Kenosha County Division of Health Performance Management System Quality Improvement Plan Version 2.0 - November 2013 1
Purpose: The Kenosha County Division of Health (KCDOH) Performance Management System and Quality Improvement Plan is a living document that describes how we will manage, deploy, and review quality health services throughout our organization. The main focus is on how we deliver our products and services to our customers and how we ensure that we are aligned to meet their socio-economic and health needs overtime. A. Mission Statements 1.) The mission of the Kenosha County Division of Health (KCDOH): To assure the delivery of health services necessary to prevent disease, maintain and promote health, and to protect and preserve a healthy environment for all citizens of Kenosha County regardless of ethnic origin, cultural, and economic resources. 2.) The mission of Performance Management System at the KCDOH: To assure the continuous use of performance data to improve the health of Kenosha County residents and yield quality public health service: by utilizing performance measures and standards to implement target goals and objectives, by prioritizing and allocating resources in an efficient and cost effective manner, and by making necessary changes in policy or program direction to meet goals 3.) The mission of Quality Improvement at the KCDOH: To assess the quality of programs, processes, and services delivered to the public at regular, consistent intervals and implement improvements that will enable the KCDOH to achieve a high level of consistent quality performance, efficiency, and effectiveness; which results in positive public satisfaction and healthy outcomes amongst the public. Performance management 1 is a systematic process aimed at helping achieve an organization s mission and strategic goals by improving effectiveness, empowering employees, and streamlining the decision-making process. The quality improvement (QI) plan describes the process and activities within the KCDOH in order ensure that quality health services are delivered to the public consistently. Quality improvement will focus on all areas of infrastructure within the KCDOH, including at the program and project level, with continuous improvement throughout the course of QI development. Establishment of realistic goals and objectives, within a defined time frame, will 1 Public Health Foundation. "Performance Management and Quality Improvement." Performance Management and Quality Improvement. Public Health Foundation, n.d. Web. 02 Aug. 2012. <http://www.phf.org/focusareas/pmqi/pages/default.aspx 2
be set for the department as part of the continuous improvement plan. Goals and objectives will be effectively communicated to staff, board of health members, and the community. B. Performance Management System Framework The Performance Management System for the KCDOH has four components. These four steps are listed below with further explanation: 1. Performance Standards establishment of organizational or system performance standards, targets, and goals to improve public health practices Define the performance standards pertinent to evaluating the performance of service/program Set goals/targets (includes outcome that is measureable and target deadline for achievement of goal) Determine indicators (how will goals be evaluated- factors to monitor) 2. Performance Measures development, application, and use of performance measures to assess achievement of such standards Determine source(s) of data (if data will be retrieved from secondary sources, identify source and individual/organization responsible; if primary data collection required, devise and attach data collection form and associated data definitions) Decide person(s) responsible for collecting data (either retrieving data from secondary data source or for facilitating the collection of primary data) Determine data collection methods (frequency of data collection, process for evaluating data integrity, aggregating and reporting data, how to document missing data) 3. Quality Improvement establishment of a program or process to manage change and achieve quality improvement in public health policies, programs or infrastructure based on performance standards, measurements, and reports Describe the activities that will be implemented to drive improvement to accomplish the stated goals Determine person(s)/group responsible for leading the QI activities (project facilitator) Determine person(s)/group responsible for monitoring improvement and making recommendation for enhancements to the process, as needed (administrative oversight) 4. Reporting of Progress documentation and reporting of progress in meeting standards and targets and sharing of such information through feedback Determine person(s)/group responsible for evaluating the performance management system Develop a progress report template (to document the effectiveness of the performance management system, progress towards the established goals, the 3
effectiveness of the measurement system in tracking progress, and documenting recommendations for enhancements, as needed) Use data to drive improvement activities The Plan-Do-Check-Act (PDCA) cycle, as suggested by the American Society for Quality, is a method for carrying out change and exploring continuous change within the infrastructure of the health department. PDCA cycles have been utilized by the KCDOH staff in the past, and have proven to be an effective mechanism in achieving quality improvement. C. Quality Improvement Principles A KCDOH Strategic Plan for 2012-2016 was developed in 2011 in conjunction with the Kenosha County Community Health Improvement Plan (CHIP). In this strategic plan, goals, strategies, and objectives for the Kenosha County Division of Health were set. These are the basis of quality improvement activities for KCDOH. Other items will be identified by each section/team during staff meetings. The KCDOH Management Team will be charged with assuring the health department executes a continuous quality improvement plan and achieves quality improvement goals. This team will guide, maintain and evaluate department quality improvement by: Providing committed leadership Developing the quality improvement plan and establishing a time frame for goals and objectives to be met Identifying areas of improvement in processes Improving staff knowledge and capacity to effectively implement performance improvement tools and measurements Utilizing PDCA cycles Evaluating quality improvement on a quarterly and annual basis Implementing effective performance communication strategies Identifying, monitoring, reviewing, and reporting results of quality improvement projects, at the program and department level. D. KCDOH Process for Performance Management 1. KCDOH Managers/Team Leaders will achieve their Strategic Plan goals/objectives utilizing the PDCA cycle as needed. 4
2. KCDOH Managers/Team Leaders will utilize the PDCA cycle to identify and achieve quality improvement items in staff meetings. The KCDOH QI Project Worksheet will be completed. 3. The KCDOH Quality Improvement Tracking Log will be used to easily track progress on QI goals and objectives. These tools will provide a basis for regularly scheduled meetings where QI will be reported and evaluated. E. Communication Regular communication and reporting between the KCDOH Management Team and other staff will be imperative in regards to updates on quality improvement. The team will meet with the Director of the Kenosha County Division of Health and provide a report for the Board of Health and the Department of Human Services on a quarterly basis. The team will review and report the progress on objectives in the quality improvement plan, update the Tracking Tool, prioritize projects and gaps identifiable, plan training activities, and other pertinent information. F. Training All KCDOH staff members have been trained in QI and it is incorporated into staff meetings. New employee orientation includes a review of quality improvement and PDCA cycle training materials. 5