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Performance Management System Workplan (Indicator 1.2)

I. Policy Statement: The Branch-Hillsdale-St. Joseph Community Health Agency has adopted a

performance management system approach to its services as a method to improve the effectiveness

of its programs, the efficiencies of its operations, the satisfaction of its customers and the

engagement of its staff. The performance management approach will incorporate four key

components, which include:

• Performance Standards

• Performance Measures

• Report of Progress

• Quality Improvement Projects

II. Background: The Performance Management System Plan has been developed in response to the

Branch-Hillsdale-St. Joseph Community Health Agency’s Strategic Plan 2015 – 2019 which identified

the following goals and objectives as part of its Strategic Priority 1:

Strategic Priority 1: Support and enhance the Agency’s infrastructure to maximize its’

performance as a public health organization of excellence.

Goal 1: Improve workforce development and strengthen systems and organizational

capacities that support the workforce.

Obj. 1.1 By September 30, 2015, develop standardized policies, procedures and training

materials for hiring and orientating employees to public health and the agency

services.

Obj. 1.2 By September 30, 2015, develop and implement a succession plan for key

organizational positions.

Obj. 1.3 By December 31, 2015, increase capacity of existing workforce.

Obj. 1.4. By December 31, 2016, identify and maintain a system for tracking and evaluating

workforce needs and assure that 75% of employees have received required and

program-specific training.

Obj. 1.5 By September 30, 2017, there will be a 25% improvement in staff engagement as

measured through key workplace satisfaction indicators.

Obj. 1.6 By December 31, 2018, institute and maintain a performance management system

that links to the Agency’s planning processes.

Goal 2: Maximize business efficiencies and effectiveness through the use of technology.

Obj. 2.1 By December 31, 2015, identify strategies that lead to improvements in insurance

billing.

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Obj. 2.2 By December 31, 2015, examine current methods for accepting client payments

using debit and credit cards and determine if improvements are needed.

Obj. 2.3 By May 31, 2016, purchase, install and maintain a new accounting system to replace

the current accounting system.

Obj. 2.4 By September 30, 2017, utilize an Electronic Health Record for 100% of applicable

customer services.

Obj. 2.5 By September 30, 2017, develop and maintain an Information Technology plan

which will be used to guide the ongoing development and evolution of technology in

support of the Agency’s programs and its strategic directions.

Goal 3: Increase the Agency’s capacity for conducting continuous quality improvement (CQI)

and assurance activities.

Obj. 3.1 By December 31, 2015, provide CQI training on an annual basis to at least 75% of

Agency employees.

Obj. 3.2 By December 31, 2015, implement and maintain a mandate/contract compliance

process which will help to assure that the Agency is in compliance with all

requirement mandated, contractual and program requirements.

Obj. 3.3 By December 31 2016, every Agency program will incorporate, monitor and report

on quality improvement outcomes to the administration.

Obj. 3.4 By September 30, 2017, the Agency will develop a Quality Improvement Report

which it will issue to the community and the Board of Health.

Through the development and implementation of this performance management plan which will

improve its data collection infrastructure and enhance its utilization of quality Improvement methods,

the Agency will maximize its performance as a public health organization of excellence.

III. Performance Management System Approach and Timeline:

Phase 1: Create a new Performance Management Committee (PMC) and Train Staff (to be completed by May 31, 2018) The Agency will form a new Performance Management Committee (PMC) consisting of the four-member Administrative Team, along with four line-staff members from different division within the Agency. Each year, two of the line-staff members will be replaced by new members (effectively creating a two-year term for line-staff on the PMC). The Agency will train the staff utilizing the following online trainings:

• Embracing Quality in Public Health: A Practitioner’s Performance Management Primer

• Performance Management Training Series

• CQI for Public Health: The fundamentals

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• Additional in-house trainings Deliverables from this phase of the project will be training certificates for committee members. Phase 2: Reevaluate the Current Strategic Plan to Assess Objective Completion (to be completed by July 31, 2018) The PMC will review the current strategic plan and workplan, identifying which goals are yet to be accomplished and create a standardized reporting mechanism to provide regular feedback. The group will work together to assess which objectives were not met by completing the current workplans and determine a course of action. Some objectives may require updated workplans, some may require quality improvement projects, and some may need to have the objectives updated. Deliverable from this phase of the project will be updated strategic plan to incorporate language about performance management and how the plan will be managed and updated in the future; updated strategic plan objectives; and standardized reporting forms for assigned staff to report their progress toward objectives bi-annually. Phase 3: Self- Assessment (to be completed by August 31, 2018)

