Performance Management System Policy and Logic Models Measure: 9.1.2 A Version 1.5 Submitter: Flathead City-County Health Department (MT) (ASI Site, 2013-2014) Demographic Information: Population served: 90,928, rural FTEs: 42 State structure: decentralized Required documentation: 1. An adopted performance management system: Submitter justification: Once effective, this policy (combined with attached logic models) will meet the requirements of this measure. Note: none of the NACCHO demonstration sites received accreditation status or an indication of the likelihood of accreditation status through the grant process, and therefore this documentation does not reflect items that have officially been approved by PHAB for the purposes of meeting a standard or measure.
FLATHEAD CITY-COUNTY HEALTH DEPARTMENT FCCHD DIVISION: Health Administration EFFECTIVE (ORIGINAL) DATE: 7/1/2014 POLICY NAME: Performance Management System POLICY #: 2014-01 ADM REVIEWED: PAGE OF PAGE APPROVED BY: REVISED DATE: 1.0 BACKGROUND: The Performance Management System (PMS) provides a framework to regularly review quality, efficiency, and effectiveness of all programs and to discuss what is working well, to celebrate and share successes, and to discuss what areas needing further development in order to actively problem solve and improve programs. The development of the local PMS utilized the Montana Department of Public Health and Human Services (DPHHS) performance management system as a model. The methodology (built around logic models) used by DPHHS has been presented, at a national level, as a model performance management system. The link between the state and local performance management system will help ensure the achievement of local and state performance standards. In addition, an important benefit of the DPHHS model is that it requires all public health programs to clearly understand and articulate how the core activities in each program will lead to measurable results. The logic model format provides a tool to help each program tell the story of what they do, why they do it, and what results they are, or should be getting. 2.0 POLICY: The Flathead City-County Health Department will maintain a Performance Management System. The Performance Management System will consist of performance standards and measures for each public health program and the Strategic Plan. Data related to the performance measures will be regularly collected and progress reporting will be conducted at least two times per year for each program. Quality improvement will be utilized, as necessary, to ensure that performance goals and targets are met. 3.0 DEFINITIONS: Performance management system: continuous use of setting organizational objectives across all levels of the department, identifying indicators to measure progress toward achieving objectives on a regular basis, identifying responsibility for monitoring progress and reporting, and identifying areas where achieving objectives requires focused quality improvement processes. Performance standards: establishment of organizational or system standards, targets, and goals to improve public health practice. Performance measurement: development, application, and use of performance measures to assess achievement of performance standards. Quality improvement: positive changes in capacity, process and outcomes. It involves changes to address public health organizational weaknesses and the use of evidence to inform decision making. Page 1 of 3
4.0 PROCEDURE: FLATHEAD CITY-COUNTY HEALTH DEPARTMENT 4.1 Organizing Structure: The Performance Management Team is responsible for implementing the performance management system. Members consist of the Health Officer, Deputy Health Officer, Health Promotion Coordinator, Environmental Health Coordinator, Community Health Director and additional program staff as assigned. The Performance Management Team: Oversees all aspects of the Performance Management System. Identifies priority quality improvement projects based on performance management results and strategic plan implementation. Evaluates the Performance Management System periodically and implements changes as necessary. The Health Department Leadership: Include staff in the development of the programmatic logic models and the development of the performance management standards and measures. Monitor, track, and report progress made towards meeting standards and performance measures on an interval as defined by each measure. Reports progress to both staff and to the Performance Management Team at least two times each year. Conducts quality improvement activities as identified by the Performance Management Team. 4.2 Performance Management Process: 4.3 Data Collection Each division, led by their respective Coordinator or Director, will be responsible ensuring data collection systems are in place to track and monitor performance standards and measures. Progress will be recorded on a reporting template stored on a share drive accessible by all staff. Policy: Performance Management System Page 2 of 3 Policy No.: 2014-01 ADM
