PurposeandScope

A.QualityManagement: Is the actof overseeingall activitiesandtasks needed tomaintaina desired level of excellence. Thisincludescreatingandimplementingqualityplanningandassurance,aswellas quality control andqualityimprovement. It isalsoreferred toas total qualitymanagement (TQM).Quality Improvement,oneaspectof quality management,isanintegrative process thatlinks knowledge, structures,processes and outcomestoenhancequality throughout anorganization.1

B.Vision:The Quality Council(QC)will aidin creating, implementing,maintaining, andevaluatingthe qualitymanagement(QM)efforts at St. Mary’s County Health Department(SMCHD) withthe intent toimprove the levelof performance.

Byprovidinga shared visionthat canserve asan effectiveguide to setthe stagefor qualitymanagement, we hope toencourage a qualityorganizationalculturethat emphasizeslearning, teamwork andcustomer focus;strivesfor institutional excellenceandstaffempowerment;and total quality andhumanresource management.Aswe achieve greaterexcellence standards, the morewehopetoengrainandreinforce an enduringculture ofqualityimprovement andexcellence,which will showviaimproved qualityofoutcomes andservices.

(Forgoals,objectives,activities,andmeasurementsfortheQualityCouncil,seeAppendixG:LogicModel)

I.ReportingStructure

(SeeAppendixB:CommunicationFlowChart)

Everyone has arole inSMCHD’squality improvementefforts.

A.QualityCouncil

The Health Officer hascharged the QC with carrying out the purposeandscopeof qualitymanagement, includingimprovementeffortsat the St. Mary’s County Health Department.It is intendedthatmembershipinthe QC consistsofonemanagementandonenon-managementpositionfromeach division. TheQC consistsof cross-sectional representativesfromexecutive management,programmanagers, andline staff, as well astwomembers from eachagency division.In addition, theagency HIPAAofficer anddesignated representativefromthe Healthy St. Mary’s Partnership (HSMP)areonthe QC. AssignmentstotheQCarefor aminimum two-year periodoftime withonlyonememberfrom each divisionrotatingoffeachyear.Longertermparticipationfromatleastonedivisional representative isencouraged to buildanddisseminate expertisethroughout theagency,thereby helping us tosustain expertiseovertime,despite potential changesinfundingor staffing.Everyyear,rotational memberswill be solicitedvia open recruitmentandgiven sixmonthtemporaryrotationsonthecouncil. Lessthanhalfof the council membershipcanrotateoff ofthe committee eachyear to maintain continuity.Whennewmembers rotateontothe council, individuals whohave participatedas ad-hoc memberswillbegiven primary consideration toparticipate asa regularmemberfromtheir divisionfor the next timeperiod.Co-chairs will beselectedbytheQC fora two year termwitha staggered rotation. If possible,oneco-chairmustbe an Executive ManagementTeammemberandtheother must bea staff person.Administrativesupportwill be availablethroughoneof themembersonthe QCor by QC

1PerformanceManagementGlossary,PublicHealthImprovementPartnership,2007

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member designationfromavailable administrativesupport staff.TheQC meetsona regularbasis and maintains records andminutesof allmeetings.Team normswill be followedbyQC. Documents willbe centralized for accessby others.

1.The QCreportstothe Executive Team.

2.The QCwill assureongoingmembershiprenewalandreplacement by reviewingannually.The current listofQCmemberscanbe foundontheQIPMembershipRoster.Uptofour adhoc membersmay rotateonto the QConasemi-annual basis, as interest andspaceallows.

3.It is expected thatthecostof timeforeachmember toparticipatewill becovered by their respectivedivisions andadministration.Nootherresourcesaresolicitednor spent by theQC.

B.Board of Health

The BOH receives a reportat least annuallywith updatesonagency QMefforts.Updatesmayinclude recommended actions forhealth policy decisions; progress toward programgoals; recommendations based onafter-actionreviews;andotherQMefforts.

C.Staff andAdministrativeSupport

Staffandadministrative supportareresponsible for:

1.Completinga programlogic modelorother framework toevaluateactivities

2.Compiling programdatafor measures

3.Participatinginannual logic model reviews

4.Workingwithmanagers toidentifyareas for improvementandsuggestingimprovementprojects toaddress theseareas,includingmeetingthe MD statepublic health standardsandPublic Health AccreditationBoard(PHAB)standards.

