Division of Public Health Services Quality Improvement Plan

Division of Public Health Services Quality Improvement Plan 2013-2016 Every day, everyone will continuously seek excellence in the quality, efficiency, and effectiveness of the programs and services we provide. September 2013 Laura Holmes, Performance Improvement Manager NH Division of Public Health Services Bureau of Public Health Systems, Policy and Performance

Table of Contents 1. Purpose, Mission and Vision... 1-2 2. Key Quality Terms... 2-5 3. DPHS Approach to Quality... 5-8 4. DPHS Culture of Quality... 8-12 5. Quality Governance Structure... 12 6. Quality Improvement Training... 16-17 7. Key Quality Goals, Objectives and Measures... 17-19 8. Measuring, Monitoring and Reporting of the Quality Plan... 19 9. Communication Plan... 19-Error! Bookmark not defined. References:... Error! Bookmark not defined. Appendix 1: DPHS Quality Improvement Project Submission Form Appendix 2: DPHS Performance Improvement Knowledge and Training Needs Survey Appendix 3: DPHS QI Culture Assessment Appendix 4: DPHS Quality Improvement 101 Training Appendix 5: NH Bureau of Education and Training Lean Training Courses Appendix 6: QI Council Charter

1. Purpose, Mission and Vision a. Purpose The NH Division of Public Health Services (DPHS) Quality Plan serves as a comprehensive guidance document that describes how DPHS will establish, manage, deploy, and review quality throughout the organization. It identifies the processes and activities that will be put into place to ensure that quality public health services are provided consistently. The plan also describes the overall management approach to quality; identifies the key quality goals the Division wishes to accomplish over a defined time frame; and outlines a proactive quality management plan to meet those goals. It is guided by the strategic direction found in DPHS mission and vision statements, in its operational strategic plan, and in its state health improvement plan. The Quality Plan also documents DPHS conformity to Public Health Accreditation Board standard 9.2: Develop and implement quality improvement processes integrated into organizational practice, programs, processes, and interventions; and measure 9.2.1 A Establish a quality improvement program based on organizational policies and direction. b. Quality Policy Statement NH Division of Public Health Services (DPHS) is committed to a quality program as a proven way to enhance our organization s performance and achieve measurable improvements in the health and well-being of New Hampshire s residents. DPHS strives to be a high-performing, quality organization that systematically evaluates and improves the quality of our programs, processes and services to achieve a high level of efficiency, effectiveness and customer satisfaction. DPHS will reach that ideal by: Engaging customers and stakeholders and focusing on their needs; Ensuring leadership support, through clear direction and active involvement by the Senior Management Team; Fostering a culture that encourages and empowers all DPHS employees to be fully engaged in continuous quality improvement; Involving employees who are subject matter experts in and are impacted by the improvement opportunity; Continuously monitoring and evaluating performance; Using data and analysis to identify problems and performance concerns, and develop solutions and improvements; and Improving quality over time by investing in a continuous cycle of measurement, analysis, reporting and improvement. c. DPHS Mission, Vision and Values DPHS Mission Statement: To assure the health and well-being of communities and populations in NH by protecting and promoting the physical, mental and environmental health of its citizens, and by preventing disease, injury and disability. NH DPHS Quality Improvement Plan 2013-2016 1

DPHS Vision Statement: To be a responsive, expert, leadership organization that promotes optimal health and well-being for all people in New Hampshire and protects them from illness and injury. In the achievement of our mission and vision, we are guided by these values: Integrity We serve with honesty, accountability and fairness. Leadership We lead in a responsive and innovative manner. Respect We respect the diversity and contributions of our staff, our partners and the public. Excellence/Quality Every day, we will continuously seek excellence in the quality, efficiency, and effectiveness of the programs and services we provide. Stewardship We aim to use resources effectively and efficiently. 2. Key Quality Terms The following vocabulary has been adopted by DPHS to facilitate clear and consistent communication about our efforts to institutionalize quality throughout the Division. Performance Management is the practice of actively using performance data to improve the public's health. This practice involves establishment of organizational or system performance standards, targets and goals and relevant indicators to improve public health practice; application and use of performance indicators and measures; documentation and reporting of progress in meeting standards and targets and sharing of such information through feedback; and establishment of a program or process to manage change and achieve quality improvement in public health policies, programs or infrastructure based on performance standards, measurements and reports. 6 Performance Measurement analyzes the success of a work group, program, or organization's efforts by comparing data on what actually happened to what was planned or intended. Performance measurement asks: Is progress being made toward desired goals? Are appropriate activities being undertaken to promote achieving those goals? Are there problem areas that need attention? Are there successful efforts that can serve as a model for others? 6 Performance measurement is an aspect of program evaluation. Performance measurement focuses on measuring what is occurring, but does not ask "why" or "how" it is occurring. Program evaluation is a broader analysis it incorporates performance measurement to assess what is occurring, but then looks further to determine cause and effect, to ask "why" or "how." 6 Performance Metrics: A collection of terms used in setting goals, indicators, measures, standards, baseline and benchmarks. 1 Goal: an issue-oriented statement of an organization's desired future direction or desired end state; goals guide an organization's effort and articulate the overall expectations and intentions for the organization, e.g., decrease childhood obesity. 1 NH DPHS Quality Improvement Plan 2013-2016 2