FLATHEAD CITY-COUNTY HEALTH DEPARTMENT 4.4 Reporting: Each division, led by their respective Coordinator or Director, will be responsible for reporting to the Performance Management Team at least two times per year. The presentation must answer the following questions: Are we on track with what we planned? Is performance getting better, worse, or staying about the same over time? What do we need to do differently, if anything? How have quality improvement tools been utilized or how will they be utilized? 4.5 Communication: Staff are invited to observe Performance Management Team meetings as desired. A schedule of programs reporting will be kept on the share drive and accessible to all staff. The Board of Health will be provided a summary of Performance Management Team meetings and as requested additional information or reports will be provided. 5.0 REFERENCES: The Public Health Foundation s Performance Management Toolkit (http://www.phf.org/pmtoolkit) Public Health Accreditation Board (PHAB) (http://www.phaboard.org) 6.0 REVISION HISTORY Revised Date Rev Letter Document Author Description of Change Policy: Performance Management System Page 3 of 3 Policy No.: 2014-01 ADM
Administration of Immunizations Community Health Division Immunizations Home Visiting WIC Communicable Disease Billing and Eligibility Quality Assurance Data and Records Education and Outreach (Schools and Daycares) Education and Outreach (Health Care Professionals) Core Activity 1
Immunization Flathead County residents are protected from vaccine preventable diseases Rate of Flathead County children aged 19-35 months that are fully immunized with the 4:3:1:3:3:1:4 series (per clinic assessment) Rate of Flathead County adolescents who are fully immunized with Tdap, MCV4, and HPV Billing and Eligibility Clients are screened and linked to the appropriate immunization programs Billing is completed efficiently Number of program assignment inaccuracies Number of denied claims Education and Outreach (Health Care Professionals) Health care providers follow ACIP, CDC and DPHHS recommendations regarding immunizations There is an effective provider coalition focused on immunizations in Flathead County Health care professionals receive recommended vaccines Rate of immunizations in health care professionals in long term care facilities (influenza and Tdap as reported in the state report) Number of Gold Star facilities Number of provider participants in coalition Number of trainings given to health care professionals about immunizations Quality Assurance Based on ACIP Recommendations Standing orders are current and reflect ACIP recommendations Vaccine Information Sheets are current Vaccine integrity is maintained Best Practices from the CDC and ACIP are followed to ensure: client safety; staff safety and education; and 5 R s Percent of standing orders reviewed annually Bi-annual state report score on: Vaccine integrity Current Vaccine Information Sheets All other areas Number of incidents reported Education and Outreach (Schools and Daycares) Providers receive recommended vaccines Immunization forms are completed in an accurate and timely manner Immunization rates of daycare providers Percent of OPI reports from schools that are timely, accurate and complete Percent of daycares that have complete immunization reports Number of Stars daycare providers Administration of Immunizations Patients are educated in CDC and ACIP recommendations at every encounter to ensure there are no missed opportunities Accurate administration of immunizations Accurate and timely charting Assuring community access to immunizations Timely completion of inventory Number of missed opportunities (DPHHS report) Number of errors in the monthly report Immunization utilization rate of clinic hours Number of months vaccine is ordered by the deadline Average number of days prior to deadline that vaccine ordering can occur Data and Records The correct vaccines are provided to each client The state registry is up to date Data can be utilized for communicable disease follow-up Schools and daycares are in compliance with immunization rules Number of providers reporting to the state registry Number of duplicate charts School immunization compliance rate (not including exemptions) Daycare immunization compliance rate 2
Farmers Market Immunizations Referrals Community Health Division Home Visiting WIC Communicable Disease Data Collection Retail Nutrition and Breastfeeding Education Operations Core Activity 3
