2014-2015 Quality Improvement Plan Goodhue County Health and Human Services Implemented: December 2014 Reviewed and Revised: Month Year, Month Year, Month Year
Purpose, Quality Culture, and Scope Our vision for quality improvement (QI) is to improve the quality of services provided to customers of Goodhue County Health and Human Services (GCHHS) and communities of Goodhue County through a structured quality improvement process. By utilizing the input and strength of staff we will fulfill the department s mission to promote, strengthen, and protect the health of individuals, families, and communities. Quality improvement is one part of an overall system of managing performance. A quality improvement plan is important as a written commitment of the agency to continuously improve its services. The purpose of the plan is to guide the development, implementation, monitoring and evaluation of efforts across all divisions to build a culture of continuous quality improvement throughout the organization. Quality improvement is a priority at GCHHS and GCHHS has formed a quality improvement committee to work towards making QI expected and supported at all levels across the department. Quality improvement is being implemented in specific program areas or with specific processes, but QI is not yet incorporated into an organization-wide culture. Structure of QI Program, Resources, Roles, and Responsibilities Structure Membership in the quality improvement committee is comprised of staff representatives from all GCHHS divisions. Membership will range from 8 to 12 people with one to two year rotating membership. Meetings will be held at least every other month with agenda and minutes maintained. The Healthy Communities Supervisor will chair the committee. Groups that form to work on QI projects will be called quality improvement project teams. Resources Staff time for training and meetings will be incorporated into existing job assignments per HHS budget. Roles and Responsibilities Specific roles and responsibilities are listed below (X = primary role, X = supporting role): 1
Responsibilities Provide ongoing leadership of QI activities within the agency Develop and approve the annual Quality Improvement Plan Facilitate QI committee meetings Develop performance management objectives and measures Measure and report progress on performance management objectives Implement QI projects (i.e. PDSA cycle) and assessment activities HHS Leadership Team Healthy Communities Supervisor Quality Improvement Committee X X X X X X X X Quality improvement project teams All staff X X X X X X X All employees are expected to continually look for strengths, efficiencies and high quality practices that can be implemented on a broader level to benefit the entire agency, to share those ideas, and to contribute to and adapt to change. Training New employee will receive 10-15 minutes of quality improvement training at orientation. QI training will be provided to all GCHHS staff at quarterly all-staff meetings and QI will be an agenda item at every quarterly all-staff meeting in an effort to build the culture of QI. Monthly department notes will include brief tips and definitions about QI. Divisions may consult with GCHHS quality improvement committee, Minnesota Department of Health Office of Performance Improvement, and/or the Human Services Performance Management Team at Minnesota Department of Human Services for quality improvement training and technical assistance. 2
The QI committee members will complete trainings to meet identified needs and to advance quality improvement knowledge, skills, and practices. Trainings may be held on a variety of performance management and QI tools. The Healthy Communities Supervisor will have advanced training such as conferences, continuing education, and online resources. The QI committee will provide just-in-time training to applicable staff as it relates to quality improvement projects to minimize the loss of knowledge. Project Identification and Prioritization The QI plan is intended to be aligned with other plans and systems to celebrate and facilitate a culture of quality in the agency and increase staff and leadership understanding and buy-in with the improvement process. Any GCHHS employee can propose a QI project by emailing the idea to any QI committee member. The proposal should be based on the need to enhance program processes, objectives, and/or performance measures. Potential sources for quality improvement initiatives: Areas where the agency or individual programs partially met or did not meet a performance measure standard Areas that could benefit from strengthening or enhancement Strategic plan measures dealing with human resources, customer service, and organizational improvement Results of evaluations of programs or administrative systems and functions Results of regular surveys of employees about their views on what is going well and systems that need improvement Regular assessment of internal and external customer service data from across the department QI projects will be approved by the GCHHS quality improvement committee. Project proposals will have priority if they are aligned with one or more of the following: Mission Strategic Plan Customer Satisfaction/Feedback o Internal customers (staff, supervisors) o External customers (community members, clients) Externally Imposed Performance Measures o Human Services Performance Measures o Program-Specific Audits (e.g. Child and Family Services Review (CFSR)) 3