The Agency will utilize the Turning Point Performance Management Self-Assessment Tool. The purpose of the assessment is to assist the Agency in identifying both strengths and weaknesses and to help it identify areas for improvement. This assessment will be completed annually by the newly created Performance Management Committee (PMC). This 8-member team will review the results of the assessment and based upon these results identify a course of action for the next phase: Standards Review. Deliverable from this phase is the completed self-assessment. Phase 4: Standards Review (by October 30, 2018) Once the assessment is completed, the Performance Management Committee will identify relevant standards that are applicable to the objectives laid out in the Strategic Plan. Based upon the standards reviewed, the committee will select key standards and indicators for measurement. They will review current data trends, establish benchmarks when available or estimate benchmarks; and set goals and target measures, if they are not already set in the Strategic Plan. Expectations related to these key standards will be initially communicated to staff through the Agency’s Staff Newsletter (the Livewire). Bi-Annually the progress will be communicated to the staff and the governing body by utilizing the standardized reporting mechanism created in Phase 2. All reports will be electronically distributed to Agency staff via email, posted on the Agency website, and distributed directly to the Board of Health. Deliverable from this phase of the process are a list of standards selected. Phase 5: Performance Measurement (Completed by December 31, 2018)

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During phase 5, using the standards and measures identified during the previous phase, the Performance Management Committee (PMC) will refine the indicators. During the ‘Indicator refinement phase’ the PMC will work to assure that the indicators used for measurement purposes reflect the Agency’s sphere of influence; that the data identified to be collected is available or could be available; the data is reliable and valid; and that the measurement being used correlates to the indicator. Once these issues are finalized, data collection will begin. Deliverable from this phase of the process are updated strategic plan objective, which include the indicators and benchmarks selected by the committee. State/National Systems which may be utilized include:

• U.S. Census (includes multiple databases and data sets)

• Michigan Childhood Improvement Registry (MDCH)

• Michigan Disease Surveillance System (MDCH)

• Vital Records and Health Statistics (MDCH)

• Michigan In-patient Database (MDCH)

• Michigan State Police – Office of Highway and Traffic Safety – Motor Vehicle Data Base

• Women, Infant and Children’s client database (MDCH)

• Certificate of Need Annual Survey (MDCH)

• Michigan Behavioral Risk Factor Surveillance System (MDCH)

• Health Resources and Services Administration (databases for health professionals and health facilities)

• CHAMPS (for Medicaid) and Networks (for Medicaid billing)

• Easy Link and Oracle (CSCHS/MDCH)

• MICIS (for AAA)

• Assistant Secretary of Planning and Evaluation (ASPE) of the Department of Health and Human Services for zip code level Marketplace enrollment data

Local Health Department Data Systems which may be utilized include:

• SWORD – Environmental Health Food Inspection Database

• Smoking Violation Database

• Meth Remediation Database

• Swimming Pool Database

• LHD Septic Failed Database

• Well and Septic Databases

• CSHCS database

• Hearing and Vision Database

• Real-time Internet Communicable Disease Reporting Database

• Health Education Database

• Abila System for Financials

• I-Synergy (Document imaging database)

• Electronic Health Record (future system to be determined) Phase 6: Reporting Progress (Bi-Annually in June and December starting in 2019) Bi-Annually the progress will be communicated to the staff and the governing body by utilizing the standardized reporting mechanism created in Phase 2. All reports will be electronically distributed to Agency staff via email, posted on the Agency website, and distributed directly to the Board of Health.

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The June report will be the month for the final report from the previous year (which will align with the issuance of the previous year’s annual report) and December will be the mid-year report. In addition, it is the expectation that program specific measures will be monitored on a monthly basis by the program coordinators/staff and that information will be shared at monthly staff meetings as reflected in both agendas and minutes. Phase 7: Quality Improvement (June, 2019 and ongoing) Once the performance measures are identified and monitored, those performance measures which are short of their targets will move to a quality improvement phase. The quality improvement phase will follow the Plan, Do, Study, Act method. The process will encompass the 9 steps as identified by Deming:

• PLAN Step 1: Identify Problem (includes estimating needed resources and obtaining any approvals to

conduct QI) Step 2: Assemble a QI Team (includes identifying roles and responsibilities, establishing initial

timeframe for improvement activity and developing AIM statement) Step 3: Examine Current Approach (includes process mapping, reviewing baseline data,

determine root causes of problem and revising AIM statement) Step 4: Brainstorm/Research/Identify Potential Solutions (includes reviewing best practices and

evidence-based models and selecting potential solution) Step 5: Develop a Theory of Improvement (includes using an if….then approach and selecting a

strategy to test theory)

• DO Step 6: Test Improvement Theory (includes testing on small scale, data collection and analyzing

outcomes)

