Blue State Quality Improvement Process

Case Study D – Blue State Quality Improvement Process

The Blue State Quality Improvement Process has undergone an evolution, beginning in the early 1990s as a performance audit, adding components over the years to transform it into a quality improvement process. Most notable added components are outcomes indicators, the integration of outcome and performance indicators, the use of the Sterling criteria for organizational excellence (modeled after the Malcolm Baldridge criteria) and the interactive nature of the quality improvement process itself.

To the extent possible within the Blue State system, outcomes and performance measures are integrated into a quality improvement approach that examines impact of public health practice and program efforts. Significant work was done in Blue State to set priorities to develop core outcome and performance measures. Until integration, there had been no organized attempt to link program data with vital statistics data or cost data with services. The integration has facilitated the understanding by program managers at all levels of the nexus between the various inputs, outputs and outcomes. The importance of outreach, appointment systems and transportation services are much clearer to all staff when the context of delivering a healthy baby is established.

The Blue State began its statewide quality improvement process by reviewing Golf County Health Department. The findings from the review were gleaned from a six-month process that included a self assessment by the local health department, a program review led by state content experts and a systems review led by a core team of state central office staff. After all the findings were reported and analyzed the local health department and Blue State attended a Concluding Workshop. The purpose of the Concluding Workshop was to present commendations and discuss opportunities for improvement discerned during the quality improvement review through an interactive review of the findings, dialogues about causal problems, and agreements on corrective actions that need to happen within specified time frames. Specific agreements were crafted during the Workshop reflecting measurable actions the local health department would undertake and actions the state health department would take to facilitate or support local action.

The site visit began with commendations to the local health department on unique or best practices that are replicable. Commendations were given to Golf County in ten different performance areas. Examples of commendations are:

Immunizations — for improvement in 2-year-old immunization coverage levels to 90 percent, from a 1999 level of 84 percent.

Environmental Health — for achieving high scores in all three parts of their Onsite Sewage evaluation, in records review, in field evaluation and in implementation of previous recommendations. Golf County is in the top 10 percent of all onsite sewage programs in the state.

Review findings addressed both traditional health status issues and performance issues related to both system inputs (staffing, funding) and outputs (service levels, clients served). Data were reviewed and displayed for core health outcomes and core performance measures. Dialogue between state and local practitioners occurred around the issues of low birth weights, neonatal and infant mortality, smoking attributable mortality, teen pregnancy, strategic planning, a quality assurance/risk management process, and clinical productivity. Discussions of these issues were framed around outcomes, with processes viewed as contributors to outcome. For example, Golf County staff agreed to examine risk, operations and outreach factors associated with infant deaths in the county (joining hospital mortality reviews, exploring whether infant deaths were family planning missed opportunities, etc.). Another agreement reached during the Workshop was that state staff would assist the locals in convincing the Blue State heart and lung associations to locate branches in Golf County.

Case Study D - Discussion Questions

This case study describes a statewide quality improvement effort to examine the impact of public health practice and program efforts at local health departments. It includes aspects of performance management in order to accomplish this end. The following questions focus on performance management issues involved in this statewide quality improvement effort.

Identify the target of this performance management application. Whose or what’s performance is being improved? Describe what the performance accomplishment is in this case study.
Which of the four components of performance management are evident in this case study? Which are not?
Does this case study demonstrate the use of performance standards? How?
Does this case study demonstrate the use of performance measurement? How?
Does this case study demonstrate the use of reporting performance? How?
Does this case study demonstrate the use of quality improvement? How?
Which specific performance management components in this case study could be enhanced? How?
Assume that the state health agency has required all local health departments in this state to complete a similar process in order to examine the impact of public health practice and program efforts within their community. What approaches might be taken to incorporate the performance management components?
Have you been (or are you now) involved in a quality improvement process? If so, which components of comprehensive performance management were in place? What suggestions do you have for improving that effort?

Case Study D - Discussion Questions: Facilitator’s Notes

Identify the target of this performance management application. Whose or what’s performance is being improved? Describe what the performance accomplishment is in this case study.

Answers/Discussion points:

This case study focuses on the impact of public health practice and program efforts at local health department’s using a quality improvement approach.