o Public Health Planning and Performance Measurement Reporting System (PPMRS) Agency Priorities and Identified Gaps Existing Program Goals/Program Evaluations Project selection criteria will be evaluated and revised as needed when this plan is next revised. Goals, Objectives, and Measures The GCHHS quality improvement committee will establish annual goals and describe activities it will undertake to achieve those goals. The QI committee is responsible for carrying out the goals of the QI Plan. Goals will be established based on analysis of results from an annual allemployee survey which includes ten questions that measure organizational QI maturity. Objectives to be achieved by December 2015:* Organizational Culture Goal 1: Assess the culture of quality improvement within the agency. Objective: In January 2015, 60% of staff will complete a ten-question survey on organizational QI maturity. Activities: a. Survey all staff in 2015 Measure: Survey completed in 2015 Goal 2: Advance the culture of quality improvement within the agency. Objective: By January 2016, 50% of staff will agree staff members are routinely asked to contribute to decisions at the agency (question 1 on the organizational QI maturity survey). Activities: a. Provide 10-15 minutes information or training about QI at quarterly all-staff meetings in 2015. b. Include brief paragraph with tips and definitions about QI in monthly department notes (may be provided by MDH Office of Performance Improvement). c. Seek contributions from staff with a suggestion box for quality improvement. Welcome comments highlighting what is going well. d. Add space for staff to suggest quality improvement projects on annual performance review self-evaluations. Measure: Percent of staff surveyed in January 2016 who agree staff members are routinely asked to contribute to decisions at the agency Capacity and Competency 4
Goal 3: Establish a quality improvement plan. Objective: By December 31, 2014, develop an annual agency QI plan that seeks to increase staff knowledge of QI and supports development of quality improvement projects. Activities: a. Creation of draft QI plan by the Healthy Communities Supervisor, Deputy Director, and Child Support Supervisor. b. Review of QI plan by QI committee. c. QI plan approved by GCHHS Director. d. QI plan presented to Goodhue County HHS Board in January 2015. Measure: Final draft GCHHS 2014-2015 QI Plan Alignment and Spread No current goals. *For the goal 2 objective, activities will be completed in 2015 but measured in January 2016. Communication The QI committee will communicate the annual QI plan, QI projects and progress to GCHHS staff at quarterly all-staff meetings and annually to the Goodhue County HHS Board. The QI committee will include a brief paragraph with tips and definitions about QI in monthly department notes. Additional updates about QI activities may be included in monthly department notes as applicable. Staff can communicate to the QI committee by putting submissions in the suggestion box or by emailing any QI committee member. Monitoring the Plan and Assessing Effectiveness The QI committee will assess staff QI maturity and progress on QI Plan goals annually. The QI committee is responsible for carrying out the goals of the QI Plan. Progress on the stated goals and objectives will be reported at quarterly staff meetings. Activities planned for the following year will be based on progress reports and recommendations from the annual plan evaluation. The QI Plan will be reviewed in September 2015 and approved annually by the QI committee and then submitted to the director for review and approval. The effectiveness of the QI plan will be measured through results from the annual staff survey on QI maturity. The QI committee will review the staff survey results as well as lessons learned from QI plan goals and any QI projects that occurred during the year. Customer and stakeholder satisfaction surveys from QI activities are also a measure of effectiveness. The QI committee, in cooperation with QI project teams, is responsible for data collection and analysis. 5
Appendix A: Key Terms Customers: both external customers, those who buy or receive services from GCHHS, and internal customers, those who are involved in or with the operation of GCHHS Customer Satisfaction: the number of customers (or percentage of total customers) whose reported experience with an entity, its products, or its services (ratings) exceeds specified satisfaction goals 1 Gap analysis: the assessment of the difference between stated goals and current reality (If there were no gap, there would be no need for any action to move towards goals) 2 Goals: general statements expressing a program's aspirations or intended effect, often stated without time limits 3 Human Services Performance Management (HSPM): Minnesota Department of Human Services system implemented in 2014 to track county-level performance measures for six population outcomes related to children s services, income supports, and adult services Measures: indicators that tell to what extent a program is performing well 4 Objectives: targets for achievement through interventions; time-limited and measurable in all cases 5 Performance Management: using data for decision-making by setting objectives, measuring and reporting progress toward those objectives, and engaging in quality improvement activities when