2015 annual performance measure report report-

Annual Performance Measure Report Report-

Kim Mueller, Health Officer

Fond du Lac County Health Department

[email protected]

2015

mailto:[email protected]

1 2015 Annual Performance Measure Report Fond du Lac County Health Department

March 24, 2015

Executive Summary 2015 is the first year that Fond du Lac County Health Department has had a live

Performance Measurement System. With the help of a consultant, procured

through grant funding, each program area identified 1-7 key indicators that they

felt represented key activities if not successfully completed would be a detriment

to their respective programs. We then identified measures, a description, a data

source, frequency of data collection and a person responsible for reporting the

data for each key indicator. All of the information is being entered into

formulated excel worksheets maintained by our Quality Improvement Manager.

We’d like to express a special thank you to Wood County Health Department for sharing this tool with

us.

Results were shown using Stoplight Charts:

Red=Not close to target. Additional resources, process improvements

needed

Yellow=Almost to target; interventions may be needed

Green=Reached and/or exceeded target

Measures that ended the year in the “Red Zone”, were added to the

Improvement Selection Matrix utilized during our first annual Quality

Improvement Planning week. Some of those measures will be addressed

through a QI Project. As you can see in the figure to the right, 34% of our

32 measures ended in the Red Zone, 22% in the yellow and 44% in the

green zone.

Throughout 2015 each program supervisor reported on the progress of

their measures at quarterly management meetings. Now that we have a complete year of data, I am

reviewing the key indicators with each program supervisor and asking the following questions:

1) Were the key indicators you chose true indicators of crucial activities in your program area? If

not what changes need to be made?

2) Are there additional indicators that you should be adding?

3) If your targeted goals were not met do you have strategies implemented to improve the process

to achieve the goals in 2016?

4) If you reached your goals in 2015 do you feel the target was too low, and if so what will your

new target be?

All of the data generated by answering the four questions above have been used to amend the key

indicators as necessary for 2016.

The following pages give a summary of each program’s key indicators, the description for each indicator,

details as to how we performed in that indicator, and the plan to either again adopt, amend or abort

that indicator for 2016. If the key indicator was amended or aborted, rationale was given.

Kim Mueller, Health Officer

This graph shows the percent of each

performance measure that ended 2015 in

each of the three zones.

34%

22%

44%


March 24, 2015

Contents Executive Summary ......................................................... 1

Contents and Programs Indicators at a Glance .............. 2

Administrative ................................................................. 3

Emergency Preparedness……………………………………………..4

Maternal Child Health…………………………………………………..5-6

Communicable Disease…………………………………………………7

Tobacco………………………………………………………………………..8

WIC……………………………………………………………………………...9

Save a Smile Dental…………………………………………….………10

Inspection…………………………………………………………………..11

Programs and 31 Key Indicators at a Glance:

Ad

min

istr

ativ

e •QI

•PHAB

•Partners

•Facebook

•Job Descriptions

Emer

gen

cy P

rep

ared

nes

s •Partners

•AAR/IP

•Staff Call Down

•ICS

Mat

ern

al C

hild

Hea

lth •First Breath

•Drug and Alcohol Referrals

•Depression Screening

•Postpartum Depression

•Safe Sleep

•Developmental Screening

•ED Visits

Co

mm

un

icab

le D

isea

se •Birth-2 Immunization

•Enterics

•Category 1 Disease

•Partner Services

•Lead

Tob

acco •Sales to

Minors

•Coalition Memberships

•New Policies

Wo

men

Infa

nt

and

Ch

ildre

n •Caseload

•Initiating Breastfeeding

•Exclusively Breastfeeding

Save

a S

mile

Den

tal

•Dentist Satisfaction

•Matching Funds-Child

•Matching Funds-Adult

•Patient's Satisfaction

Insp

ecti

on •Wells Tested


March 24, 2015

Administration:

Key Indicator #1 of 5

% of Quality Improvement projects initiated due to a Project Proposal being submitted as a result of not meeting a key indicator or program area target.

•Description: According to PHAB Standard 9.2; Measure 9.2.2.A, our Health Department must have 2 examples of quality improvement activities; one in a program area and the other from an administrative area. Management Team will review Project Proposals at quarterly meetings; supervisors will analyze tracking tool for areas to improve quarterly and report at management meetings.

•Target=2; Actual=3

•Year End-Will ABORT this key indicator.