Objective: a measurable target that describes a specific end result or change that a service or program is expected to accomplish within a given time period; a specific, measurable, achievable, result-oriented, time-bounded (SMART) step to achieving a goal. Objectives define specific results that will show movement toward your goals the mileposts along the road. They help you track progress toward achieving your goals and carrying out your mission. 1, 6 Example: Increase the percent of 3 rd grade students with dental sealants from 20% to 50% by 2020. Objectives can be long-term, intermediate, or short-term. Types of objectives: o Outcome objectives: describes changes in health status, attitudes, behavior, knowledge or ability that will occur in the long-term or the short-term as a result of one or more activities performed. 1, 6 Examples: Long-term outcome objective: Increase the percent of youth who report eating fruits and vegetables from 22.3% to 24% by 2020. Short-term outcome objective: Increase the number of schools implementing the NH Dept. of Education School Nutrition Rules from 10 to 200 by 2020. o Process objectives: set a number of specific activities that need to be completed by defined individuals or groups or to, for, or with individuals or groups by specific dates, in order to attain an outcome objective. They describe the participants, interactions and activities, e.g., conducting educational classes, performing a test or procedure, investigating a complaint, collecting or analyzing data, meeting with stakeholder groups, adopting a plan. Example: Increase the number of schools that have completed NH Dept. of Education School Nutrition Rules training from 0 to 200 by 2020. 1, 6 Activities: the processes, tools, events, technology, and actions that are an intentional part of program implementation. These interventions are used to meet the objectives. 1 Baseline: the initial level of performance at which an organization, process, or function is operating upon which future performance will be measured. 1 Benchmark: a level of performance established as a standard of quality; a nearterm standard with which an indicator or particular performance measure is compared. 1 Indicator: a precise definition of a process designed to measure an outcome or the achievement of a goal. 1 NH DPHS Quality Improvement Plan 2013-2016 3

Performance Measure: a basis for comparing performance or quality through quantification (e.g., count, rate, percent, number of). Quantifiable standards used to evaluate and communicate performance against expected results; a tool to gauge organizational progress, set direction and encourage alignment of a program activity to a population health goal. 1, 6 Standard: is a generally accepted, objective standard of measurement such as a rule or guideline against which an organization's level of performance can be compared. A performance standard establishes the level of performance expected. Standards may be set based on national, state, or scientific guidelines; by benchmarking against similar organizations, based on the public's or leaders' expectations, or other methods. Standards can be descriptive or numerical. 1, 6 o Descriptive standard: characterizes certain infrastructure components or certain activities that is, certain capacities or processes that are expected to be in place. Examples: A system for communicable disease surveillance and control shall be maintained. The local public health system is actively involved in the development and review of public health policies. The information systems in use enable the collection, use, and communication of data. o Numerical standard: establishes a quantifiable level of achievement. Numerical standards are often used as minimum standards. Example: At least 80% of mental health clients and their families will be satisfied with the mental health services received. (Continuous) Quality Improvement in public health is the use of a deliberate and defined improvement process, (e.g., Plan-Do-Study-Act, Plan-Do-Check-Act, Lean), which is focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community. 12 Quality Methods are practices that build on an assessment component in which a group of selected indicators [selected by an agency] are regularly tracked and reported. The data should be regularly analyzed through the use of control charts and comparison charts. The indicators show whether or not agency goals and objectives are being achieved and can be used to identify opportunities for improvement. Once selected for improvement, the agency develops and implements interventions, and re-measures to determine if interventions were effective. 4 Examples of methods include Plan-Do-Study- Act, Lean process improvement, Dartmouth Clinical Microsystems, Six Sigma, etc. NH DPHS Quality Improvement Plan 2013-2016 4