Farmers Market Increase access to fresh fruits and vegetables for WIC clients Support the local economy Farmers Market redemption rates Number of farmers participating Customer survey results (FM Season 2015) Retail The barriers to accessing nutritious foods are removed Retail stores comply with WIC rules Clients comply with WIC rules Percent of stores below X number of sanctions # of outreach events at retailers per year # of participants out of compliance (quarterly) WIC Improved nutritional understanding, nutritional health, and breastfeeding support for Women, Infants and Children in Flathead County Number of program participants in Flathead County Referrals Provide access to needed services both within the Health Department and at other community agencies Number of referrals made to additional services Percent of referrals followed-up Data Collection Collect accurate data that can provide a clear picture of the health needs of WIC clients on a local, statewide and national data Number of months between equipment calibration Quality Assurance metric (yet to be determined) Nutrition and Breastfeeding Education Provide education on nutrition and breastfeeding that allows mothers to make informed decisions Provide education utilizing various methods to meet the needs of the client Number of breastfeeding mothers Average length of time breastfeeding Average number of days breast pumps are utilized in a quarter Number of participants utilizing WIChealth.org % of clients receiving three nutritional education visits Operations Have the necessary operations in place to support the WIC program in Flathead County Staff are properly trained to administer the WIC program and maintain the integrity of the program Score on the DPHHS monitoring site visit Percent of clients with failed appointments Customer Service satisfaction Percent of staff that have completed the required Mspirit training modules and competency based trainings 4
Community Outreach Immunizations Operations Community Health Division Home Visiting WIC Communicable Disease Client Advocacy Direct Client Services Team Building and Professional Development Core Activity 5
Community Outreach The public knows about the home visiting serves and makes proper referrals Appropriate referrals are made from the Health Department to other community organizations Number of un-enrolled people that attend Group Connections Number of agencies that refer to home visiting services Number of providers to education is provided Home Visiting Enhance child growth and development, promote parenting and ensure early intervention services as needed so all Flathead County children will enter school healthy and ready to succeed. Operations All grant and program requirements are met in a timely manner Flathead County clients are provided the needed home visiting services Average amount of time to chart (determined via chart audit) matic caseloads Client Advocacy There is collaboration of services between the Health Department and other organizations The client is empowered to advocate for themselves The client is provided the necessary resources to be successful Percent of clients that achieve their goals Improvement on LSP Child improvement on ASQ Team Building and Professional Development The success of each coworker is enhanced through team building and professional development Percent of reflective listening requirements completed Percent of months in which a case study was reviewed Percent of educational needs met with a speaker Direct Client Services The fidelity of the programs are ensured Public health concepts are promoted Immunization rate of children enrolled in home visiting programs Number of clients that attend Group Connections Frequency of home visits Percent of clients for which goal setting has been completed The Parents as Teachers framework is followed 6
Trailer Courts and Campgrounds Wastewater Treatment and Disposal System Body Art Environmental Health Division Food Service Establishments Subdivision Review Air Quality Public Accommodations Pools/Spas Training, Education, and Outreach Licensing, Inspections, Complaints and Enforcement Quality Assurance Core Activities 1
Licensing, Inspections, Complaints and Enforcement: License fees provide supplemental funding to conduct inspection, investigation and enforcement Establishments are compliant with health and safety rules Percent of inspections completed (per DPHHS report) Time until initial action on complaints Percent of complaints resolved Number of critical violations recorded Pools and Spas Pools and spas are safe for the community to use Illnesses and injuries related to pools and spas are avoided Number of onsite Certified Pool Operators Number of pool closures with followup Quality Assurance Accuracy and consistency in data, inspections, training and enforcement Number of verification audits completed Training, Education and Outreach: Sanitarians are competent to conduct inspections, investigations and enforcement Operators are knowledgeable of current pool and spa rules Percent of pool and spa FCCHD sanitarians that are currently CPO certified Number of CPO educational packets distributed 2