•Rationale: This key indicator is no longer necessary as we will continue with the Annual Quality Improvement planning which will identify projects for areas needing improvement in all program areas.


Number of times the PHAB Standards and Measures are reviewed at staff meetings

•Description: To maintain and continually improve on familiarity of accreditation standards and measures, staff will review PHAB Standards and Measures regularly. Each program department will log and submit # quarterly to accreditation coordinator.

•Target=24; Actual-3 (Workforce Development Meetings)

•Year End-Will AMEND this key indicator.

•Rationale: The standards were mentioned, but not formally reviewed at management meetings. We will change this indicator to : # of times the PHAB Standards and Measures are discussed in depth including ideas for documentation at any staff meeting or training.


% of job descriptions that are complete and include core competencies

•Description: PHAB Standard 8.2; Measure 8.2.1.A; "Health departments must have a competent workforce with the skills and experience needed to perform their duties and carry out the health department's mission….Employee training and core staff competencies assure a competent workforce."

• Target=100%; Actual=100%

•Year End-Will ABORT this key indicator in 2016.

•Rationale: All job descriptions are now in the appropriate format.


% of partners the Health Department engages to promote evidence based public health policy

•Description: Engaging partners in public health practice and policy assures strong, effective health programming community wide.

•Target=5; Actual=22

•Year End-Will ABORT this key indicator for 2016

•Rationale: Number of partners is not easily quantified and ever evolving.


# of Facebook Followers

•Description: By increasing number of followers we will be reaching more residents with crucial health information and will be able to keep them informed in the event of a public health emergency.

•Target=400; Actual=283 at Year End

•Year End-Will ADOPT this key indicator again for 2016.


March 24, 2015

Emergency Preparedness


% of partners who have signed the Public Health Emergency (PHEP) Record of Review.

•Description: Broad partners are engaged in planning. Updates are made to the PHEP and Mass Care Plan and must be reviewed with all partners involved.

•Target=100%; Actual=31%

•Year End-Will AMEND this key indicator for 2016.

•Rationale: Instead of using the signature page, which often was forgotten, will use meeting minutes for proof of review.


At least one HSEEP compliant After Action Report (AAR) and Improvement Plan (IP) will be completed within 60 days of event/exercise.

•Description: A completed HSEEP-compliant After Action Report with Improvement Plan posted to the PCA Portal within 60 days of event is a core objective of the PHEP grant.


•Year End-Will ADOPT this key indicator again for 2016


% of staff who acknowledge receipt of receiving a call through the Staff Call Down Lists

•Description: The Supervisor Call Down or Calling Tree will be used to contact all public health staff needed to respond to a public health emergency. Acknowledgement will be through live answer or returned call/email/text.

•Target=100%; Actual 24 of 41 staff =59%

•Year End-Will ADOPT this key indicator again for 2016, using the Supervisor Call Down


% of staff who have completed ICS training required for their emergency response roles on the Mass Clinic Plan.

•Description: In order to assure that all staff are adequately trained in ICS for the roles they are assigned, we will identify staff roles in the Mass Clinic ICS 207 and designate ICS level needed.

•Target=100%

•Actual 40 of 44 staff=91%



March 24, 2015

Maternal Child Health


% of women enrolled in PNCC who smoke and are enrolled in First Breath

•Description: First Breath is a statewide program targeted at perinatal tobacco cessation. It has been shown that women who are enrolled in this program during pregnancy, decrease or stop smoking at a higher rate than those not enrolled in this program.

•Target=50%; Actual=2.75% (Measured Quarterly; Actual is the average for the year)

•Year End-Will ADOPT this key indicator again for 2016. We will also ADD another measure-% of pregnant women enrolled in PNCC who smoke who are offered First Breath.

•Rationale: The addition of key indicator 1A is to show that we are not ignoring the tobacco use of our clients. Key indicator measures the enrollment into First Breath, but does not capture the clients who are offered, but decline First Breath. Adding this key indicator will capture all PNCC clients; those who are enrolled and those who decline. If a client is not offered First Breath, this will be captured in the measurement of 1A.


% of women enrolled in PNCC who report current alcohol or drug use who receive a referral to drug and alcohol services.

•Description: Alcohol and/or drug use during pregnancy can have serious health implications to a developing fetus as well as a newborn baby. Many of these health complications can have devastating, lifelong effects. Early referral and access to drug/alcohol programs will decrease or eliminate serious health effects to mother and child. Referrals made to Agnesian Alcohol and Drug Tx Program.

