performance 12

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Turning Point

From Silos to Systems:Performance Management

in Public Health

Turning PointPerformance Management Collaborative

October 2002



Turning Point

Learning ObjectivesGain understanding of the

components of a performancemanagement system

Identify at least three benefits ofperformance management



Turning Point

Turning Point·s National

Excellence Collaboratives,2000-2004Funded by Robt. Wood Johnson Foundation

- States, communities, national partners² Combine collective experience, skills² Take next steps in transforming public health

Review of literature & current practice; analysis

Development of innovative modelsTesting and disseminating innovationEvaluation



Turning Point

Turning Point: NationalExcellence Collaboratives

Public Health Statute Modernization

Performance ManagementInformation TechnologySocial MarketingLeadership Development



Turning Point

Performance ManagementCollaborative (PMC)

Illinois*New YorkMontanaAlaska

New HampshireMissouriWest Virginia

* Lead State

7 Turning Point States



Turning Point

More PMC MembersTP National Program Office at Univ. ofWA/School of Public Health

National Partners² ASTHO² NACCHO² CDC

² HRSA² ASTHLHLO



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PMC Vision

W idespread use of dynamic andaccountable public healthperformance management



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PMC GoalsTo develop useful and feasible performancemanagement models for states

To stimulate national dialogue and consensuson performance management in public healthTo support the application of performance

management as a core discipline of publichealth practice



Turning Point

What Is PerformanceManagement?

The practice of actively using

performance data to improve thepublic·s health.Performance management can be

carried out at the program,organization, community and statelevels.



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Four Components ofPerformance Management

Performance StandardsPerformance MeasuresReporting of Progress

Quality Improvement



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Why Develop a PM System?To maximize public health·seffectiveness. This requires² More than measurement alone² More than standards alone² All four PM components to be

continuously integrated into a system ofperformance management



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Managerial Action

Qualityimprovementefforts

Policy change

Resourceallocation

change

Program change

Using Data to Achieve Results



Turning Point

Survey of PerformanceMgmt. Practices in States

Baseline Assessment

² Conducted by PHF² 47 of 50 States RespondedSurvey Asks About:² Use of Performance Targets, Reports² Impact on Program and Policy² Need for New Tools



Turning Point

Nearly All SHAs Have Some PerformanceManagement Efforts

However, only about half apply performance management efforts statewidebeyond categorical programs

Fi gure 1. A gencies or programs to which SH A s apply performance management efforts (N=47)

C ategor icalprograms

only43% (20)

None4% (2)

SHA w id e32% (15)

Local publ i chealth

agenc ies only4% (2)

SHA w id ean d local

publ ic healthagenc ies

17% (8)



Turning Point

R eporte d Pos it ive Outcomes:

Improved delivery of services²programservices, clinical preventive services, essentialservicesImproved administration/management²contracting, tracking/reporting, coordinationLegislation or policy changes

Performance Management Efforts R esult in Improve d

Performance for Three-Quarters of SHAs

Fi gure 19. Percentage of SH A s that reporttheir performance management effortsresulted in improved performance (N=41)

No24% (10)

Yes76% (31)



Turning Point

SHAs Most L ik ely to Have C omponents of PerformanceManagement for Health Status;

Least Lik

ely for HumanR

esource DevelopmentFi gure 8. A reas most and least likely to have performance targets, measures or standards, reports, andprocesses for quality improvement (Q I)/change, of SH A s that apply performance management efforts SH A wide, SH A wide and to local public health agencies, or to local public health agencies only (N=25)

Most L ik ely Least L ik ely

Performance Targets y Health Statusy Data & Information Systems

y Human Resource Developmenty Public Health Capacity

Performance Measures or Stan d ar d s

y Health Statusy Data & Information Systems

y Human Resource Developmenty Customer Focus and Satisfaction

PerformanceR

eportsy

Health Statusy Data & Information Systemsy Management Practices


Process for QI/ C hange y Health Statusy Customer Focus and Satisfactiony Management Practices




Turning Point

Top Three Mo d els/ F ramewor k s Expl ic itly Incorporate d by SHAs Into The ir Performance Management Efforts

Healthy People Object ives

C ore Publ ic HealthF unct ions

Ten Essent ial Publ icHealth Serv ices

S tates use a variety of performance management models/frameworks, in avariety of combinations



Turning Point

Most SHAs Have Performance Measures, Targets, an d R eports, Wh ile F ewer States Have

Process for Qual ity Improvement or C hange*Fi gure 15. Percentage of SH A s that have specified components of performance management for publ ic health capac i ty (N=25)

36 (9)

44 (11)

60 (15)

40 (10)

0

10

20

30

40

50

60

7080

90

100

Performance Targets Performance Measuresor Stan d ar d s

Performance R eports Process for QI/ C hange

P e r c e n

t a g e o

f S t a t e s

( N =

2 5 )

*Correlation analysis revealed that there is a comparatively weak relationship between having performance targets,performance measures or performance reports and process for quality improvement (Q I)/change. That is, in general,fewer states indicated that they did have a process for change, even though they indicated having performance targets,performance measures, or performance reports. This was the case for all areas of performance management studied(Human Resource Development, Data & Information Systems, Customer Focus and Satisfaction, Financial Systems,Management Practices, Public Health Capacity, and Health Status). Figure 15 illustrates this finding.