5.Conductingqualityimprovement projects in conjunctionwithmanagers andother appropriate staff (program evaluator, community healthassessment staff, HIPAAcoordinator, etc.)

6.ReportingQMtrainingneeds tomanagers

D.ProgramManagers

Managers are responsible for:

1.Orientingall staff toQuality Councilprocess,plan, andresources

2.Developingan initiallogicmodel and/orwork planfor eachprogram, includingidentificationof performancemeasuresanda data collectionplan

3.Reviewingthedata fromlogic models and/orwork plans onan annual basiswith staff

4.Initiatingandparticipatingin problemsolvingprocessesand/orQMprojects

5.IdentifyingstaffQMtrainingneeds, providingaccess totraining, andtrackingattendance

6.Reportingtotheir directorstheir findings fromtheir logic model review,QM projects,public health statestandards gaps, andidentifiedQMtraining needs

7.Revisingprogramlogicmodels and/or workplans based onfindings fromannualreviewandQM

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E.DivisionDirectors

Directorsareresponsible for:

1.ReportingtotheQConlogic model results,selectedoutcomemeasures,programevaluation efforts,QMprojects(BPA,RCI), audit results (ifapplicable),customerservice evaluation,public health standardgaps,and QMtrainingneeded(i.e. the annual DivisionReports).

2.Identifyingandselectinguptotwoareas needingimprovementtobringtotheQC as priorities annually (see SectionVforhowtoselecttwoareas)andpresentingthese ideas totheQCduring the DivisionReport.At least oneof these projectsshouldbe a new projectidea.

3.EnsuringthataninitialQI/QPProjectDefinition Documentis completedforeachprojectand presentedtotheQCwithin2monthsof theDivisionReport.

4.Assuringimplementationandfollowthrough ofQMprojectsby:1) providingmonthly updates tothe QCthroughthe divisional QCrepresentative;and2)ensuringthat the projectlead completesthefinal QualityProject/ActivitySummaryReportand Storyboard.

DivisionDirectorsmustprovide an annual divisionreporttotheQC personallyorjointlywithstaff.QM project reports duringtheyearcanbe presented by designatedstaff.Directorsmaybe askedto participate inQMcommittees andwork groups.

F.Executive Leadership Team

The ExecutiveLeadershipTeam(ELT)willoverseeall aspectsofthe StrategicManagement Systemand establish thespecific processes,schedules andreportingmethods that governthe creationandusageof the strategic plan,QI plan,agency priorities, CommunityHealthImprovementPlan, agencyoperational plan, program evaluation, standards implementation,andbudget process.The ELTwill assurethatthe QC develops an annual qualityimprovement planandassists in implementingcontinuous quality improvementmethodologythroughout theorganizationwithapproval bytheELT.

ELTwill identify areas fromthe strategicplan, priorityareasor program evaluationeffortsthatwill be

added totheQI planforimprovement, and/ordown-streamed andmeasured at the programlevel.

II.ApprovalofQIPlanandAnnualEvaluation

The QCwill annuallyreviewandmakesuggested revisions tothis QIPlan.Whenreviewing, the QCwillwork tomaintainalignmentwithHealthy St. Mary’s 2020, Public HealthAccreditationBoard(PHAB) Standards, statewide indicators,andnational QMefforts. A report summarizingthe reviewprocess,findings, andsuggested modificationswill be submitted tothe ExecutiveTeamfor approvalwithinthe first quarterofeachyear.

III.QualityImprovementEfforts

QMeffortsinclude reviewandimprovement of all programs andprocessesthat have adirectorindirect influence onthe qualityofpublic health services provided by SMCHD.ThefollowingQMeffortswill be reported totheQC:

A.Customer Service

All employeeswith jobfunctionsthat require interactions with thegeneralpublic, stakeholders, and partners willreceive appropriate customerservicetraining. Trainingneeds will be identified by the program evaluatorandprogrammanagersandreportedtotheirdirector.Customerservicetrainingfor appropriate staffwill be periodicallyoffered byHumanResourcesorother applicable resources. Trainingattendanceshouldbe documentedelectronically toverify staffparticipationand toproduce aggregate reports.If trainingis provided by HumanResources,documentationof attendance will be kept byHR staff.