Quality Improvement Tools are designed to assist a team when solving a defined problem. Tools will help the team get a better understanding of a problem or process they are investigating or analyzing. Examples of tools include brainstorming, cause-andeffect, flowcharts, control charts, Pareto charts, histogram, and process mapping, among others. Strategic Planning vs Program Planning and Evaluation: A strategic plan results from a deliberate decision-making process and defines where an organization is going. The plan sets the direction for the organization and, through a common understanding of the mission, vision, goals, and objectives, provides a template for all employees and stakeholders to make decisions that move the organization forward. (Swayne, Duncan, and Ginter. Strategic Management of Health Care Organizations. Jossey Bass. New Jersey. 2008). 4 Widely used by profit-based, nonprofit and governmental organizations alike, a strategic plan is a leadership tool grounded in decisions the organization has made about strategic priorities for the near future - usually the next three to five years. The plan not only communicates these priorities but also provides a basis for future decision-making. The strategic plan is not intended to be a stand-alone document; rather, it should be aligned with other important assessment, planning and evaluation work such as a local community health improvement process, an agency quality improvement (QI) plan, operational/work plans or even an annual report. 7 Generally speaking, strategic planning occurs at the organizational level, while program planning and evaluation are program-specific activities that feed into the strategic planning. Program evaluation alone does not equate with quality improvement unless program evaluation data are used to design program improvements and to measure the results of the improvement as implemented. 8 3. DPHS Approach to Quality The DPHS approach to quality is rooted in the Performance Management System 6 framework developed by the Turning Point Collaborative. This practice involves the strategic use of performance measures and standards to establish performance targets and goals, prioritize and allocate resources, inform managers about needed adjustments or changes in policy or program directions to meet goals, frame reports on the success in meeting performance goals, and improve the quality of public health practice. Performance Management components include: Performance Standards, Performance Measures, Reporting of Progress, and Quality Improvement. To support the utilization and institutionalization of performance management, DPHS developed a performance management application (PMA). This IT system allows for the monitoring, analysis and reporting of performance data. The following section describes the DPHS approach to quality: a. Strategic Planning A strategic plan provides a clear picture of where an organization is headed, what it plans to achieve, the methods by which it will succeed and the measures to NH DPHS Quality Improvement Plan 2013-2016 5

monitor progress. 7 The strategic plan provides information that guides decisions on resource allocation and on taking action to achieve its goals and priorities. The DPHS Strategic Plan identifies priority areas for organizational improvement. These priority areas align with the objectives in the State Health Improvement Plan (SHIP) and other DPHS goals and objectives. These Division-level performance objectives will be visualized, monitored and reported on in the PMA. b. Performance Standards National standards, state specific standards, benchmarks from other jurisdictions, or agency specific targets should be used whenever appropriate to define performance expectations and align performance objectives. DPHS is committed to the consistent use of performance standards when identifying performance indicators, objectives and targets. c. Performance Measurement DPHS will use meaningful performance indicators to measure and monitor progress on meeting goals and objectives for population health outcomes, program outcomes, and organizational effectiveness, including the achievement of capacity standards and quality improvement activities. DPHS Bureaus, Sections and Programs should establish key performance indicators and objectives for the achievement of short- and long-term population health outcomes, program outcomes, and organizational goals. Key performance indicators and objectives will be entered, monitored, and continuously refined in the PMA. Performance indicators should be selected by programs in coordination with other DPHS programs and with the input of pertinent managers to avoid duplication of data collection. Standardized indicators should be used when appropriate. Data should be collected to enable adequate measurement of progress in achieving performance objectives. d. Reporting/Progress Reviews Bureau Chiefs are responsible for the performance of the programs within their area. In addition to current management practices, DPHS managers and staff should use the PMA to routinely track, monitor, analyze and report progress on meeting performance objectives. DPHS managers should communicate progress on meeting goals and objectives routinely within their areas and determine the frequency and structure of reporting that progress within their Bureaus. An annual DPHS performance dashboard should be produced by the Performance Improvement Manager for presentation to DPHS staff by the Director and for publication. The Performance Improvement Manager should produce and present dashboards on progress in achieving DPHS Quality objectives quarterly to NH DPHS Quality Improvement Plan 2013-2016 6

DPHS management and staff. DPHS programs should make progress reports available to stakeholders and partners, the media, and the public. e. Quality Improvement (QI) DPHS will continue its commitment to quality by supporting the efforts of employees to continually improve the effectiveness and efficiency of the organization and the services we provide. While we frequently make changes to processes and program activities, employees are encouraged to follow these five principles when striving to improve the quality of their programs and day-to-day work: 1. The improvement focuses on systems or processes, not on individuals 2. Ideas for improvement are identified by customers and front line staff 3. The improvement is designed iteratively through testing of ideas/changes 4. Change ideas are tested using data and the improvement is measured 5. Improvements are regularly revisited to sustain the improvement QI is never done (Source: North Carolina Institute for Public Health Quality) To institutionalize quality, employees are encouraged to focus improvements at all aspects of the organization: in its services, products, processes, policies, and overall operations. 11 To foster this, DPHS management and staff should: demonstrate leadership and commitment to sustain the institutionalization of quality and continuous quality improvement; incorporate adequate QI training into the budgeting process; support efforts to routinely seek out customer expectations, needs, satisfaction, and knowledge; incorporate performance improvement and QI expectations into job descriptions, staff evaluations, and job interviews; empower each other and members of staff to make improvements; and focus on improving processes i. QI Tools and Techniques Adopted DPHS has adopted the Institute for Healthcare Improvement s Model for Improvement (Plan-Do-Study/Check-Act) and Lean Process Improvement as techniques staff and managers can use to identify and implement quality improvement projects. Employees may also use The Dartmouth Institute s Clinical Microsystem approach to improvement and are free to explore other QI methods. ii. QI Project Identification All DPHS employees are encouraged to initiate QI projects at any level (Division, Bureau, Section or Program) to improve organizational processes, policies, or infrastructure. QI projects may be carried out by individuals or project teams. Employees may form QI project teams independently or NH DPHS Quality Improvement Plan 2013-2016 7

