards and indicators for measurement. They will review current data trends, establish benchmarks when available or estimate benchmarks; and set goals and target measures. Expectations related to these key standards will be communicated to staff using a Performance Management Newsletter which will be issued three times a year. The first issue will provide information about the standards, why they were selected, how they will be utilized and how data will be collected and used to track progress. Issue 2 will focus on mid-year progress reporting, and associated successes, challenges and barriers, along with any needed revisions that have resulted. Issue 3, which will be part of the Annual QI report, will provide final reporting for the year on the indicators, and will celebrate the overall process, along with any specific QI successes that have occurred. All newsletters/reports will be electronically distributed to Agency staff. The mid-year report and final report will be posted on the Agency website and distributed directly to the Board of Health. Phase 3: Performance Measurement (Completed by May 31, 2015) During phase 3, using the standards and measures identified during the previous phase, the QI team will refine the indicators. During the Indicator refinement phase the Agency QI team will work to assure that the indicators used for measurement purposes reflect the Agency s sphere of influence; that the data identified to be collected is available or could be available; the data is reliable and valid; and that the measurement being used correlates to the indicator. Once these issues are finalized, data collection will begin. State/National Systems which may be utilized include: U.S. Census (includes multiple databases and data sets) Michigan Childhood Improvement Registry (MDCH) Michigan Disease Surveillance System (MDCH) Vital Records and Health Statistics (MDCH) Michigan In-patient Database (MDCH) Michigan State Police Office of Highway and Traffic Safety Motor Vehicle Data Base Women, Infant and Children s client database (MDCH) Certificate of Need Annual Survey (MDCH) Michigan Behavioral Risk Factor Surveillance System (MDCH) Health Resources and Services Administration (databases for health professionals and health facilities) CHAMPS (for Medicaid) and Networks (for Medicaid billing) Easy Link and Oracle (CSCHS/MDCH) MICIS (for AAA) 3 P a g e

4 Assistant Secretary of Planning and Evaluation (ASPE) of the Department of Health and Human Services for zip code level Marketplace enrollment data Local Health Department Data Systems which may be utilized include: SWORD Environmental Health Food Inspection Database Smoking Violation Database Meth Remediation Database Swimming Pool Database LHD Septic Failed Database Well and Septic Databases CSHCS database Hearing and Vision Database Real-time Internet Communicable Disease Reporting Database Health Education Database Navigator/CAC database CMHC for Financials (future system to be determined) I-Synergy (Document imaging database) Electronic Health Record (future system to be determined) Stellar Database for Lead (local database loaded with state data) Phase 4: Reporting Progress (June and September 2015, January (2016) and ongoing) Reporting will occur through a standardized reporting format. Newsletters will be issued in January, June and September. After year one, the January newsletter will be used to inform staff concerning the upcoming year s indicators (which will correspond with the Agency s calendar year and align with the SPC review). June will be the month for the final report from the previous year (which will align with the issuance of the previous year s annual report) and September will be the mid-year report. All newsletters/reports will be shared with the staff electronically and posted on the Agency s website. January and June reports will be submitted to the Board of Health and the Agency s stakeholders per the Strategic Plan. In addition, it is the expectation that program specific measures will be monitored on a monthly basis by the program coordinators/staff and that information will be shared at monthly staff meetings as reflected in both agendas and minutes. Phase 5: Quality Improvement (June, 2015 and ongoing) Once the performance measures are identified and monitored, those performance measures which are short of their targets will move to a quality improvement phase. The quality improvement phase will follow the Plan, Do, Study, Act method. The process will encompass the 9 steps as identified by Deming: PLAN Step 1: Identify Problem (includes estimating needed resources and obtaining any approvals to conduct QI) Step 2: Assemble a QI Team (includes identifying roles and responsibilities, establishing initial timeframe for improvement activity and developing AIM statement) Step 3: Examine Current Approach (includes process mapping, reviewing baseline data, determine root causes of problem and revising AIM statement) 4 P a g e