Customerservicesatisfactionwill be evaluated at program and service levels,andannuallyrolled upat the agency levelandreviewedbytheQC,toassurecustomerservicestandardsaremet.Providers and coalitions shouldalsobeevaluatedtoensure thatSMCHDismeetingthe customers’ needs. Division reportswill includeresultsfromprogramand/orservicesatisfactionsurveys.A coresetof questions will be used byall customerservicesurveys.HSMPstaffwill assist program staff indevelopingandimplementingsurveys.

B.Evaluation for AgencyDivisionsandPrograms

Evaluationis defined asthesystematic applicationof social(or scientific) researchproceduresfor assessingthe conceptualization, design, implementation, andutilityof SMCHDservices.Itwill consistof creatinga logic model for eachprogramanddivision inthe agency, creatingeffectivedatacollection tools tomeasureeachof the impactandpopulationoutcomes,reviewingdatawith staffonan annual basis, updatingthe logic modelsorotherframework,andreportingontheoutcomestothedivision director.Staffandprogrammanagersareresponsible forconductingevaluations. Findings will beused toinformplanningandQMefforts.

C.HIPAACompliance

IssuessurroundingHIPAApolicies, confidentiality, datasharing, security, andrecords retentionwill be evaluated andreportedtothe QC,either directlyby the HIPAA/QualityAssurance Coordinatoror throughthe annual AdministrativeDivisionReport.

D.Improvement Plans fromAfter ActionReviews

After ActionReviews(AAR) areconductedafter preparedness exercises, epidemiologicoutbreaks,orother public health events.Animprovement planis createdafter identifyingissues.Primaryfindings and major improvements will be reportedtotheQC, ideallywithin30daysaftercompletionof the improvement planwhen impacting2ormore divisions.

E.StrategicPlanReview

The SMCHDStrategicPlanincludes objectivesaroundassessment activities,useof health datatomake programandpolicy decisions, AfterActionReviewissues,andpreventionpriorities. TheStrategicPlan goals,objectives,andperformancemeasureswill be reviewedperiodically bytheExecutive Teamwith recommendations forQMactivitiesreported tothe QC.Fromthe StrategicPlanningreviewof local health data (includingthe State’scorePublic Health Indicators, Healthy St. Mary’s 2020, access indicators, and other data)andthePlan’sgoals,objectives,andperformancemeasures, recommendations for quality improvement effortswill be reportedtotheQC.

F.PublicHealth Standards ReviewandPublicHealthAccreditationEvaluation

Every fiveyears, SMCHDwillbe evaluatedonour level of compliancewiththePublic Health Accreditation Board(PHAB) standards. AccreditationthroughPHABprovidesameansfora department toidentify performanceimprovementopportunities,toimprovemanagement,developleadership, andimprove relationshipswiththe community.The process isonethat willchallengethe health departmenttothink about what businessitdoes andhowitdoesthat business. Itwill encourage andstimulate qualityandperformanceimprovementin the health department.It will alsostimulate greater accountabilityand transparency.

Accreditationdocuments the capacityof thepublic health department todeliver the threecore functionsof public health andthe TenEssentialPublicHealth Services.Thus, accreditationgives reasonableassuranceofthe rangeofpublic health servicesa department shouldprovide. Accreditation declaresthat the healthdepartment has an appropriatemissionandpurposeandcandemonstratethat it will continuetoaccomplish itsmissionandpurpose.Sitevisitswill be conductedbya peer teamof threetofourPHABtrainedsitevisitors.

The visit servesseveral purposes:verifytheaccuracyof documentationsubmitted by the health department, seekanswerstoquestionsregardingconformitywiththe standardsandmeasures,and provideopportunityfordiscussionandfurther explanation. Sitevisitswill typically lasttwotothree days, dependinguponthecomplexityof the application.

Withintwoweeks followingthe sitevisit,the sitevisitteamwill developa sitevisit report. Thereport will describe: (1) how conformitywitheachmeasurewas demonstrated,or detailwhatwasmissing;(2) areasof excellenceor unique promisingpractices; and(3)opportunities for improvement.