Turning Point

Most States Use Ne ither Incent ives nor D is incent ivesto Improve Performance

Fi gure 18. Percentage of SH A performance efforts that include incentives or disincentives to improveperformance (N=40)

Note: Respondents could choose more than one response, so total does not equal 100

63 (25)

8 (3)

20 (8)

13 (5)

30 (12)

0

10

20

30

40

50

60

70

80

90

100

Incent i ves for Agenc i es, Programs,

Div i s ions

Incent i ves for Staff D is i ncent i ves for Agenc i es, Programs,

Div i s ions

Dis i ncent i ves for Staff None

P e r c e

n t a g e o

f S t a t e s

( N =

4 0

)



Turning Point

F un di ng for Performance Management C hosen asNumber One Way to Improve States¶ Efforts

Fi gure 5. Types of aid identified as most useful to SH A s to improve SH A performancemanagement efforts, in rank order (N=47)

Number of SH A s that ranked eachanswer 1-3

1st 2n d 3r d 1. Funding sources/support 18 7 3

2. Detailed examples/a set of models from other states¶performance management systems 9 10 4

3. Consultation/technical assistance 3 5 7

4. ³How to´ guide/toolkit (tie) 4 5 34. A set of voluntary national performance standards for

public health systems (tie) 6 1 5



Turning Point

What Did We Learn?SHA performance management practices arewidespread, although often not system-wide orwith processes leading to quality improvement orchanges.SHAs report their efforts result in improvedperformance, with positive outcomes broadlydefined.

No single framework is used by most SHAs, andthere are insufficient data to inform leaders·choices in performance management approach.



Turning Point

Learning Projects

Nat·l PH Performance StandardsFlorida Quality Improvement ProgramBalanced ScorecardState-Based Standards in WA

Workforce Preparedness Centers



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More Learning ProjectsWI Performance-Based Contracting

MI Accreditation ProgramFoundation on Accountability HealthCare Quality Measures

Professional Credentialing



Turning Point

PHS M iss ionan d Purpose

----------------Philosophy

Goals"Core Functions"

Structural C apac ity-----------------

Information ResourcesOrganizational Resources

Physical ResourcesHuman ResourcesFiscal Resources

Processes-------------------The 10 Essential

Public HealthServices

Outcomes---------------Effectiveness

EfficiencyEquity

C onceptual F ramewor k of the Publ ic Health System as a Bas is for Measur ing Publ ic Health System Performance

MACR

O

C

ONTEXT

PUBLI

C

HE

ALTH

S YSTEM

Source: Handler A, Issel M, and Turnock B. 2001. A conceptual framework to measure performance of thepublic health system. Am J Public Health, 91:1235-1239.



Turning Point

PHS M iss ionan d Purpose

PhilosophyGoals

"Core Functions"

Structural C apac ity-----------------

Information ResourcesOrganizational Resources

Physical ResourcesHuman ResourcesFiscal Resources

Outcomes---------------Effectiveness

EfficiencyEquity

C onceptual F ramewor k of the Publ ic Health System as a Bas is for Measur ing Publ ic Health System Performance

Processes-------------------The 10 Essential

Public HealthServices

Source: Handler A, Issel M, and Turnock B. 2001. A conceptual framework to measure performance of thepublic health system. Am J Public Health, 91:1235-1239.

MACR

O

C

ONTEXT

PUBLI

C

HE

ALTH

S YSTEM



Turning Point

Four componentsof a performancemanagementsystem

Source: Turning Point Performance Management Collaborative,From Silos to Systems: Performance Management in Public Health(in press).



Turning Point

In a performancemanagementsystem...

All components shouldbe driven by the publichealth mission and

organizational strategyActivities should beintegrated into routinepublic health practices

The goal is continuousperformance and quality

improvement

Source: Turning Point Performance Management Collaborative.



Turning Point

T he Management Challenge9 of 10 compan ies fa il to execute strategy

Vis ion Barr ier: Only 5% of the workforce understandsthe strategy

People Barr ier: Only 25%of managers haveincentives linked tostrategy

Management Barr ier:85% of executive teamsspend <1 hour per month

discussing strategy

R esource Barr ier: 60%of organizations don¶t linkbudgets to strategy

Source:Balance Scorecard Collaborative, www.bscol.com



Turning Point

Future PerformanceManagement Issues

How do we move from ´silos to systemsµ?

How do we create a model quality improvementprocess that converts performance data intoinformation then action?

How can we inform and influence federalinitiatives to improve performance of publichealth?



Turning Point

What·s the Transformation?Widespread Use shifts from ameasurement to a more balanced andcohesive management model

Shifts from categorical to a systems-

wide scope targeting capacity,process and outcomes



Turning Point

Performance ManagementSeries of Reports

Literature ReviewBaseline Assessment Survey ofStatesFrom Silos to Systems: PerformanceManagement in Public HealthToolkit

performance 12

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