A performance management (PM) system consists of an organizational monitoring tool such as a dashboard or scorecard combined with the improvement processes of quality improvement (QI), ultimately designed to improve the public's health. The Public Health Accreditation Board (PHAB) accreditation process created a renaissance in QI and PM. In an era of growing public health threats, there is a substantial need to strengthen health departments through the use of a PM system. The future of health departments depends upon their ability to effectively and efficiently use their resources.
Health department leadership could choose to do more with less, but this is a nonsustainable option. Health departments could do less with less, but this is often an unrealistic option as they are governed by political bodies and answer to a public that expects to be kept healthy and safe. The most viable option is for health departments to do their very best with the resources they have through the use of a PM system.
Accreditation, and the emphasis on a PM system, is a key factor in the long-term sustainability of health departments. The public health history and potential benefits of a PM system are well described.1 , 2 The PHAB Standards and Measures Version 1.5 states, “Domain 9 focuses on the use and integration of performance management and quality improvement practices and processes for the continuous improvement of the public health department's practices, programs, and interventions.”3 Quality improvement and PM are applied across the PHAB Standards and Measures.
An example of the combination of QI and PM to create a PM system comes from the California Department of Public Health (see the Figure). The right side of the figure is the Quality Performance System, or PM system. The figure begins with the “Goal” sphere where the health department sets priorities. Next, the organizational priorities are turned into measureable indicators that fit into the “Measure” sphere. The measure step includes the use of a dashboard or scorecard. The health department then regularly tracks and reports on the progress of the measured indicators, which is the “Progress” sphere. If any indicators are going in the wrong direction, the health department can decide to launch a QI project to improve the indicator. This step leads from the “QI” sphere into the QI cycle described by the spheres on the left. The work of the PM system is continuous and should engage a health department quality performance council.
Accreditation is driving the use of PM as described in the 2016 National Association of County & City Health Officials' Profile where local health departments that were accredited as of June 2017 were more likely to report that agency performance data are used on an ongoing basis to drive improvement efforts than health departments that had not registered with PHAB by June 2017 (odds ratio = 7.7, P < .001).4
Performance management is described by the Public Health Foundation as
the practice of actively using performance data to improve the public's health. This practice involves strategic use of performance measures and standards to establish performance targets and goals. Performance management practices can also be used to prioritize and allocate resources; to inform managers about needed adjustments or changes in policy or program directions to meet goals; to frame reports on the success in meeting performance goals; and to improve the quality of public health practice.5
Performance management is not the evaluation of individual employee performance. Performance management is a model for monitoring the health department's priorities. Performance management creates transparency and accountability. A famous saying of unknown origin states, “What gets measured gets done.”
The Association of State and Territorial Health Officials' PM leadership guide states, “The performance of a health department that creates and deploys a PM system will improve, often dramatically.”1 Among the many benefits the department will experience are transparency, prioritization, and enhanced decision making.
Public health PM system studies and management literature focus primarily on QI. The PM component of the system requires commitment from the highest executive levels of the department and often does not have the immediate positive impacts of a focused QI project. Performance management has been described as a primary tool for health department leadership and has been recommended to be implemented even before QI.6 Performance management is critical to developing a high-performing health department and is required for accreditation.
Public Health Accreditation Board Standard 9.1 is the use of a PM system to monitor achievement of organizational objectives and states,
For the health department to most effectively and efficiently improve the health of the population, it is important to monitor the performance of public health processes, programs, interventions, and other activities. A fully functioning performance management system that is completely integrated into health department daily practice at all levels includes: 1) setting organizational objectives across all levels of the department, 2) identifying indicators to measure progress toward achieving objectives on a regular basis, 3) identifying responsibility for monitoring progress and reporting, 4) identifying areas where achieving objectives requires focused quality improvement processes, and 5) visible leadership for ongoing performance management.7
Public health is expert in tracking and monitoring data. Epidemiology is a core public health practice. Performance management applies public health data expertise to the business practice of tracking key management and health outcomes. The PM format is transparent and creates accountability for decisions based upon the system's data.
Public health accreditation has been a major driver of the adoption of QI practices in health departments. In the 2016 National Association of County & City Health Officials' Profile, local health departments that were accredited as of June 2017 were more likely to report that the health department had implemented a formal QI program agency-wide than health departments that had not registered with PHAB by June 2017 (odds ratio = 27.0, P < .001).4
In a survey of accredited health departments, 1 year after they were accredited,
- ninety-seven percent strongly agreed or agreed that accreditation had stimulated QI and performance improvement opportunities within their health department;
- ninety-five percent reported that they perceived that their health department's awareness of or focus on QI efforts had improved as a result of accreditation; and
- ninety-two percent strongly agreed or agreed that accreditation had strengthened the culture of QI within their public health department.8
Many articles describe the value and successes of health department QI projects.9 , 10 In the last 5 years, the number of QI trainings has exploded. Accredited health departments have become QI leaders and are models for other state and local government agencies.