The report issharedwith ExecutiveTeam, JointManagement, Boardof Health, programstaffandthe QualityCouncil.The AccreditationTeam will reviewanddiscuss boththe Standards andMeasures, includingsitereviewersummariesandfindings, makingrecommendationstotheExecutiveTeam. Organizational inefficiencies, identifiedby standardsreview,will be reportedtoQC; recommendations will be integratedintotheQIP asindicated, includingopportunitiesforQMprojects.

(SeeAppendixC:2016QualityCouncilReportingCalendar)

IV.2016SelectedQualityManagementProjects

FromDivisionreportsorother informationobtained by theQC, projectsmay berecommended forfocused QMefforts.QMprojectsmayalsobe submitted tothe QC for technicalassistance.Projectscouldusemany QMmethodologies, such asRapidCycle Improvement(RCI), BusinessProcessAnalysis (BPA),focus groups, surveys, andmore. A follow-upprogressreporttothe QC after projectcompletionwill be required.

The QCwill monitorupto15quality improvement projectsatanyonetime. Fromeachof the Division Reports tothe QC(annually in March), uptotwoprioritized qualityimprovement areasfromeach division will be selectedformonitoringandassessmentofimprovementwithinan establishedtimeframenotto exceed ayear.TheQI/QPProject DefinitionDocument, QMProjectLog,andtheQualityProject/Activity Summary Reportswillbe used forreportingtothe QC, withimprovementobjectivesidentified prior to initiationof the projectas identified intheProjectDefinition Document.If areasare selected bythe QC, programmanagersorother appropriatestaffwill be askedtofillouta preliminary ProjectDefinitionform andreportbacktotheQCwithin2monthsof projectselection. Attheconclusionof a project,the program managerorother staffwillbe requiredtocomplete a QualityProject/Activity SummaryReportand Storyboard.The QMProjectLogwill be kept by the QCanddivisional QC representatives will be charged with postingregularupdates.TheQCwill usetheseformsandmechanismstomonitor work and schedule reports.

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Inadditiontodivisional projects,theQC willalsoreviewavailableaggregatedata(e.g. DivisionReports, aggregatedcustomerserviceinformation,etc.)andidentifyopportunities forcross-divisionalprojects.The QC will prioritizepotentialproject ideasandsubmitarecommendationtoELTatleastannually.TheQCmay providetechnicalsupport tosubsequent, authorized cross-divisionalQI teamsandwillmonitor project progressviathe tools andmechanisms described above.

Staff andtheQC shouldselectquality improvement projectstomonitorthatarehigh-risk,high-volume,or problem-proneandalignwiththe strategicplanandSRHD’smission,visionandvalues.

(SeeAppendixD:SampleSelectedQualityImprovementObjectivesLogandAppendixE:QualityImprovementObjectivesandPerformanceMeasuresTrackingFormandProgressReporttoQualityCouncil.)

V.CommunicationPlan

On a periodic basis,articlesaboutQMeffortswill be published ina varietyof venues. Presentationsmaybe givenatDistrictandJointManagementMeetings.Periodic updatesabout theQC activities willbe given to ExecutiveTeam,the Boardof Health, and ProgramManagers. Managerswill be responsible forongoing communicationtostaffabout the QIPlanandprocess establishedwithinour agency.

Resources(materials,templates,data collectiontools,andtrainings) availabletostaff arepostedonthe SMCHDIntranet underCommunications.As newresourcesbecome available,theywill be posted tothe Intranet andannounced tostaff.

Formalrecognitionofstaffthathas completed QMprojectswill be considered by theCouncilannually. Recognitionmay include storyboarddisplays, presentationstothe Boardof Health (BOH),presentationsat QualityCouncilmeetings, or for local,regional, state,or national awards andconferences.

VI.TrainingPlan

Program Managementwillreceive anannual update onchangesmade tothe plan.Managerswill beresponsible fororientingalloftheir staff tothe Quality Council rolesandprocess, QI Plan, and available resources.