Which of the four components of performance management are evident in this case study? Which are not?

Answers/Discussion points:

All four components were evident in this case study. A performance management system is the continuous use of all the above practices so that they are integrated into an agency’s core operations. Performance management can be carried out at multiple levels, including the program, organization, community, and state levels. However it is applied, the performance management cycle is a tool to improve health, increase efficiency, and create other benefits and value for society.

Does this case study demonstrate the use of performance standards? How?

Answers/Discussion points:

Performance standards include identifying relevant standards, selecting indicators, setting goals and targets and communicating expectations. Performance standards are objective standards or guidelines that are used to assess an organization’s performance. They may be set on national, state or scientific guidelines or be based on the public’s or leader’s expectations.
In this case study, the standards are the Sterling criteria for organizational excellent (modeled after the Malcolm Balridge criteria).

Note: For additional questions refer to Section II: Performance Standards of the Performance Management Self-Assessment Tool.

Does this case study demonstrate the use of performance measurement? How?

Answers/Discussion points:

Performance measurement is the refining of indicators and defining measure. Performance measures are quantitative measures of capacities, processes, or outcomes relevant to the assessment of a performance indicator. It also includes developing a data system which can collect the data based on the measures.
The self-assessment by the local health departments, a program review by the state content experts and a systems review led by a core team of state central office staff are the performance measures.

Note: For additional questions refer to Section III: Performance Measurement of the Performance Management Self-Assessment Tool.

Does this case study demonstrate the use of reporting performance? How?

Answers/Discussion points:

The reporting of performance component includes analyzing data, feeding data back to managers, staff, policy makers, and constituent, and developing a regular reporting cycle.
The Concluding Workshop presented commendations and discussed opportunities for improvement during the Quality Improvement review through an interactive review of the findings, dialogues about problems, and agreements on corrective actions.
Data were reviewed and displayed for core health outcomes and core performance measures.
Data was fed back to constituents and a dialogue between state and local practitioners occurred.

Note: For additional questions refer to Section IV: Reporting of Progress of the Performance Management Self-Assessment Tool.

Does this case study demonstrate the use of quality improvement? How?

Answers/Discussion points:

Quality improvement process relies on the use of data for decisions to improve policies, programs and outcomes, then manage those changes and create a learning organization.
Quality improvement agreements were crafted during the Workshop regarding actions both local health departments and the state health department would take.
Based on the Workshop, the state staff agreed they would assist the local health department in convincing the Blue State heart and lung associations to locate branches in Golf County.

Note: For additional questions refer to Section V: Quality Improvement Process of the Performance Management Self-Assessment Tool.

Which specific performance management components in this case study could be enhanced? How?

Answers/Discussion points:

Reporting of Progress – The Blue State should set up a regular reporting cycle of the local health departments.

Additional Questions to Discuss:

Is there a set specific performance standards, targets, or goals? How do you determine these standards? Is there benchmark against similar state organizations or use national, state, or scientific guidelines?
Is there a way to measure the capacity, process, or outcomes of established performance standards and targets? What tools do you use to assist in these efforts?
Is there documentation or reporting of progress? Is this information regularly available to managers, staff, and others?
Is there a quality improvement process? What do you do with the information gathered in the progress report or document? Is there a process to manage changes in policies, programs, or infrastructure that are based on performance standards, measurements, and reports?

[The questions below build on the ability to identify performance management concepts and component in this case study and ask course participants to relate this case study to their own experience. It may not be possible to address these issues in case study discussion if time is limited.]

Assume that the state health agency has required all local health departments in this state to complete a similar process in order to examine the impact of public health practice and program efforts within their community. What approaches might be taken to incorporate the performance management components?

Answers/Discussion points:

The local health departments can use this process to examine the impact of public health practice and program efforts on their community.
Self-assessments can be performed by the different program areas in the local health department, a program review by a core team at the local health department and stakeholders within the community, and a systems review by a team of Board of Health members.

Have you been (or are you now) involved in a quality improvement process? If so, which components of comprehensive performance management were in place? What suggestions do you have for improving that effort?

Answers/Discussion points:

Use the Performance Management Self-Assessment Tool to help identify all the components of the system that should be applied.