desired progress toward those objectives is not being made 6 Plan-Do-Study-Act (PDSA): an iterative, four-stage problem-solving model for improving a process or carrying out change, also called rapid cycle improvement or PDCA (Plan-Do-Check- Act) 7 Public Health Planning and Performance Measurement Reporting System (PPMRS): Minnesota Department of Health system for counties to report annually on performance measures related to local public health s six essential services Program: any activity, project, function, or policy that has an identifiable purpose or set of objectives 8 1 Adapted from Washington County Department of Public Health and Environment (MN) QI Plan, 2014 2 Adapted from Fillmore-Houston Community Health Service (MN) QI Plan, 2012 3 Adapted from Public Health Accreditation Board (PHAB) Acronyms and Glossary of Terms Version 1.5, 2013, http://www.phaboard.org 4 Adapted from Fiscal Policy Studies Institute, 2014, http://resultsaccountability.com 5 Adapted from PHAB 6 Minnesota Department of Health Office of Performance Improvement, 2014, http://www.health.state.mn.us/qi/ 7 Adapted from Washington County 6
Program Evaluation: individual systematic studies conducted periodically or on an ad hoc basis by program managers or by external experts to assess how well a program is working 9 Quality Culture: QI is fully embedded into the way the agency does business, across all levels and programs; leadership and staff are fully committed to quality, and results of QI efforts are communicated internally and externally 10 Quality Improvement (QI): the use of a deliberate and defined improvement process and the continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality that improve the health of the community 11 Quality Improvement Committee: group of 8-10 staff representing all GCHHS divisions who oversee efforts related to QI culture, performance management, and QI project selection Quality Improvement Plan: document outlining how the department will conduct continuous quality improvement activities for the year, including annual objectives Quality Improvement Project Team (QI Team): group of applicable GCHHS staff who work on a specific QI project using the PDSA model and quality improvement tools Quality Improvement Tools: graphs or techniques designed to assist a team when solving a defined problem or project, such as a check sheet, scatter diagram, control chart, fishbone diagram, Pareto chart, or histogram, among others 12 Resources: sources of support, e.g. human, organizational, informational, and fiscal resources 13 Stakeholders: all persons, agencies and organizations with an investment or 'stake' in the health of the community, including persons and organizations that benefit from and/or participate in the delivery of services that promote, strengthen, and protect the public's health and overall well-being 14 Strategic Plan: document resulting from a deliberate decision-making process and setting the direction for the organization through a common understanding of the organization s mission, vision, goals, and objectives 15 8 U.S. Environmental Protection Agency Program Evaluation Glossary, http://www.epa.gov/evaluate/index.htm 9 Adapted from U.S. Environmental Protection Agency 10 Adapted from Washington County 11 Minnesota Department of Health 12 Adapted from Washington County 13 Adapted from PHAB 14 Adapted from PHAB 15 Adapted from PHAB 7
Appendix B: Organizational QI Maturity Survey This survey will be administered to all GCHHS staff annually in January. Organizational Culture Strongly Agree Agree Neutral Disagree Strongly Disagree Don t Know 1. Staff members are routinely asked to contribute to decisions at my agency. 2. When trying to facilitate change, staff has the authority to work within and across program boundaries. 3. The key decision makers in my agency believe quality improvement is very important. 4. My agency currently has a pervasive culture that focuses on continuous quality improvement. Capacity/Competency Strongly Agree Agree Neutral Disagree Strongly Disagree Don t Know 5. The leaders of my agency are trained in basic methods for evaluating and improving quality, such as Plan-Do-Study-Act. 6. My agency has a quality improvement plan. 7. My agency currently has a high level of capacity to engage in quality improvement efforts. Alignment and Spread Strongly Agree Agree Neutral Disagree Strongly Disagree Don t Know 8. Job descriptions for many individuals responsible for programs and services at my agency include specific responsibilities related to measuring and improving quality. 9. Customer satisfaction information is routinely used by many individuals responsible for programs and services in my agency. 10. My agency currently has aligned our commitment to quality with most of our efforts, policies and plans. Source: http://www.health.state.mn.us/divs/opi/pm/lphap/qiplan/docs/qimaturitytool_subset.pdf 8
Appendix C: 2014-2015 GCHHS QI Committee Members Member Ruth Greenslade, Healthy Communities Supervisor (Facilitator) Term Ends N/A Mary Heckman, Deputy Director 7/31/16 Theresa Miller, Nursing Supervisor 7/31/15 Krista Early, Family Health Supervisor 7/31/15 Sharon Watson, Child Support Supervisor 7/31/16 Kris Johnson, Social Services Supervisor 7/31/16 Laura Larson, Eligibility Worker 7/31/16 Patti Evenson, Account Technician 7/31/16 Susan Johnson, Emergency Preparedness Coordinator Retiring 12/19/14 Lisa Woodford, Case Aide 7/31/15 9