QUALITY IMPROVEMENT & PERFORMANCE MANAGEMENT: Case Report
Clackamas County Public Health Division, a local public health agency in Oregon, has had an active quality improvement committee in place since 2012 tasked with ensuring implementation and monitoring of the performance management system. The agency was accredited through the Public Health Accreditation Board in June 2014 (Table 1). The agency pursued national accreditation to be recognized as a high-performing public health agency. It has allowed the organization the opportunity to better communicate the value of public health programs and services for its elected officials, partners, and community members. The purpose of this case report is to share Clackamas County Public Health Division's journey to create a culture of quality through use of its performance management system and leveraging the accreditation process to move this important work forward across the agency.
Clackamas County's Board of Commissioners is the Board of Health and in 2009 developed its first jurisdiction-wide strategic planning process with requirements for performance and customer-based budgeting required for all departments. While performance measures and customer service processes were in place, they were not initially being actively used by staff across all levels of the organization to drive performance improvement activities.
In 2009 and 2010, the Public Health Division began development of its department-level strategic plan, community health assessment, and community health improvement planning efforts. These activities laid the foundation to begin the agency's development of a formal infrastructure for implementation of its performance management system and pursuit of national accreditation in 2012.
Based on a gap assessment of the Public Health Accreditation Board Standard & Measures Version 1.0,1 it became apparent to agency leadership that there were many pieces related to the performance management system in place; however, there was no ongoing formal structure for how process improvements occurred across all levels of the organization. The assessment also highlighted the need for more staff involvement in quality improvement activities across all levels of the organization. To address these areas of opportunity, the agency created a Quality Improvement Committee with representation from each program area and dedicated a staff member to coordinate, facilitate, and project manage the group.
The Quality Improvement Committee adopted the Public Health Foundation's Turning Point Model2 as the framework for its performance management system. The committee has developed a charter that focuses on implementation and monitoring of the agency's performance standards (eg, benchmarks, targets, and goals), performance measures (eg, key performance indicators), reporting on progress (eg, regular review and updates on performance using data), and quality improvement (eg, implementation of improvement activities or projects). The performance management system is implemented with the stated commitment of leadership support for quality improvement activities, a focus on the customer experience and being intentional to ensure that all resources dedicated to the performance management system are in alignment with the agency's overall strategic imperatives. The agency has a performance management plan that describes the framework, roles, and responsibilities for implementation of the plan that is updated annually by the Quality Improvement Committee. Clackamas County Public Health Division has been intentional in not developing a separate quality improvement plan due to the agency adopting a philosophy that quality improvement is one aspect of the performance management system and has embedded this information within its performance management plan.
The Quality Improvement Committee meets on a monthly basis to review agency performance data, including customer satisfaction results, performance measure dashboard, progress of quality improvement activities, quality improvement training curriculum, and updates the agency's performance management plan, as needed.
To address the gap in staff knowledge and participation in the performance management system, the agency developed quality improvement certification levels for staff. There are 3 levels of certification described in Table 2 to develop a structured format for staff expectations and development in implementing the performance management.
Through development of the processes described in the earlier section, the agency has been able to create and maintain a culture of quality improvement and is well positioned for reaccreditation in 2019. In the past 2 years, the agency has conducted an annual quality improvement planning process. This process brings agency leadership and Quality Improvement Committee members together for a full-day retreat to review organizational data and determine the 5 to 7 quality improvement projects that are going to be resourced each year. This includes development of a project timeline, identification of team members, facilitators, types of quality improvement tools needed, and measures of success. The agency has completed 1 annual cycle and has successfully completed 7 projects with participation of staff across the entire organization. Agency leadership and the governing entity continue to see progress in the creation of a culture of quality throughout the organization.
Advice to Other Health Departments
The Clackamas County Public Health Division has learned many key lessons, developing its performance management system that other agencies may want to consider:
- Focus on foundational work that can be sustained long-term instead of imposing organizational deadlines.
- Prioritize meaningful activities and projects that can be implemented and sustained in a short period of time. This will help engage staff across the organization and create their buy-in.
- Develop strong operation plans with dedicated staff responsible for ongoing monitoring. Work over time to ensure content is aligned. It may take a couple of planning cycles to get everything working together in a smooth fashion.
- Seek out a network of colleagues, such as a regional, state, or national association. There is no need to recreate the wheel.
In the past year, the agency has updated its strategic plan and each program's performance measures have been revised as the agency works to restructure the organization to align with the Foundational Public Health Services Model.3 The agency plans to have key program performance indicators available online for community members to assess the organization. Individual development plans are also being introduced for staff across the agency to strengthen workforce planning efforts, such as succession planning, knowledge transfer, mentorship opportunities, and promotional pathways for all employees. The performance management system provides a framework and structure for these activities to be bolstered and ensures that the agency's commitment to a culture of quality continues to be built upon. The Quality Improvement Committee continues to develop ways to communicate how these new initiatives are connected and how data should be used to drive decision making—see Figure, for example.