request assistance from the PIM, members of PHIT, a DPHS QI Coach or Facilitator, or other QI-trained employees. Supervisors and managers are encouraged to empower staff to identify and initiate quality improvement projects within their areas, as well as to participate in QI projects outside their Bureau when their expertise or perspective is needed. Bureau Chiefs are encouraged to coordinate QI initiatives among programs that share similar objectives. Employees are encouraged to use QI methods and tools to make improvements. QI projects may be initiated formally through the DPHS QI Project Submission Process (Appendix 1) or informally within an individual s program, section or bureau. Employees who wish to initiate a QI project that may impact the Division as a whole are encouraged to seek approval of Senior Management Team through the DPHS QI Project Submission Process. To ensure the success of these projects, employees are encouraged to receive QI training offered by DPHS or the NH Bureau of Education and Training (BET). Employees who have received QI training or are Continuous Improvement Practitioners (CIP) are encouraged to serve as QI Coaches or Facilitators throughout the Division. Annual improvement priorities for the Division should be identified by the QI Council based on reviews of organizational performance and the ability to affect improvement. Methods to identify improvements include: Using the PMA or an analysis of performance data to identify areas where a public health standard, objective or target is either partially met or not being met Identifying an objective in the DPHS Strategic Plan that is not being met Using results of evaluations of programs or administrative systems and functions Surveying employees on processes that need improvement; Analyzing internal and external customer data or satisfaction survey data. iii. QI Project Approval 4. DPHS Culture of Quality Employees are encouraged to discuss QI project ideas with supervisors before initiating a project. Employees should seek approval by Senior Management Team before initiating Division-level QI projects. a. History of Quality DPHS has embraced quality improvement since early 2000 with the adoption of the Turning Point model for performance management and in leading several performance improvement initiatives. And while over those years DPHS has built a strong foundation and commitment to performance management, it has not been able to implement a performance management system due to the lack of staff and NH DPHS Quality Improvement Plan 2013-2016 8

financial resources. Past performance management and quality improvement efforts have been sporadic and ad hoc; training and capacity has been unevenly distributed among bureaus, sections and programs; and QI training has been largely driven by grant and/or funding requirements. Highlights of our past achievements include: Participation in the Robert Wood Johnson Turning Point Performance Management Collaborative resulting in performance-based contracting with providers of local community and public health services, creating the DPHS Bureau of Policy and Performance Management (BPPM), leading the Division in adopting the Collaborative s Performance Management System model, and engaging in formal internal and external processes focusing both on assessment and quality improvement of the state and local public health system infrastructure, as well as in the delivery of public health programs and services. Convening of the New Hampshire Performance Management Collaborative and publication of Improving the Public s Health in New Hampshire: A Performance Management Approach, a report that showcased 11 performance measures and demonstrated DPHS' adoption of a performance management model that includes analyzing data to make changes to improve services and outcomes. 2005 Assessment of the local and state public health system capacity through the use of the National Public Health Performance Standards (NPHPS), resulting in the NH Public Health Improvement Action Plan, an effort of over 100 public health stakeholders working on six strategic priorities (www.nhphplan.org/), establishment in law of the Public Health Improvement Services Council providing oversight to public health improvement and planning activities, the creation of the nhphplan.org website which provides an inventory of public health programs in the state, the development and implementation of a public health marketing campaign, and development of NH HealthWRQS, a web-based public health data query system. Convening of the Public Health Improvement Team (PHIT) to serve as a resource for the Division in applying the Plan, Do, Study, Act approach to quality improvement, reviewing various programs performance on selected measures and making recommendations for change and improvement. Participation in the Robert Wood Johnson Foundation funded Multi-State Learning Collaborative (MLC) working on delineating performance measures for the Division, establishing workforce competencies for health officers, assisting local health agencies to conduct the National Association of County and City Health Official s capacity assessment to determine readiness for accreditation, taking steps towards accreditation readiness at the state level, NH DPHS Quality Improvement Plan 2013-2016 9