Trailer Courts and Campgrounds Environmental Health Division Wastewater Treatment and Disposal System Body Art Food Service Establishments Subdivision Review Air Quality Public Accommodations Licensing, Inspections and Enforcement Rules, Statutes and Local Policy Training, Education, and Outreach Complaints and Investigations Quality Assurance Pools/Spas Core Activities 3
Food Service Establishments The community has a safe product for consumption Foodborne illnesses and related deaths are avoided Licensing, Inspections and Enforcement: Public licensed establishments meet or exceed minimum sanitation and safety standards License fees provide supplemental funding to conduct inspection, investigation and enforcement Establishment compliance with health and safety standards is observed and recorded Establishment health and safety standard deficiencies are corrected if existing Percent of reimbursement received Number of critical violations recorded Standard 3: Percent of Standard 3 quality records completed Standard 9: Risk Factor Study Complaints and Investigations: Investigations are addressed in a collaborative, consistent and timely manner All complaints are addressed and resolved in a consistent and timely manner Time until initial action on complaints Percent of complaints resolved Standard 5: Percent of protocol elements that are written Rules, Statutes and Local Policy: Knowledge is maintained on the most current rules, statutes and local policies and they are utilized in a consistent manner Rules, statutes and local policies are reviewed to determine the need for revisions and governing entities are informed of needed updates/amendments Standard 6: Percent of sampled establishments for which compliance and enforcement was taken correctly Percent of local policies reviewed on an annual basis Training, Education and Outreach Sanitarians are competent to conduct plan review, inspection, investigation and enforcement Operators are knowledgeable of current food and consumer safety rules The general public is informed about food safety Standard 2: Percentage of retail food program sanitarians that have completed program standard 2 criteria Standard 4: Performance rating on standard 4 quality elements Standard 7: Number of industry and consumer interactions Standard 7: Number of educational outreach activities Number of Gold Star Recipients Average duration of Gold Star Award Quality Assurance: Accuracy and consistency in data, inspections, training and enforcement Standard 8: FTE to inspection ratio Standard 9: Number of self-assessments completed Standard 9: Number of verification audits completed 4
Trailer Courts and Campgrounds Wastewater Treatment and Disposal System Body Art Environmental Health Division Food Service Establishments Subdivision Review Air Quality Public Accommodations Pools/Spas Licensing, Inspections, Complaints and Enforcement Quality Assurance Core Activities 5
Licensing, Inspections, Complaints and Enforcement: License fees provide supplemental funding to conduct inspection, investigation and enforcement All establishments are inspected for compliance with health and safety rules Public Accommodations Illnesses and injuries related to pools and spas are avoided Percent of inspections completed Time until initial action on complaints Percent of complaints resolved Quality Assurance Accuracy and consistency in data, inspections, training and enforcement Number of verification audits completed 6
Environmental Health Trailer Courts and Campgrounds Wastewater Treatment and Disposal System Body Art Food Service Establishments Subdivision Review Licensing, Inspections, Complaints and Enforcement Quality Assurance Training, Education and Outreach Division Air Quality Public Accommodations Pools/Spas Core Activities 7
Licensing, Inspections, Complaints and Enforcement: License fees provide supplemental funding to conduct inspection, investigation and enforcement All establishments are inspected for compliance with health and safety rules Percent of inspections completed Time until initial action on complaints Percent of complaints resolved Body Art Illnesses and injuries related to body art are avoided Training, Education and Outreach Artists are knowledgeable of current body art rules The general public is informed about body art safety Number of hits to the FCCHD Body Art page Quality Assurance Accuracy and consistency in data, inspections, training and enforcement Number of verification audits completed 8
Trailer Courts and Campgrounds Wastewater Treatment and Disposal System Body Art Licensing, Inspections, Complaints and Enforcement Quality Assurance Environmental Health Food Service Establishments Subdivision Review Division Air Quality Public Accommodations Pools/Spas Core Activities 9
Licensing, Inspections, Complaints and Enforcement: License fees provide supplemental funding to conduct inspection, investigation and enforcement All establishments are inspected for compliance with health and safety rules Trailer Courts and Campgrounds Illnesses and injuries related to trailer courts and campgrounds are avoided Percent of inspections completed Time until initial action on complaints Percent of complaints resolved Quality Assurance Accuracy and consistency in data, inspections, training and enforcement Number of verification audits completed 10