•Target=100%; Actual=33% (Measured Quarterly; Actual is the average for the year)



% of PNCC clients who are screened for depression prenatally

•Description: The Edinburgh Postnatal Depression Scale tool is used to assess depression during the 1st and 3rd trimester as part of a mental health initiative. Referrals and/or resources are made available to clients who are identified as at risk for depression. Mental health is linked to overall health and positive outcomes for pregnancy and parenting.


•Year End: Will AMEND this key indicator in 2016. % of Depression screens completed prenatally at time of admission into PNCC by RN.

•Rationale: The EPDS depression screen is completed (or should be) at the time of admission into PNCC. The initial PNCC assessment is often started by WIC staff, but they do not complete depression screens. Our 2015 data may not have been an accurate picture of depression screens completed because the RN completes it and if the assessment from WIC staff has already been entered into SPHERE, the screening score may not be captured into SPHERE (data collection tool). Amending this will allow us to capture accurate number of screens completed as well as determining compliance of data entry of depression screen scores.


March 24, 2015

Quality Improvement: Key Indicator #1 and #4 have

been added to the 2016 Annual Quality Improvement

Plan for process review and improvement.

Maternal Child Health (cont’d)


% of eligible postpartum moms who are screened for postpartum depression

•Description: Postpartum depression is a leading complication of childbirth. A client may not have been part of PNCC, but is referred during the postpartum period. The standard best practice is to assess for postpartum depression after 2 weeks of birth, using the Edinburgh Postnatal Depression Scale.

•Target=100%

•Actual=49% (Measured Quarterly; Actual is the average for the year)

•Year End: Will ADOPT this key indicator again in 2016.


% of clients who receive safe sleep education at the postpartum visit will verbalize an increase or change in knowledge.

•Description: This is part of the safe sleep initiative, providing client education of safe sleep practices as well as a crib referral to those in need of a safe sleep environment.

•Target=100%




Maintain 100% of POCAN children who receive developmental screening at age related intervals using the PAT curriculum.

•Description: PAT is Parents as Teachers curriculum which uses the ASQ-3 and ASQ-SE tool for assessing development at age related intervals.


•Year End: Will AMEND this key indicator in 2016

•Rationale: The new indicator will be % of Children in Parenting (POCAN) program who complete an ASQ-SE using the PAT curriculum. PAT is Parents as Teachers curriculum which uses the ASQ-3 and ASQ-SE tool for assessing development at age related intervals. As part of a community coalition effort to promote social/emotional development in young children, increasing screening of children at risk for potential delays in their social/emotional development can lead to earlier intervention. The ASQ-SE is the screening tool for assessing social/emotional development.

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Install


Maintain 0% of POCAN childen who have an ER visit for an injury.

•Description: The POCAN programs mission is to increase and improve parenting skills as well as prevent injury and promote safety in those families identified to be at risk.


•Year End: will ADOPT this key indicator again in 2016.


March 24, 2015

Communicable Disease:


% of FDL County children who are compliant with 4 DTaP, 3 Polio, 1 MMR, 3 Hib, 3 Hepatitis B, 1 Varicella, and 4 Pneumococcal Conjugate (PCV) vaccinations by their second birthday

•Description:ACIP Recommended vaccines for children by age 2: 4 DTaP, 3 Polio, 1 MMR, 3 Hib, 3 Hepatitis B, 1 Varicella, and 4 Pneumococcal Conjugate (PCV).

•Target=75%

•Actual=73% (Measured twice yearly; Actual is at year end)

•Year End-Will ADOPT this indicator again for 2016.

•Rationale: We are in the process of sharing these results with area providers, and implementing additional strategies to improve our results. Having a well-immunized population is a crucial public health strategy.


% Venous Blood Lead Levels (VBLL) greater than 10 micrograms per deciliter

•Description: WI Childhood Lead Prevention Program.

•Target=100%

•Actual=100% (Measured Annually)

•Year End: Will AMEND this key indicator for 2016. Indicator will be modified to 5 micrograms/deciliter.

•Rationale: This change is consistent with best practices for lead poisoning prevention, and better reflects the range of interventions provided by the Health department.


% residents with enteric diseases are contacted withing 3 business days after posted in WEDSS system

•Description: Timely investigation can prevent others from becoming ill. Wisconsin Division of Public Health Communicable Disease Surveillance Guidelines indicate that Local Health Departments are expected to initiate contact within 72 hours for enterics.