Training - Eachyeardivisions report theirQMtrainingneeds tothe QualityCouncil.Agencytrainings are createdtomeet theseidentifiedneeds andtoadvance QM knowledge,skillsandpracticesin theagency. Trainings maybe heldonavarietyof performanceandqualitymanagement topics, including:data analysis, logicmodels, program evaluation, quality improvement methods andtools(RCI,BPA, survey development, etc.), andthePublic Health Standards forSMCHDstaff.The PHStandards describethemeasures around program evaluation,quality improvement,anddata-drivendecision-makingthatresult inprogramand policychanges.

Technical Assistance–Technicalassistance willbe available throughthe IToffice uponrequestas well as throughdivisionalQC members.Additionally,technicalassistance/workshopswill be builtintotrainings as appropriate.

Topical Trainings- Trainingswill beoffered if atrendemerges that employeesindifferentdivisionsandwork groups areinterestedinthe sametopicoftraining.

VII.Evaluation

On anannual basis, theQCconducts anevaluationof their work including: anannual staff evaluationof awareness, knowledge,behavior,QC progress towards goals,qualityofwork,andotheroutcomes; aself- assessmentusinginternal collaborative evaluationtools; anda reviewofthe QC logicmodel data.The data andoutcomesare discussedin a QCmeeting, andanactionplanisdeveloped aspart ofthe work planfor the upcomingyear. Afterwards the QIplanis updatedtoreflectany improvementstoprocessandprotocol that were introduced.

VIII.References

A.CDC,Performance ManagementandQuality Improvement:

B.Public Health AccreditationBoard,StandardsandMeasures:process/public-health-department-standards-and-measures/

C.Public Health Foundation, Turning PointPerformanceManagement Framework: px

IX.Appendices

Appendix A:QualityCouncilGoalsActivitiesWork Plan, page 8-9.

Appendix B: CommunicationFlowChartforQuality Improvement, page 10.

Appendix C:2016QualityCouncil ReportingCalendar, page 11

Appendix D:SelectedQualityImprovementProjectLog, page 12.

Appendix E:QualityImprovement/QualityPlanning ProjectDefinition DocumentQualityProject/Activity Summary Report, page 13-15.

Appendix F:2016QualityCouncil MembershipList, page 16.

Appendix G: Logic Model, page 17-19.

Appendix H:Glossary of Terms, page 20-22.

Appendix I: QualityCouncil MemberRoles, page 23-24.

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QUALITYCOUNCILGOALSACTIVITIES/WORKPLAN

2016

APPENDIXA

1March 2016

Individual: Enhancing skills,knowledge,attitudes andmotivation / LEAD / BY WHEN
a. Maintainintranet pagewithresource list, Quality Management
(QM)training, andinformationonQMefforts / CommunicationSub
Committee / Bi-Yearly
b. ConductQMtrainings withstaff / Program Managers Staff / Referto
TrainingSub Committee Training Calendar
c.Holdtechnicalassistance(TA)workshops / QualityCouncil (QC)
DivisionReps and Program Managers / Ongoing
d. Identify,review, monitor andmake recommendationsonQM
projects / QualityCouncil (QC) / Monthly
Interpersonal:Increasingsupport forQMwithpeers / LEAD / BY WHEN
a. SubmitQMprojectstoIntranet / QC Support / Monthly
b. Annual SMCHDrecognition of staffandcompleted QM projects / Health Officer, BOH
QC Member / Periodic
c.EncourageQM projectleadstaff tosubmitapplications for
broader acknowledgementofQMEfforts(Coordinatewith Exec Team/QC) / QMProject Leads / Ongoing
Organizational(QC):Improving policiesandpractices of theQC / LEAD / BY WHEN
a. Conductandevaluate agency reviewofQM / QC / Yearly
b. Present andreportonupdatedQI planandcouncilprogressto
PM andBOH / QC Co-Chair toPM;
Health Officer toBOH / 1stQtr
Community:Increaseinterdivisional collaborationand
partnershipstoeffect QMat SMCHD / LEAD / BY WHEN
a. Makerecommendations toExecTeamforinterdivisional/agency
QMprojectsbased onidentified needs / QC ExecTeam
members / ThirdQtr
b.Assure that programsconductingsimilarwork knowaboutQM
projectscompletedin another division / QC / As needed
PublicPolicy (Agency):Developingandinfluencing SMCHDQM
policy / LEAD / BY WHEN
a. Monitor agencycustomer service / QC, HSMP staff / June
b. Hear/reviewdivisionreportsandprogressonperformance
measurestodetermine howbettertoimproveQM projects / QualityCouncil (QC) / Seemeeting
schedule
c.Monitor programevaluationeffortsandprogress / DivisionDirectorwith
QC asst. / June
d.Monitoragencymovement towardQM,includingstandards
information / QC / November
e.Monitoragency performancemeasures andreport
improvement / QC / June

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1.Individual: Maintain intranet page with resources list (QI Training) and information on QI efforts; Conduct QI trainings with divisions; Conduct TA workshops; Identify, review, monitor and make recommendations on QI projects.