Quality improvement is all about improving systems and processes. Health department systems and processes have been built over decades as a result of managerial decisions made with little to no data and intended to fix poorly identified problems. Such systems and processes are not unique to health departments, and there is much to be learned from the application of QI principles in other industries.
Public Health Accreditation Board Standard 9.2 is the development and implementation of QI processes integrated into organizational practice, programs, processes, and interventions, and states,
Performance management system concepts and practices serve as the framework to set targets, measure progress, report on progress, and make quality improvements. An important component of performance management systems is the implementation of a quality improvement program. This effort involves integration of a quality improvement component into staff training, organizational structures, processes, services, and activities. It requires application of an improvement model and the ongoing use of quality improvement tools and techniques to improve the public's health. Performance management leads to the application of quality improvement processes.11
Quality improvement projects are generated from a variety of sources. A PM dashboard can identify the need for a QI intervention. Often, QI projects arise from leadership directives, customer complaints, audits, and even the media. The most popular QI model used by public health is Plan, Do, Study, Act. Several other models are growing in popularity such as Kaizen, Lean, and Six Sigma. All of the models use and teach critical QI skills and tools such as the affinity diagram, brainstorming, cause and effect/fishbone diagram (Ishikawa), flowchart, and force field analysis.12
To improve the quality of public health services and improve the public's health, PM systems need to become a way of life in health departments across the United States. The future of PM systems depends on the following:
- Greater emphasis on the use of PM measures and dashboards.
- Full support of health department leadership.
- Lessons from other industries.
- Development of a national public health management dashboard.
- Defining health department customers and focusing on customer needs.
- Public health undergraduate- and graduate-required PM system courses.
- Performance management system maturation focused on community health outcomes.
- Mature health department PM systems as models for other health departments, the rest of government, and community partners/contractors.
- Training and support for community partners in the development and use of PM systems.
- Coordination/integration of health department PM systems with community partners' PM systems.
Public health accreditation has spread and matured PM systems. The success of this effort is being proven through research and experience. These systems will continue to proliferate and ultimately strengthen the entire public health field.
1. Chapman RW. Performance Management Leadership Guide. Arlington, VA: ASTHO; 2016.
2. Beitsch LM, Yeager VA, Moran J. Deciphering the imperative: translating public health quality improvement into organizational performance management gains. Annu Rev Public Health. 2015;36:273–287.
3. Public Health Accreditation Board. Public Health Accreditation Board Standards and Measures, Version 1.5. Alexandria, VA: Public Health Accreditation Board; 2014:203.
4. Beitsch LM, Kronstadt J, Robin N, Leep C. Has voluntary public health accreditation impacted health department perceptions and activities in quality improvement and performance management? Supplement, Impact of Public Health Accreditation J Public Health Manag and Pract. 2018;24(3):S10–S18.
6. Chapman RW, Beitsch LM. Performance management systems: a public health model practice. J Public Health Manag and Pract. 2017;23(3):311–314.
7. Public Health Accreditation Board. Public Health Accreditation Board Standards and Measures, Version 1.5. Alexandria, VA: Public Health Accreditation Board; 2014:204.
8. Siegfried A, Heffernan M, Kennedy M, Meit M. Quality improvement and performance management benefits of public health accreditation: national evaluation findings. Supplement, Impact of Public Health Accreditation. J Public Health Manag Pract. 2018;24(suppl 3):S3–S9.
9. McLees AW, Thomas CW, Nawaz S, et al Advances in public health accreditation readiness and quality improvement: evaluation findings from the National Public Health Improvement Initiative. J Public Health Manag Pract, 2014;20(1):29–35.
10. Riley WJ, Beitsch LM, Parsons HM, Moran JW. Quality improvement in public health: where are we now? J Public Health Manag Pract. 2010;16(1):1–2.
11. Public Health Accreditation Board. Public Health Accreditation Board Standards and Measures, Version 1.5. Alexandria, VA: Public Health Accreditation Board; 2014:213.
12. Brassard M, Ritter D. The Public Health Memory Jogger II: A Pocket Guide of Tools for Continuous Improvement and Effective Planning. Salem, NH: GOAL/QPC and Public Health Foundation; 2007.