and working with local mini-collaboratives to conduct performance improvement around childhood obesity and pregnant women and smoking. b. Recent Culture of Quality 2010 marked a pivotal time for DPHS in its efforts to implement system-wide performance improvement. As a result of Division-wide strategic planning conducted that year, DPHS identified its central challenge: To demonstrate measurable improvements in health and well-being, and included implementing a performance management system as a strategic imperative. To understand why DPHS has not been successful in institutionalizing performance improvement, DPHS conducted a root cause analysis. Some of the reasons identified were: a lack of knowledge of performance improvement; a lack of perceived value of performance improvement throughout the organization; a perception that performance improvement is an add-on to already heavy workloads; a lack of dedicated staff to support performance management; inconsistent requirements of external funders; and the absence of an IT system to monitor and track performance for DPHS. From this root-cause analysis, a work plan was created that included the following activities: create a culture of performance improvement; survey staff relative to their knowledge, attitude and training needs; develop a performance management training and mentoring program; and research IT systems that can monitor program performance. Energized by strategic planning and the awarding of funding in 2010 by the CDC National Public Health Improvement Initiative (NPHII) grant, DPHS was able to make great strides in addressing past barriers and since that time has either initiated or completed these activities, and more. The PHIT conducted a survey of staff and results indicated that among a variety of issues the majority felt they had a basic understanding of performance improvement concepts, however, they were not confident enough in their level of knowledge to apply it to their program operations, nor were they required to by their supervisors. Competing priorities, lack of time, and scarce resources prevented staff from pursuing performance improvement activities. The survey also indicated that staff prefers training to be provided in-person and in a classroom setting rather than via webinar or self-guided tutorials. (Appendix 2) In 2011, a full-time Performance Improvement Manager was hired to lead the Division in developing and implementing a performance management system, facilitate Division-wide QI training and QI initiatives, and assist the Division in developing performance measures, public health improvement plans, and applying for public health accreditation. In addition, the PHIT evaluated its purpose and shifted its focus toward assisting the Division in developing a culture of quality by creating within itself a cadre of QI coaches, facilitators and mentors, providing an avenue for staff to initiate and conduct QI projects, and promoting and championing QI and QI activities occurring within the Division. NH DPHS Quality Improvement Plan 2013-2016 10

Based on survey results, feedback by PHIT members, and interviews with select states that participated in the Multi-State Learning QI Collaborative, the Bureau of Public Health Systems, Policy and Performance initiated a QI training program that includes instruction in basic QI methods and tools to QI project teams, and workshops for leadership to address topics in QI culture and change management. In December, the Public Health Foundation kicked off the training program with a cultural assessment workshop for DPHS leadership, and the Performance Improvement Manager followed-up with workshops for each DPHS Bureau (Appendix 3). The QI Team training began the following September as a year-long series of hands-on workshops and webinars provided by the North Carolina Center for Public Health Quality (Appendix 4). Additional staff training in Lean process improvement is encouraged by DPHS and financially supported by the NPHII grant or other funding when available. Also in 2011, DPHS published a state health assessment titled The New Hampshire State Health Profile 2011. This assessment compiled 38 indicators selected to best describe the health of the people in New Hampshire. Between 2011 and 2013, DPHS built the NH Health WISDOM (Web-based Interactive System for Direction and Outcome Measures), a data reporting and performance management tool. In addition to querying health outcome and demographic data, the Performance Management Application (PMA) within WISDOM will enable the Division and its programs to identify and track performance indicators and compare measures of progress to targets and benchmarks; provide a framework for aligning strategies throughout the organization; and assure periodic measurement and reporting of performance indicators important to achieving Division goals and objectives. WISDOM and the PMA module is expected to be launched in October 2013 To aid in the development of content for WISDOM and to launch efforts toward implementing performance management, the DPHS State Epidemiologist and the PIM led the Division through a strategic planning effort called the GO (Goals and Objectives) Plan. By using a logic model approach, DPHS managers and staff identified eight broad goals with aligned specific goals and Division-level objectives. Using the GO Plan and a standard template structured ranking method, the DPHS identified 10 public health priority areas with supporting objectives. These priority objectives will serve to focus the development of WISDOM, serve as a foundation for the State Health Improvement Plan, and inform a revised DPHS organizational strategic plan. Through GO planning, program staff also made initial efforts toward identifying Program-level performance objectives. This work has evolved into current efforts toward identifying key performance indicators and objectives for all programmatic and organizational units, aligned with the Division-level objectives identified in the GO Plan. This information and its supporting data will provide the content for the PMA. NH DPHS Quality Improvement Plan 2013-2016 11