2.Interpersonal: Recognize and acknowledge QI efforts; Encourage QI project lead staff to submit applications for broader acknowledgement of QI efforts.

3.Organization: Present and report on updated QI plan and council progress.

4.Community: Make recommendations to Exec Team for interdivisional/agency QI programs.

5. Public Policy: Monitor agency customer service; hear division reports; monitor program evaluationefforts.

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APPENDIX B

Communication Flow Chart for Quality Improvement

St. Mary’s County Health Department

APPENDIX C

2016QUALITYCOUNCILREPORTINGCALENDAR

DATAREVIEW BY QC
Date Scheduled: / REPORTTO
CustomerService / Second Quarter / ExecutiveTeam
Quality Improvement Update / FirstThird Quarters / ProgramManagement
DivisionReports
Administration / March
Community andFamily Services / May
DiseasePreventionand Response / April
Environmental PublicHealth / May
Health Promotion / April
Quality ImprovementProjects
Scheduledthroughout year / Seelog
QCEvaluation andDataCompilation
QI PlanReview / Fourth Quarter / ExecutiveTeam,Program
Management, Board of Health
QC LogicModel datareview / FourthQuarter

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SelectedQualityImprovement ObjectivesLog – ACTIVE

AppendixD

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Reporting Area / LeadStaff / SMARTObjective / Start Date / Complete Date / Report Date to QC / Status / Story
Board
(CircleYesor No,Ifyesinsert
dateofstoryboardcompletion)
Admin
Y/N(Date):
Y/N(Date):
Environmental
Y/N (Date):
Y/N (Date):
Health PPromotions
Y/N (Date):
Y/N(Date):
Preparedness
Y/N (Date):
Y/N (Date):
Y/N (Date):
Y/N (Date):
Non-Divisional
Y/N(Date):
BOH

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St. Mary’s County Health Department

QualityProject/ActivitySummaryReport

AppendixE

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Title of Project:

Division/AreaReporting:Lead Staff:

Start Date:CompleteDate:

Initial reporttoQC Date:Report back toQC Date(s): OverallObjective forProject:

MethodUtilized: / QI (cross-programmaticor larger scope processimprovement QI (singleprogramor smallerscopeprocessimprovement) QP(newprocess/servicedesign)
AnalysisSummary: / IfQI:Whatrootcauseswereidentified?IfQP:Whatkeycustomerneedswereidentified?
AnalysistoolsUtilized:
(Checkallthatapply) / Flow Charts Pareto Diagram Histogram
Cause-Effect Diagrams
Data CollectionMatrix Other: / 5s
BPA/ Work Flow Analysis Other: / Qualitative Survey Affinity Diagram Customer NeedsMatrix Benchmarking
Other:
Change
Summary: / Brieflydescribechangesmadeandhowtheyaddresseitheridentifiedrootcausesorcustomerneeds:
Measure#1 / Measure#2 / Measure#3
Statementofmeasure:
(A%,number,count,average)
(e.g.Percentofhighriskpregnantwomenwithprenatalvisitin1sttrimester)
TargetPopulation:
(e.g.Allpregnantwomen)
Numerator:
(Fillthisoutifyourmeasureisa
%)(e.g.#highriskpregnantwomenwith1sttrimesterprenatalvisit)
Denominator:
(Fillthisoutifyourmeasureisa
%)(e.g.#ofhighriskpregnantwomen
Sourceofdata:
(e.g.Clinicvisitrecords)
Baseline:
(e.g.85%)
TargetorGoal:

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(e.g.95%)
Results:
(e.g.90%)
Didyoureachyourtargetorgoalforyourobjective?
1. / a.Ifyes,howwillyousustainorcontinueimproving?
b.Whatongoingmeasuresdidyouputinplace?Specify.
c.Whoisprimaryowneroftheprocessandresponsibleformonitoringthemeasure(s)andhowfrequentlywillthisbedone?
d.Whattoolswillyouuseforongoingevaluationoftheprocess(i.e.,processcontrol)?
LogicModelsTrend/Run ChartsControl Charts
HistogramBox PlotsOther
2. / Ifno,whatvariableswereinvolvedinnotreachingyourgoal?
3. / Whatisyourplantoaddressthevariablesthatpreventedyoufromreachingyourtargetorgoal?
If projectiscomplete, pleaseprovideanabstract regardingyour project.Theabstractshould includeall thefollowing descriptive:
Title of Project
Project Description,including Problem andQIActivities Objective
Results
ContactInformation
TheQualityCouncil may ask youtodevelopa story boardandmay request thatyoureport back onyour efforts tosustain orfurther improvetheprocessyoustudied/designed.

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QualityImprovement/QualityPlanningProjectDefinitionDocument

ProjectName:
1–3 wordidentifier / Sponsor(s):
Whoisgoverning andresourcingthisproject? (Division, Program, Manager or Exec Leader)
Problem/Opportunity:
1-3 sentence descriptionofthe problem/opportunity (withoutassumptionofcause or solution)andwhy itis important(ImpactonProgram or Division/Agency strategic goals)
TypeofProblem/Opportunity:
QI (cross-programmaticor larger scope processimprovement QI (singleprogramor smallerscopeprocessimprovement) QP(newprocess/servicedesign)
OverallObjective):
1 sentence declarationastowhattheprojectteam istodowithoutassumptionofcause or solution. (A.k.a. mission statement, purposestatement, etc.). (Remember S.M.A.R.T. =direction+ measure/whatyouare improving+target+timeframe).
PerformanceMeasure(s):
The quantitative indicator(s)whichwoulddemonstrate performance had improved.More than2-3 measuresmay indicatelackoffocus.(i.e., %, number, count, average, etc.) / Target(s):
How muchimprovementisexpected/hopedfor?
Process(es)tobeaddressed:
Describe the boundaries/scope (i.e., the “start” and“stop”)ofthe process(es). / Customer(s):
Whois/are the PRIMARYrecipient(s)ofthe “output” or service?
TeamLeader:
Whoisprimarily responsiblefor the conductand success ofthisproject?(May coincide withthe process owner)
TeamFacilitator:
Whowillbe assistingthe leader with QI methodsandtoolsandgroupprocess facilitation? (Tip:Startwithdivision’sQC representative)
TeamMembers:
Whowillbe active participantsontheprojectteam?Ensure representationofprocess stepsandother key stakeholders.Forprojects of smaller scope, you may nothave team members other thanleadand/or process owner)
Constraints:
Are there time, space, financial, system, policy,organizationalor other constraintsthattheteam leader and membersshouldbe aware of? / ResourceRequirements:
Whatresources are available tothe team to supportcompletionofits mission?(Time, IT, budget, CHAPE staff support, etc.)
Howdoyouthinkyouwillproceedwithanalyzing thisproblemforrootcause(QI)orcustomerneed(QP)?
(Tip:Consultwithyour QC representative ifneeded)
TargetStartDate:
TargetEndDate:
ProcessOwners:
Whowillbe primarily responsible formaintainingprocess performance after completionoftheproject?