Trailer Courts and Campgrounds Wastewater Treatment and Disposal System Body Art Environmental Health Food Service Establishments Subdivision Review Complaints Permitting Division Air Quality Monitoring Public Accommodations Pools/Spas Public Awareness Compliance Core Activities 11
Compliance: Flathead County is compliant with air quality rules Percent of required compliance testing completed Complaints All complaints are addressed and resolved in a consistent and timely manner Air Quality Flathead County maintains health ambient air and compliance with the Clean Air Act Monitoring FCCHD is compliant with the Montana Department of Public Health and Human Services air quality contract FCCHD collects the appropriate data to monitor air quality and make decisions on immediate actions Number of days out of the Episodic Control Matrix is updated Public Awareness: The public is knowledgeable of air quality rules and is not unknowingly breaking the rules The general public is informed on about air quality Time until initial action on complaints related to smoke Time until initial action on other complaints Percent of complaints resolved Permitting: All those that require a permit have received one (e.g. trade waste, firefighting, Christmas tree burning, construction demolition) Percent of those that have a permit of those that should have a permit Number of calls to the air quality hotline Number of hits to the FCCHD air quality website page Number of radon kits sold Percent of air quality alerts issued of those that should have been issued. 12
Trailer Courts and Campgrounds Wastewater Treatment and Disposal System Body Art Complaints Permitting Regulations Environmental Health Food Service Establishments Subdivision Review Education and Certification Division Air Quality Public Accommodations Pools/Spas Core Activities 13
Permitting: The wastewater treatment and disposal system permitting process is completed correctly and the appropriate information has been provided Percent of applications submitted that contain all the required information Number of repeat site visits Complaints All complaints are addressed and resolved in a consistent and timely manner Time until initial action on complaints Percent of complaints resolved Wastewater Treatment and Disposal System Protect water, public health and safety Regulations Sanitarians are knowledgeable on regulations Regulations are utilized in a consistent manner Regulations are regularly reviewed for needed updates Percent of regulations reviewed on an annual basis Percent of sanitarians that have displayed all required competencies for the wastewater treatment and disposal system program (recorded per joint inspections) Education and Certification: Installers and Designers are licensed and knowledgeable on regulations and standards Property owners understand the regulations and the COSA Number of educational outreach activities to installers/designers Number of joint meetings with the Planning Department 14
Trailer Courts and Campgrounds Wastewater Treatment and Disposal System Body Art Environmental Health Food Service Establishments Subdivision Review Complaints Outreach Division Air Quality State Rules Public Accommodations Review Process Pools/Spas Core Activities 15
Review Process: Reviews are completed in a timely manner Percent of applications that are completed within a 45 day timeline Complaints All complaints are addressed and resolved in a consistent and timely manner Time until initial action on complaints Subdivision Review To protect the environment and public health through review of water quality, storm water, solid waste and wastewater disposal Outreach The public is informed about subdivision rules Number of educational materials available regarding the subdivision review process State Rules: Sanitarians are knowledgeable on rules Rules are applied in a consistent manner Number of sanitarians that are certified subdivision reviewers 16
5/27/2014 Cancer Control and Screening Implement Evidence Based Practices Health Promotion Division Tobacco Use Prevention Public Health Emergency Preparedness Cancer Screenings Patient Advocacy Safe Kids Safe Communities Core Activity 1
