F-00565A

DEPARTMENT OF HEALTH SERVICES
Division of Medicaid Services
F-00565A (05/2018) / STATE OF WISCONSIN
COUNTY PERFORMANCE PLANGOAL
Date / County Name / Region
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GOALS
Goal #Enter Goal Number.
Date: Click here to enter a date.
Goal:
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I. / What is currently happening? What is currently influencing / impacting this area?
(Drivers: Leadership, Organization, Competence) (System Changes/Challenges / Barriers)
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II. / How will the program look different (practices and/or policies)?
What system changes are needed to implement this Goal?
What support from program leadership is needed to influence this goal?
What is needed to develop staff competence for carrying out this goal?
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III. / What is your plan for accomplishing this outcome?
Implementation STAGES:
☐Exploratory (capacity, resources, values, alignment)
☐Installation (prepare for change)
☐Initial Implementation (try, assess and adapt)
☐Full Implementation (systems in place to evaluate impact of change). / Implementation DRIVERS:
  • Competencies -select, train and coach,
  • Leadership -technical and adaptive
  • Organizational Development -fiscal, contracts, supervision, data system and data based decision making

Driver / Action Step / Who is responsible? / When? / How will the state and/or RESource support you in this?
IV. / What evidence will show this outcome and the steps have been accomplished?
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OUTCOME REVIEW
Goal Review #Enter Goal Review Number.
Review Date: Click here to enter a date.
Goal:
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I. / Review and evaluate the impact of the action steps.
What is the status of the steps?
Which steps were completed?
What is the evidence that the step is completed?
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II. / What is the current status of this outcome?
What system changes have been done in regards to this goal?
What has changed within the leadership in regards to this goal?
How has staff competence grown in regard to this goal?
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III. / Is the goal complete? What is the evidence?
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IV. / What is your updated plan for accomplishing this goal?
Driver / Action Step / Who is responsible? / When? / How will the state and/or RESource support you in this?

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