•Target=100%


•Year End: Will ADOPT this key indicator again for 2016.

•Rationale: Communicable disease follow up is a state-mandated function of the local health department, and vital to the health of the community.


% of Category 1 Diseases that have follow up within 24 hours of initial report

•Description: Wisconsin Division of Public Health Communicable Disease Surveillance Guidelines indicate that Local Health Departments are expected to initiate contact within 24 hours for Category 1 Diseases.

•Target=100%


•Year End: Will ADOPT this key indicator in 2016

•Rationale: While the incidence of Category 1 diseases remain low, these diseases are among the most serious threats to our citizens (Examples include active/infectious TB, measles, and novel diseases like Ebola)


% of Partner Services referrals initiated within one week of notification

•Description: WI Partner Services Guidelines state that contact is initiated within one week of referral.

•Target=100%



•Rationale: Partner services is conducting follow up and contact investigations with citizens who have HIV; rapid intervention and referral to medical services is a significant factor in reducing spread of infection, and improving quality of life to the case.


March 24, 2015

Tobacco


% of organizations memberships into the Multijurisdictional Coalition (MJC)

•Description: CDC Best Practice for Comprehensive Tobacco Control Programs-2014 is an evidence based guide to help states plan and establish effective tobacco control programs to prevent and reduce tobacco use. Networked Partnerships: Strategic collaboration is crucial at the national, state and local levels. These partnerships can be made between multiple types of organizations and content areas to promote progress toward health goals. Although many partners are working towards a common mission, they may fill different roles. In this way, networked partnerships can work to ensure the accomplishments of all activities necessary to achieve public health goals.

•Target=43%

•Actual=9%



# of new policies addressing smokefree or tobacco free

•Description: CDC Healthy 2020 Objectives include Social and Environmental Changes: Reduce the proportion of nonsmokers exposed to secondhand smoke; Increase the proportion of persons covered by indoor worksite policies that prohibit smoking.

•Target=2

•Actual=3



% of tobacco sales to minors

•Description: CDC Best Practices Comprehensive Tobacco Control Program: Recommendations for Preventing Tobacco Use Among Youth/CDC Healthy 2020-Mobilizing the community to restrict minors' access to tobacco products in combination with additional interventions (stronger local laws directed at retailer, active enforcement of retailer sales laws, and retailer education with reinforcement).



•Also ADD an additional key indicator-100% of sales to minors will result in a citation being issued to the tobacco retailer who sold the tobacco to a minor. The type of product sold will also be documented: smokeless tobacco, cigarettes, little cigars, or e-cigarettes. This information could influence educational materials sent to tobacco retailers and their employees in hopes of decreasing tobacco sales by type.

•Rationale: Measures the number of employees who receive a citation for an illegal sale of tobacco to a minor under WI State Statute 134.66.


March 24, 2015

Women Infants and Children (WIC)

ADDITIONALLY: WIC will be adding another key indicator:

% of total breastfeeding peer contacts that were successfully responded to by breastfeeding moms.

Rationale: WIC remains committed to improving breastfeeding rates by continuing to employ two part time

Breastfeeding Peer Counselors, one who is bilingual to communicate to Spanish speaking participants.

Breastfeeding Peer Counselors provide mom-to-mom support through phone calls, home and hospital visits, text

messages, newsletters, and in-office support.

The peer counselors are available nights and weekends so women have support when they need it. All pregnant

and breastfeeding women receive contact from a breastfeeding peer counselor. In 2015, 75% of the total contacts

made by breastfeeding peers were responded to by breastfeeding Moms.


% of WIC caseload at or above WIC Grant

•Description: WIC is one of the nation's most successful and cost-effective nutrition intervention programs. Studies demonstrate that the WIC Program protects or improves the health/nutrition status of low-income women, infants and children.

•Target=97%

•Actual=98% The average caseload for 2015 was 96% totaling to 1720 participants on average. For two quarters the goal was met and for two quarters the goal was not. Caseload numbers can be affected by a variety of factors such as weather, personal time constraints and scheduling conflicts. Since the funding is adjusted based on the caseload, the program continues to be a cost effective program that focuses on achieving a healthier community through nutrition education and by providing healthy foods.

•Year End-Will ADOPT this key indicator again for 2016. The caseload for 2016 has not been adjusted and is expected to remain the same. WIC will continue to monitor the trends in the caseload for 2016 as it provides insight for what percentage of the caseload is being reached.


