Public Health Accreditation Board President and CEO Kaye Bender Discusses Performance Management and Quality Improvement
In September 2011, the Public Health Accreditation Board (PHAB) launched the national public health department accreditation process for state, local, and tribal health departments. Accreditation helps state health agencies identify opportunities to deliver more effective and efficient public health services. It consists of adopting a set of standards, advancing quality and performance and measuring health departments’ performance against the standards, and recognizing health departments that meet the standards. It also provides health departments with tools to successfully implement programs and processes that will ultimately improve the health of the population the agency serves. As of February 2017, 19 state health departments and the District of Columbia Department of Health are accredited.
ASTHO spoke with Kaye Bender, PhD, RN, FAAN, president and CEO of PHAB, to discuss the importance of performance and quality improvement within the PHAB accreditation standards and measures.
Why should state health agencies care about performance management and QI?
We often use the analogy that running a health agency is like running a business. The population within the jurisdiction of a health agency expects to receive services from that agency to improve the public’s health. Performance management and QI provides state health agencies with the tools to measure the success of these services and recognize when they are not meeting goals so they can improve those services. Performance management and QI also encourage good governance and transparency within the agency while making the agency a better steward of the public’s money.
Who should lead performance management and QI work within health agencies? What is the role of leadership, programmatic staff, and performance improvement staff?
Performance management and QI works best and makes the most impact when the agency director champions this work and makes it a priority for the agency. The director should ask for and receive regular reports on the progress of agency-wide work, engage in the performance management and QI work him/herself, and institutionalize performance management and QI work across the agency. State health agencies can be too big for this, and if that is the case, the deputy can be an effective champion. The director or deputy should also encourage teams to do this work. This will help get staff buy in and input at all levels. Some health departments also have an office or division of QI and that’s a good complement to operationalizing the leadership’s intentions.
What is Domain 9 and why is it an important component of accreditation?
As stated in the PHAB Standards and Measures, “Domain 9 focuses on the use and implementation of performance management and quality improvement practices and processes for the continuous improvement of the health agency’s practices, programs, and interventions.” Domain 9 helps state health agencies make important decisions about what they want to achieve within programmatic areas and as an agency as a whole. We don’t want state health agencies to do performance management or quality improvement (QI) work just to do it. The goal of Domain 9 is to ensure that state health agencies are intentional about their priorities and goals. This intention should be agency-wide.
Performance management for PHAB, as it is found in Domain 9, is designed to reflect activities agencies are typically already doing administratively and within programmatic areas (e.g., enforcing public health laws or ensuring a competent and diverse public health workforce). It involves monitoring organization objectives over time to see progress or areas for improvement. Performance management should be systematic and consistent across agency programs and the entire public health system. QI activities arise when processes or programs identified from a performance management system need to be improved.
When states apply for accreditation and submit documentation to show conformity with the performance management measures in Domain 9, what challenges do you see?
State health agencies provide examples of the QI projects or activities that they have engaged in to improve processes and programs. However, there is often not a standardized approach to performance management and QI across the state health agency. In other words, performance management and QI is not always consistent across programs or divisions.
We also see state health agencies doing QI work before performance management work, when it should really be the latter. Ideally, state health agencies should measure and monitor their performance toward established goals and targets. If they are not meeting those goals and targets, they should then engage in quality improvement efforts to determine the root cause and improve policies, programs, and outcomes. When QI efforts precede performance management work, state health agencies risk engaging in unnecessary QI projects when there may be simple solutions that are just as effective (e.g., changing a vendor or hiring another employee). Some things that need to be improved do not need a full quality improvement process to make the necessary changes.
The national trend towards accountability and quality in state health agencies reinforces the increasing importance of performance management and QI initiatives in public health. Leveraging resources through QI tools and techniques, such as self-evaluation through a set of standards and measures, improvement cycles like plan-do-study-act, and data-driven performance management may contribute to improved health agency performance, and ultimately improved health outcomes.
This is the first of a series of blog posts focused on the QI initiatives taking place within state health agencies. Future blog posts will feature examples of specific QI tools, methodologies, and practices that state health agencies have found particularly useful in improving programs, processes, and initiatives.
Visit ASTHO’s Accreditation and Performance web page for quality improvement and performance management toolkits and case studies.
Leah Silva, JD, is senior analyst for quality improvement and performance management at ASTHO. She supports initiatives and projects related to state, territorial, and freely associated state health agency accreditation and quality improvement.