c. Desired Future State of Quality By 2015, DPHS will be an organization with an institutionalized a performance management system and that considers quality a cultural norm. DPHS will accelerate its evolution by focusing on the use of performance data, particularly those concerning customer knowledge and satisfaction, to drive improvement efforts, achieve performance targets, and empower its workforce to improve the overall efficiency and effectiveness of daily activities. Performance improvement within DPHS will be guided by a shared organizational vision, i.e., a strategy that identifies measureable Division-level goals, objectives, and relevant performance targets. This strategy cascades through the organization through aligned program- or unit-level performance objectives and to the specific activities that are linked to the achievement of those objectives. This line of sight from program or unit activity to Division-level goal illustrates the causal relationship between Program performance and the Division s ability to meet public health improvement goals. It allows employees to focus on improvement at any point along that line and helps them to understand how their day-to-day work contributes to the achievement of health outcomes in the population. To improve quality and to regularly report on progress in meeting performance objectives, DPHS managers and staff will use the PMA. Managers and staff will regularly input and update performance information in the PMA for broad goals and specific goals, Division-level objectives and targets, performance objectives and targets, and activities that drive the achievement of those objectives. Standards that inform these objectives, e.g., Healthy People 2020, National Prevention Strategy, CDC Guide to Community Preventive Services, Public Health Accreditation Board, etc. will also be regularly identified in the PMA. Managers and staff will use WISDOM/PMA to measure, track and report on progress meeting performance objectives, analyze data driving the achievement of those objectives, and identify improvement opportunities (QI projects) based on that data. WISDOM/PMA will also be used to generate performance dashboards, data reports, progress reports, public health assessments and profiles, and track implementation of the State Public Health Improvement Plan and the DPHS Strategic Plan. Ultimately, DPHS will transition into an organization that uses performance data to help drive decisions on program planning, policy development, and resource utilization and allocation toward the goal of becoming an efficient and effective leadership organization. 5. Quality Governance Structure The success of the Quality Program hinges on the widespread and systematic practice of performance management and quality improvement throughout the division. As such, the governance structure reflects the need to institutionalize these practices. a. Organizational Structure NH DPHS Quality Improvement Plan 2013-2016 12

The DPHS Quality Program is a performance improvement initiative under the direction of the Chief of the Bureau of Public Health Systems, Policy, and Performance (BPHSPP) and serves to implement Strategic Priority F: Implement Performance Management toward achievement of the overarching strategic challenge to Demonstrate Measureable Improvement in the Health of the New Hampshire Population. The Quality Program is managed and implemented by the Performance Improvement Manager (PIM), as Chief of the Public Health Improvement Section reporting to the BPHSPP Bureau Chief. Administrative support for the Quality Program is provided by the BPHSPP administrative assistant with assistance by the Executive Secretary. The following bodies provide oversight, guidance and/or support to the Quality Program: DPHS QI Council: The purpose of the DPHS Quality Improvement Council is to serve in a leadership role within the Division to develop and sustain a culture of quality. The Council will work to institutionalize a system for performance management and quality improvement (figure 1) to ensure the highest level of efficiency and effectiveness in the services we provide to the population of New Hampshire. The Council coordinates with the DPHS Management Team and other leaders to assure alignment with other DPHS strategic initiatives, such as organizational strategic planning, state health improvement planning, and public health accreditation. The Council s primary goals include: 1. Serve as champions of a DPHS Culture of Quality and institutionalization of the Six Ingredients of a Quality Culture (Appendix 1); 2. Guide and support the implementation of the DPHS Quality Plan (Appendix 2); 3. Support the implementation and instutionalization of performance management (Figure 1) and the Performance Management Application (PMA); 4. Assist with staff skills-building related to performance management and quality improvement; 5. Facilitate the success of quality improvement projects throughout the Division; and 6. Ensure that DPHS is well-prepared to meet and sustain national public health accreditation. The Council is comprised of diverse individuals from across the division representing each bureau/area and from different levels within the organization. It is co-chaired by the Performance Improvement Manager and another DPHS representative selected by the Council on a rotational basis. At least one member of the DPHS Senior Management Team will be a member of the Council. The Council may form workgroups consisting of additional DPHS employees to assist in completing deliverables. The Council will meet NH DPHS Quality Improvement Plan 2013-2016 13