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Appendix F

2016QualityCouncil Members

The Quality Council was created in2016

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Appendix G

Committee:Responsible: Quality Council

Quality CouncilChair and Quality Council Team

Program Theory / Inputs / Activities / Outputs / Process Outcomes / Impact Outcomes / Population Outcomes / Measurements / Standards
The QC will aid in creating implementing, maintaining, and evaluation the quality improvement efforts at SMCHD with the intent to improve the level of performance of key processes and outcomes. / QC members, division, directors, QJ Plan, staff, managers, Board of Health. / Individual: Enhancing skills, knowledge, attitudes, and motivation.
Maintain internet page with resources list (including QI training) and information of QI efforts. / # updates / Links worked. Content was easy to navigate and understand. Resources were up to date. / Increased access to QI information, tools, and resources. / By 2017, 90% of employees will be able to define and appropriately use QI tools and methods and implement them. / Survey end of year.
Conduct QI trainings with divisions. / # trainings / Trainings were rated at 4/5 on all satisfaction questions on evaluation. Met all identified training needs. / Increased awareness of QI processes. Increase use of QI tools. / Training evaluations – end of year survey. / 9.1.5 Require staff participation in evaluation methods and tools training.
Conduct T.A. workshops. / # workshops
# participants / Q.C. members are seen as a resource for QI. Assistance was helpful/useful. QI stories were concise and tailored to target audience. / Increase quality of reporting to QC. Increased appropriate implementation of QJ tools. / End of year survey.
Identify, review, monitor, and make recommendations on QI projects. / # projects started
# projects completed / Lead project staff had enough support, information and access to resources. Recommendations were appropriate and useful. / Increased support for science based methodologies. Improved program and project outcomes. / End of year survey. Review of key processes and outcomes performance. / 9.1.3 Monitor performance measures for processes, programs, and interventions.
Interpersonal: Increasing Support for QI from Peers
The QC will aid in creating implementing, maintaining, and evaluation the quality improvement efforts at SMCHD with the intent to improve the level of performance of key processes and outcomes. / QC members, division, directors, QJ Plan, staff, managers, Board of Health. / Recognize and acknowledge QI efforts. / # articles
# events / Events were appropriate for QI promotion. Staff felt encouraged to apply for recognition. / Increased staff/manager awareness of QI projects that are occurring. / By 2017, 90% of employees will be able to define and appropriately use QI tools and methods and implement them. / End of year survey.
Encourage QI project lead staff to submit applications for broader acknowledgment of QI efforts. / # award recipients
# presentations / Staff felt encouraged and supported to submit applications. Applications were appropriate for recognition. / Increased visibility and recognition of the QI efforts employees were involved in. Increased % of submitted projects receiving awards. / Review awards earned for QI projects. End of year survey.
Organization: Improving policies and practices of the QC.
Present and report on updated QI plan and council progress. / # presentations (JM, Exec team, BOH) / Information was concise and easy to understand. Met BOH presentation standards. / Increased awareness of QI processes and agency improvements. Exec Team and BOH approved plan. / Improved level of performance of key processes and outcomes. / End of year survey. Presentation feedback. / 9.1.1B Engage governing entity in establishing agency policy direction re:performance management system. 9.2.1 Establish a quality improvement plan based on organizational policies and direction.
Community: increase interdivisional collaboration and partnerships to effect QI at SMCHD.
The QC will aid in creating implementing, maintaining, and evaluation the quality improvement efforts at SMCHD with the intent to improve the level of performance of key processes and outcomes. / QC members, division, directors, QJ Plan, staff, managers, Board of Health. / Make recommendation to Exec Team for interdivisional agency QI projects. / # project recommendations / Recommendations were based on identified needs. / Increased agency level measures improvement. Increased agency efficiency. / By 2017, 90% of employees will be able to define and appropriately use QI tools and methods and implement them. / QI report from Exec Team. End of year survey. / 9.1.1B Engage governing entity in establishing agency policy direction re:performance management system.
Public Policy: Influencing SRHD QI policy
Monitor agency customer service. / # programs and divisions participating / Report covered the five selected agency measures of customer service. / Increased understanding of customer service QI needs. Maintain level of customer service. Increased use of customer service evaluation. / By 2017, 90% of employees will be able to define and appropriately use QI tools and methods and implement them. / Review customer service QI needs identified. Customer Service report. / 9.1.4B Implement a systematic process for assessing and improving customer’s satisfaction with agency services.
Hear division reports. / # reports / Division directors had enough support and supervision to properly complete report. Recommendations were appropriate. / Increased awareness of division status and improvement projects needed and ongoing. / Review division QI needs. End of year survey.
Monitor program evaluation efforts. / # reports / Received adequate information and assistance to complete. / Increased logic model use, data reviews, and utilization of work plans. Improved logic model indications. / Yearend survey. / 9.1.3B Evaluate the effectiveness of processes, programs, and interventions and identify needs for improvement.

1March 2016