• STUDY Step 7: Study the Results (includes comparing results against baseline data, identifying side

effects, identify if improvement has occurred and reporting outcomes)

• ACT Step 8: Standardize the Improvement or Develop New Theory (includes expanding test to a

wider scale or developing new improvement theory and testing it) Step 9: Establish Future Plans (includes celebrating successes, communicating results, making

long term plans for additional improvements) (See Agency’s QI Plan for additional information) IV. Roles and Responsibilities:

All Agency staff will participate in developing, using and updating the performance management plan,

through representation of Performance Management Committee (PMC) members or through activities

at quarterly staff meetings. The PMC will be responsible for assuring that updates to this plan are

included in the Strategic Plan and communicated to the Agency Board of Health. The following roles and

responsibilities have been identified:

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Board of Health:

• Provides high-level oversight and accountability;

• Is aware of final outcomes and projects that affect BHSJ CHA;

• Provides an outside perspective on QI initiatives;

• Receives updates in regards to performance management and QI initiatives and approves

annual report;

• Provides access to resources and trainings as appropriate.

Health Officer and Division Directors:

The Health Officer and Division Directors will:

• Be apprised of all current projects;

• Allow time at all staff meetings to discuss ongoing and completed projects;

• Approve the work of the committee

• Participate as required on the work of the committees as it relates to the programs in their

divisions and/or cross-divisional projects

The Health Officer and Division Directors are also relied upon to facilitate communication between the

Performance Management Committee (PMC) and the Board of Health.

Quality Improvement Committee Members:

The roles of the QI Committee members include:

• Providing a forum for all members of BHSJ CHA to provide input on QI initiatives

• Identifying and facilitating division-wide QI projects

• Establishing guidelines, forms and a reporting format for projects

• Providing feedback and guidance to the division’s programs/teams; and

• Collecting, analyzing and evaluation project information

Division Programs (All Staff)

It is expected that division staff will:

• Discuss and develop QI opportunities

• Implement and evaluate projects; and

• Over time become engaged in QI opportunities (including suggesting ideas, providing feedback

to their QI committee representative, participating in projects and encouraging other staff to

participate).

V. Communication Strategies

The Performance Management Committee’s members represent each program of the BHSJ CHA to

ensure that all staff have an opportunity to contribute to the Performance Management Plan. To that

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end, members are responsible for facilitating regular communication between the PMC committee and

staff in their respective program.

Program Meetings – PDFs of agendas and minutes of the meeting and reports will be available to all

staff and will be available on a centralized location of the Agency server, in a Strategic Plan folder.

Performance Management Committee – will receive updates twice a year from all QI committees so as

to track progress in the implementation of the strategic plan. They will use this information to update

the agency’s action plan and report on the Strategic Plan’s progress to the Board of Health.

Board of Health – The Board of Health will receive updates twice a year at the June and December

meeting.

LiveWire – The Agency’s internal staff newsletter will be utilized as well to distribute updates, showcase

progress and celebrate success in the areas of performance management, workforce development and

quality improvement.

VI. Staff Training:

The Agency will train the staff utilizing the following online trainings:

• Embracing Quality in Public Health: A Practitioner’s Performance Management Primer

• CQI for Public Health: The fundamentals

All staff will complete the MPHI’s Embracing Quality in Public Health: A Practitioner’s Performance

Management Primer and submit their certificates to the Administrative Services Director. Members of

the PMC team and Administration team will also participate in advanced training through the following

modules:

• Performance Management Training Series – Great Lakes Public Health Training Collaborative

• CQI for Public Health: Tool Time – The Ohio State University’s Center for Public Health Practice

• CQI for Public Health: The Fundamentals – The Ohio State University’s Center for Public Health

Practice

Additional resources are made available through the Agency’s Website at Employee Links>Quality

Improvement. The Agency is currently working on a Workforce Development project which will seek to

improve the orientation and training of employees, as well as how this information is tracked. Through

this project, the Agency is seeking:

• To utilize an online training system which will track staff development needs and efforts to meet

those needs

• Provide opportunities for staff to learn about the core functions of public health practice and

additional topics (i.e., quality improvement, performance management, Blood Borne Pathogens,

HIPAA, data analysis, customer service, cultural competency, etc.)

• Increase competency of staff and provide opportunities for professional growth

• Increase amount of recognition and appreciation for staff.

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(See Strategic Plan, Strategic Direction #1, Goal 1.

VII. Resources

Branch-Hillsdale-St. Joseph Community Health Agency, Strategic Plan FY 2015-2019

Office of Accreditation and Quality Improvement, Michigan Public Health Institute,

https://www.mphiaccredandqi.org/

Center for Public Health Practice, Ohio State University, http://cph.osu.edu/practice

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