monthly at a regularly scheduled time which best accommodates the membership, with the schedule set well in advance. Council co-chairs will schedule meetings and prepare agendas. They will take minutes or seek a minute taker at meetings. DPHS Senior and Extended Management Team: Provide leadership for the DPHS vision, mission, and strategic plan; and provides guidance for the Quality Improvement Council in support of the achievement of their goals. At least one member of the DPHS Senior Management Team will serve on the Council. DPHS Strategic Planning Team: Serves as an advisory body for the development and implementation of the DPHS Strategic Plan. The Strategic Planning Team may also be called upon to assist the PIM or the QI Council in brainstorming and/or decision-making regarding performance management and QI. b. Roles and Responsibilities Performance Improvement Manager (PIM): Coordinate, implement, support, guide and define the Quality Program Serve as administrator of the PMA and be responsible for its maintenance, provide training and instruction on its use to employees, use the PMA to report progress made by the Division, and provide recommendations on its use and future development to DPHS management Serve as co-chair on the QI Council Coordinate performance management and quality improvement training to DPHS employees and provide technical assistance as needed Facilitate and track QI efforts being conducted across the Division Assist with QI projects as needed Facilitate the integration of QI principles into DPHS policies and protocols Facilitate the communication of QI results Provide regular updates on the progress of the Quality Program at Extended Management Team meetings Serve as liaison among employees, QI Council, Strategic Planning Team, and management teams in regard to performance management and QI Apply QI principles to daily work Extended Management Team Provide leadership for DPHS vision, mission, strategic plan, and performance management and quality improvement efforts Advocate for and support a culture of quality, including messages and presentations to staff and internal and external partners Promote an empowering QI learning environment for the Division NH DPHS Quality Improvement Plan 2013-2016 14

Implement performance management practices, utilize the PMA to facilitate improvement efforts and reporting of progress, and ensure utilization of PMA by Program Managers or other managers Serve on the QI Council as needed Regularly report on performance of your area of responsibility at Extended Management Team meetings Communicate with managers and supervisors to identify opportunities for improvement Facilitate the initiation of QI activities within your area of responsibility and support staff and managers in their QI efforts Participate in QI project teams as needed or required Assure managers and staff have access to resources to carry out QI projects and training Provide managers and staff with opportunities to share results of QI efforts Apply QI principles to daily work Senior Management Team Provide leadership for DPHS vision, mission, strategic plan, and performance management and quality improvement efforts Advocate for and support a culture of quality, including messages and presentations to staff and internal and external partners Promote an empowering QI learning environment for the Division Implement performance management practices, utilize the PMA to facilitate improvement efforts and reporting of progress, and ensure utilization of the PMA by managers Monitor, track, and analyze progress made on Division performance objectives (performance dashboard) Monitor, track and analyze the performance of the programs and organizational units within their areas Define the structure and frequency of performance reviews Serve on the QI Council as needed Communicate with the QI Council to identify and prioritize opportunities for improvement Ensure managers and staff have access to resources to carry out QI projects and training Facilitate the success of QI projects; sponsor and/or participate in QI projects as needed Apply QI principles to daily work Managers Provide leadership for DPHS vision, mission, strategic plan, and performance management and quality improvement efforts Implement performance management practices, utilize the PMA to facilitate improvement efforts and reporting of progress NH DPHS Quality Improvement Plan 2013-2016 15

Communicate progress and QI results regularly to supervisor Serve on the QI Council as needed Familiarize staff with the Quality Program and Quality Plan Assure staff have access to resources for QI training and to carry out QI projects Initiate or facilitate the initiation of QI activities within your area of responsibility Communicate with staff to identify opportunities for improvement Support staff in their QI efforts and participation in QI activities and project teams Participate in QI project teams as needed or required Provide staff with opportunities to share QI project results Share QI successes and lessons learned with supervisors and staff Document QI activities within your area of responsibility Evaluate staff regarding QI activities Advocate for and support a culture of quality, including messages and presentations to staff, internal and external partners, and stakeholders Promote an empowering QI learning environment for the Division Apply QI principles and tools to daily work Staff: Develop an understanding of basic QI principles and the ability to use QI methods and tools through training Communicate with supervisors to identify opportunities for improvement Participate in at least one QI project annually Facilitate or coach QI project teams as needed Communicate QI successes and lessons learned Advocate for and support a culture of quality, including messages and presentations to staff, internal and external partners, and stakeholders Promote an empowering QI learning environment for the Division Apply QI principles and tools to daily work c. Budget and resource allocation DPHS performance management and quality improvement activities are supported by funding from a 5-year CDC National Public Health Improvement Initiative (NPHII) grant (2010-2015). Currently, the NPHII grant provides $250,000 annually distributed toward the salary and benefits for a full-time PIM, salary for a part-time intern, development and maintenance of the performance management application, QI training and equipment, and administrative costs related to this initiative. 6. Quality Improvement Training DPHS is committed to providing all employees with sufficient training in quality improvement methods and tools. To facilitate and sustain a culture that supports the institutionalization of quality, every employee will have the opportunity to integrate NH DPHS Quality Improvement Plan 2013-2016 16