5 Step 4: Brainstorm/Research/Identify Potential Solutions (includes reviewing best practices and evidence-based models and selecting potential solution) Step 5: Develop a Theory of Improvement (includes using an if.then approach and selecting a strategy to test theory) DO Step 6: Test Improvement Theory (includes testing on small scale, data collection and analyzing outcomes) STUDY Step 7: Study the Results (includes comparing results against baseline data, identifying side effects, identify if improvement has occurred and reporting outcomes) ACT Step 8: Standardize the Improvement or Develop New Theory (includes expanding test to a wider scale or developing new improvement theory and testing it) Step 9: Establish Future Plans (includes celebrating successes, communicating results, making long term plans for additional improvements) (See Agency s QI Plan for additional information) IV. Roles and Responsibilities: All Agency staff will participate in developing, using and updating the performance management plan. This plan will also be shared with the Strategic Planning Committee who will be responsible for assuring that updates to this plan are included in the Strategic Plan and communicated to the Agency Board of Health. The following roles and responsibilities have been identified: Board of Health: Provides high-level oversight and accountability; Is aware of final outcomes and projects that affect BHSJ CHA; Provides an outside perspective on QI initiatives; Receives updates in regards to performance management and QI initiatives and approves annual report; Provides access to resources and trainings as appropriate. Health Officer and Division Directors: The Health Officer and Division Directors will: Be apprised of all current projects; Allow time at all staff meetings to discuss ongoing and completed projects; Approve the work of the committee Participate as required on the work of the committees as it relates to the programs in their divisions and/or cross-divisional projects 5 P a g e

6 The Health Officer and Division Directors are often relied upon to facilitate communication between the Strategic Planning Committee, Quality Improvement Committee and the Board of Health. Quality Improvement Committee Members: The roles of the QI Committee members include: Providing a forum for all members of BHSJ CHA to provide input on QI initiatives Identifying and facilitating division-wide QI projects Establishing guidelines, forms and a reporting format for projects Providing feedback and guidance to the division s programs/teams; and Collecting, analyzing and evaluation project information Division Programs (All Staff) It is expected that division staff will: Discuss and develop QI opportunities Implement and evaluate projects; and Over time become engaged in QI opportunities (including suggesting ideas, providing feedback to their QI committee representative, participating in projects and encouraging other staff to participate). V. Communication Strategies The QI Committee s members represent each program of the BHSJ CHA to ensure that all staff have an opportunity to contribute to the Performance Management Plan. To that end, members are responsible for facilitating regular communication between the QI committee and staff in their respective program. Program Meetings PDFs of agendas and minutes of the meeting and reports will be available to all staff and will be available on a centralized location of the Agency server, in a QI folder. Strategic Planning Committee will receive updates twice a year from all QI committees so as to track progress in the implementation of the strategic plan. They will use this information to update the agency s action plan and report on the Strategic Plan s progress to the Board of Health. Board of Health The Board of Health will receive updates twice a year at the June and January meeting. The June meeting will include of an annual QI report, which corresponds to the release of the Agency s Annual Report. Dashboard The Agency will post on its website a dashboard to help inform the staff, the Agency s stakeholders and the public of progress that is being made on selected standards. LiveWire The Agency s internal staff newsletter will be utilized as well to distribute updates, showcase progress and celebrate success in the areas of performance management, workforce development and quality improvement. 6 P a g e

7 VI. Staff Training: All staff will complete the MPHI s Embracing Quality in Public Health: A Practitioner s Performance Management Primer and submit their certificates to the Human Resources Director. Members of the QI team and Administration team will also participate in advanced training through the Ohio State University s Center for Public Health Practice Online Learning. In addition to the MPHI course, these members will complete the following modules: CQI for Public Health: Tool Time CQI for Public Health: The Fundamentals Addressing Workforce Development in Your Agency Additional resources are made available through the Agency s Website at Employee Links>Quality Improvement, including a Web page and including the As part of the workforce development process which is included in the Strategic Priority #1, the Agency will be embarking on a Workforce Development project which will seek to improve the orientation and training of employees, as well as how this information is tracked. Through this project, the Agency is seeking: To utilize an online training system which will track staff development needs and efforts to meet those needs Provide opportunities for staff to learn about the core functions of public health practice and additional topics (i.e., quality improvement, performance management, Blood Borne Pathogens, HIPAA, data analysis, customer service, cultural competency, etc.) Increase competency of staff and provide opportunities for professional growth Increase amount of recognition and appreciation for staff. (See Strategic Plan, Strategic Direction #1, Goal 1. VII. Resources Branch-Hillsdale-St. Joseph Community Health Agency, Strategic Plan FY Office of Accreditation and Quality Improvement, Michigan Public Health Institute, https://www.mphiaccredandqi.org/ Center for Public Health Practice, Ohio State University, ` 7 P a g e

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