5/27/2014 Implement Evidence Based Practices Local worksites have cancer prevention policies and systems # of new cancer prevention worksite policies/systems in place as result of the Cancer Control and Screening % of Colorectal Cancer Toolbox elements adopted at provider offices working with the Cancer Control and Screening % of Colorectal Cancer Toolbox elements in place at provider offices 12 months following the completion of work with FCCHD (Sustainability) Cancer Control and Screening Reduce number of cancers diagnosed in Region 1 Reduce cancer related health disparities in Medicaid population Percent of diagnosed patients enrolled in Medicaid Number of breast, cervical, and colorectal cancer diagnosis in Region 1 Cancer Screenings: To increase the knowledge on and the number of Region 1 residents completing the recommended breast, cervical and colorectal cancer screenings Ratio of new Cancer Screening program participants vs. re-enrolled participants Adherence rate of colorectal card screenings % of Native American participants screened (as relative to the Flathead County Native American goal for the grant year) Patient Advocacy Link diagnosed patients to care Percent of diagnosed patients enrolled in Medicaid Number of MOUs in place to treat patients diagnosed with colorectal cancer
5/27/2014 Cancer Control and Screening Promote Community Involvement Health Promotion Division Tobacco Use Prevention Public Health Emergency Preparedness Promote Smokeand Tobacco-free Environments Prevent Tobacco Use Among Young People Safe Kids Safe Communities Promote Tobacco Cessation Core Activity 3
5/27/2014 Promote Community Involvement The community participates in promoting a tobacco-free Flathead County Tobacco Use Prevention Reduce tobacco use in Flathead County Prevalence of tobacco use among adults Prevalence of tobacco use among youth Number of community partners that participate in Days of Action Number of other events with community partners participating Number of people attending events and presentations Prevent Tobacco Use among Young People Educate and empower youth to make good choices related to tobacco Percent increase in knowledge of tobacco on pre/post test (STAND) Percent increase in knowledge of tobacco on pre/post test (youth tobacco presentations) Promote Smokefree and Tobacco-free Environments Increase number of smokefree and multi-unit housing complexes Increase the number of businesses with tobacco-free campuses Ensure compliance with the Clean Indoor Air Act Percent of housing complexes with an ideal campus policy Percent of housing complexes with a smoke-free building policy Number of businesses newly smoke-free with which the Tobacco Use Prevention program has worked Number of community events newly smoke-free of with which the Tobacco Use Prevention program has worked Number of workers covered by new smoke-free campus policies Promote Quitting Increase number of calls to the Quit Line and ensure people are aware of cessation resources Percent of total Quit Line calls from Flathead County
5/28/2014 Cancer Control and Screening Planning Health Promotion Division Tobacco Use Prevention Public Health Emergency Preparedness Safe Kids Safe Communities Training Response Corrective Action Core Activity 5
5/28/2014 Planning: Staff and community partners understand their role when responding to a public health emergency Public Health Emergency Preparedness Respond to events impacting local public health through planning, assessment, and development of critical capacities Percent grant deliverables completed quarterly Percent of response plans and procedures reviewed every fiscal year Training: Staff and community partners are trained to respond to a public health emergency Percent of staff having completed ICS 100, 200, and 700 Percent of staff having completed ICS 300 and 400 Percent of staff and community partners that have completed annual training on Emergency Medical Countermeasures Response: Staff and community partners demonstrate response skills when responding to a public health emergency Number of key community partners participating in a tabletop or functional exercise Percent of community response partners complying with quarterly call-down drills Corrective Action: Staff and community partners improve response to a public health emergency Percent of After Action Reports completed for every emergency preparedness related event Percent of AARs completed in one month from completion of an event Percent of corrective action items completed within the allotted timeframe
5/28/2014 Cancer Control and Screening Health Promotion Division Tobacco Use Prevention Public Health Emergency Preparedness Provide Education Safe Kids Safe Communities Enforcement Core Activity 7
5/28/2014 Enforcement Support enforcement through adequate equipment and policies Safe Kids Safe Communities Increase awareness about the benefits of seatbelt usage Increase the correct usage of child restraints Reduce the number of alcohol related traffic crashes Increase the correct usage of child restraints Number of alcohol related traffic crashes Percent of law enforcement cases that meet minimum requirement for DUI convictions Number of policy makers contacted regarding primary seat belt law Provide Education: Flathead County residents have knowledge of how to live safely Number of car seat technicians certified Number of car seats checked % of helmets distributed with education Number of schools participating in a young drivers campaign 8