quality practices into their day-to-day work. The Division should make efforts to identify sources of funding for QI training each year. Currently, QI training funds are provided by the NPHII grant. To sustain ongoing QI training, Bureau Chiefs are encouraged to include QI training in their respective grant applications and budgets. With adequate funding, DPHS will contract training provided by instructors qualified in a variety of QI techniques (Lean, the Institute for Healthcare Improvement s Model for Improvement, PDSA, etc.). At a minimum, DPHS should provide staff with opportunities to participate in Lean Process Improvement courses provided by the NH Bureau of Education and Training (BET), and additional training opportunities, such as webinars and online tutorials, when available. Employees should be encouraged by their supervisors to participate in the training provided. Over time, each Bureau should train a majority of their staff and survey their confidence in using basic QI methods and tools. When the majority of DPHS employees feel confident, basic QI training should be prioritized to new employees; advanced training and refresher opportunities should be developed and offered when possible. Trained employees should be encouraged to become QI coaches or complete Certified Continuous Improvement Practitioner training offered by NH BET in order to assist QI project teams across the Division. New employees should receive an orientation by their supervisor to the DPHS culture of quality and be made aware of their role and responsibilities regarding performance management and QI. An annual review of employees responsibilities regarding performance management and QI should be included in individual performance evaluations. 7. Key Quality Goals, Objectives and Measures a. Over-Arching Challenge: Demonstrate Measureable Improvements in the Health of New Hampshire Populations b. Cross-Cutting Strategic Priority: Implement Performance Management within DPHS Goal 1: Managers and staff practice performance management and use quality improvement methods and tools in their daily work. Performance Indicators: Managers confident in using basic performance management practices o Target: 100% of senior, section and program managers understand basic performance management practices by September 1, 2014 DPHS employees skilled in using QI methods and tools o Target: 10% of DPHS employees by October 1, 2013 o Target: 25% of DPHS employees by October 1, 2014 o Target: 50% of DPHS employees by October 1, 2015 NH DPHS Quality Improvement Plan 2013-2016 17

Managers trained in leadership skills o Target: 100% Senior Management Team members by November 1, 2013 o Target: 100% of Extended Management Team members by November 1, 2013 Goal 2: Managers use the PMA to track and report on progress made in meeting Division and Program performance objectives. Performance Indicators: Programs have entered program information into the PMA o Target: 100% of Programs by September 1, 2013 Programs have at least 1 key performance indicator (KPIs) in the PMA o Target: 100% of Programs by October 1, 2013 Programs have a strategic alignment for at least 1 objective in the PMA o Target: 100% of Programs by October 1, 2013 Programs with data have a report (graph) of progress for at least 1 KPI o Target: 100% of Programs by January 1, 2013 Programs without available performance data have completed a data acquisition plan o Target: 100% of Programs without available performance data by November 1, 2013 Goal 3: Managers regularly report on progress meeting performance objectives. Performance Indicators: Managers with available data present performance dashboards at Extended Management Team meetings o Target: 100% of Managers with available data by October 1, 2014 Goal 4: Managers use the PMA to identify successes and areas for improvement Performance Indicators: Managers present performance dashboards at Management Team meetings o Target: 100% of Managers with available data present at Management Team meeting by October 1, 2014 NH DPHS Quality Improvement Plan 2013-2016 18

Goal 5: Quality is continuously improved throughout the Division Performance Indicators: Priority QI projects are identified annually by the QI Council and completed within the year by designated task forces o Target: 2 priority QI projects identified by 11/1/2013 o Target: 2 priority QI projects are completed by 11/1/2014 Managers have proposed, sponsored, approved or participated in at least one QI project o Target: 100% of Senior Management Team members by October 1, 2014 o Target: 100% of Extended Management Team members by October 1, 2014 o Target: 100% of Program Managers by October 1, 2014 Staff have proposed or participated in at least one QI project o Target: 10% of staff by October 1, 2013 o Target: 25% of staff by October 1, 2014 o Target: 50% of staff by October 1, 2015 Employees use QI methods and tools in their daily work o Target: 100% of employees by January 2016 8. Measuring, Monitoring and Reporting of the Quality plan Measuring, monitoring and reporting of progress on the goals and objectives of this plan is the responsibility of the QI Council. The objectives and targets listed above will be entered into the PMA and be aligned to Broad Goal 8: Strive to Become an Efficient and Effective Leadership Organization. Data to support evidence of progress should be gathered by the PIM and entered into WISDOM/PMA. The PIM should generate a dashboard of progress that can be viewed by any DPHS employee. Progress will be presented regularly at Extended Management Team meetings and at DPHS Staff Meetings. Progress on the Quality Plan should be discussed with the QI Council and recommendations for improvement activities should be sought if targets are not being met. Revisions and updates to the Plan should also be discussed and made. The Quality Plan will be updated annually by the QI Council. 9. Communication Plan DPHS will communicate its shared vision of quality through consistent messages at Program, Section, Bureau and DPHS staff meetings. Linkages between quality improvement and strategic priorities such as strategic planning, public health improvement planning, public health accreditation, empowerment, workforce development, and program evaluation should be communicated by managers at all levels. NH DPHS Quality Improvement Plan 2013-2016 19