% of WIC mothers initiating breastfeeding

•Description: WIC programs work within the community to establish breastfeeding as the norm for infant feeding. Healthy People 2020 goal is that at least 81.9% of infants are breastfed in early postpartum and 60.5% percent will breastfeed until at least 6 months.


•Year End: Will ADOPT this key indicator again for 2016. It was found that there were some discrepancies in the documentation of breastfeeding initiation which may have caused numbers to be lower than expected; suspect that numbers were higher than what the data shows. Will continue to track next year.


% of WIC infants breastfeeding exclusively at 3 months of age

•Description: Exclusive breastfeeding is the ideal nutrition and supports optimal growth and development for the first six months. Exclusive breastfeeding is defined as the provision of breastmilk only, no other liquids or solids. Healthy People 2020 target for exclusive breastfeeding is 44.3% at 3 months and 23.7% at 6 months.

•Target=44%

•Actual=43% (Measured Quarterly; Actual is the average for the year) The state average is 44% for infants that are exclusively breastfeeding at 3 month of age. WIC’s goal was to strive to meet the state average for infants exclusively breastfeeding in 2015. Quarter 1 =40%, Quarter 2=42%, Quarter 3=45%, Quarter 4=45%. WIC constantly improved each quarter until the goal was met and then the program was able to continue to exceed the goal.


•Rationale: Exclusive breastfeeding rates continue to be an excellent indicator for long term breastfeeding success and thus it is important to continue to collect and monitor this data.


March 24, 2015

Save A Smile Dental


Amount of available funds to match medical assistance reimbursements for Child SAS for the next year commited by October 31, 2015.

•Description: SAS strives to meet the basic dental needs of FDL County residents with Medical Assistance. According to the Provider Agreement "dentists will be compensated an amount equal to 200% of the maximum allowable fee reimbursed under MA or usual and customary charge for such service, whichever is less". Funds need to be secured annually and then continually monitored to insure adequate levels for reimbursement for Children SAS.

•Target= $250,000

•Actual=$170,000



Amount of available funds to match medical assistance reimbursements for Adult SAS for the next year commited by October 31, 2015.

•Descripiton: SAS strives to meet the basic dental needs of FDL County residents with Medical Assistance. According to the Provider Agreement "dentists will be compensated an amount equal to 200% of the maximum allowable fee reimbursed under MA or usual and customary charge for such service, whichever is less". Funds need to be secured annually and then continually monitored to insure adequate levels for reimbursement for Adult SAS.

•Target=$100,000

•Actual=$194,000



# of patients/parents indicating satisfaction with the services provided.

•Description: Surveys will be given at the dentist office after the visit.

•Target=100%


•Year End: Will ADOPT this key indicator again in 2016. Will also create and implement an incentive program for the dental office staff to increase the number of surveys collected.


% of 39 contracted dentists indicating satisfaction with the Save a Smile dental program.

•Description: To ensure participating in SAS is going smoothly for contracted dental provider and their office staff. An annual provider survey, and program coordinator makes frequent calls and visits to dental office to get input.

•Target=100%

•Actual=100%



March 24, 2015

Inspection:


% of contacts made with well owners who have used us to test their water and received unsafe bacteria and/or nitrate results.

•Description: Drinking unsafe water due to high bacteria or nitrate levels is a health hazard.

•Follow-up educates the resident on the health concerns and offers recommendations of rectifying the problems

•Target=100%

•Actual=100% (total was 19)

•Year End-Will ABORT this key indicator for 2016.

•Rationale: This indicator achieves 100% target because it is part of the routine process of lab procedures to achieve greater awareness of water quality and health impacts to the residents of Fond du Lac County and surrounding areas.

•2 New Indicators for 2016:

•# of Licensed Establishments receiving routine inspections in a timely manner.

•Rationale: Agent contracts require annual inspections to be completed in a timely manner.

•# of radon test kits distributed annually by various offices in Fond du Lac County with elevated results that receive additional follow-up information from Health Dept staff.

•Rationale: Each year home owners purchase radon test kits from municipal offices in Fond du Lac County. Data collected from online results would be assembled to produce more accurate, updates, maps and information for public use in determining radon levels throughout the community. Follow-up calls/letters to the home owner will provide options of reducing radon levels in the home.

2015 annual performance measure report report-

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