Cdc performance Improvement Managers Network Call September 27, 2012 Today’s Presenters

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Engaging Leadership and Gaining


CDC Performance Improvement Managers Network Call

September 27, 2012

Today’s Presenters: Jim Pearsol, Association of State & Territorial Health Officials

Jessie Baker, Vermont Department of Health

Kristin Adams, Indiana State Department of Health

Deb Koester, OSTLTS Consultant

Moderators: Melody Parker & Trina Pyron, CDC/OSTLTS

Kelly (Operator): Welcome and thank you for standing by. All lines are currently in a listen-only mode. Today’s conference is being recorded. If you have any objections, you may disconnect at this time. Now I will turn the call over to Ms. Melody Parker. Ma’am you may begin.

Melody Parker: Thank you, Kelly. Greetings and salutations everyone. This is Melody Parker and welcome to the September Performance Improvement Managers Network call. I am with the Office of State, Tribal, Local and Territorial Support and I am joined here today by colleagues from OSTLTS. Trina Pyron and I will be co-moderating this call today. Thanks so much for joining us. This is our eighth call this year. As most of you know, the PIM Network is indeed a forum that is intended to support all performance improvement managers and learning from each other as well as from partners and other experts. These calls are a way for members of the Network to get to know each other better, learn about best practices and share information about resources and training opportunities related to our work in quality improvement and performance management. The session on engaging leadership and engaging buy-in from the 2012 NPHII grantee meeting this past May was so incredibly popular that those of you who missed it will now have the opportunity to hear it. So on today’s call we are pleased that we are able to bring the presenters of that session together again.

But, before we introduce our speakers I’d like to review some of the technological features of today’s call. For those of you who are not able to access the web portion of today’s call, you can refer to the slides that were e mailed to you yesterday. For those of you on the LiveMeeting site, you will see the slides on your screen. You can also download these slides via the icon at the top right of your screen. You’ll see it. It looks like three very tiny sheets of paper up there on the right. If you are on the web, you’ll also be able to see other sites participating in today’s call by looking at the attendees link at the very top of the page on the same toolbar there on the left. We have two ways today to take your questions and your feedback. First, you can type in your questions and comments at any time using the Q&A box which you can find by clicking Q&A in the toolbar at the top of your screen. Second, we’ll also open the lines for discussion after our presenters have completed. So please, mute your phone now by either using your phone’s mute button or by pressing star 6 on your phone’s keypad. Please note that we’ll announce the identity of those submitting questions via LiveMeeting. If you’d prefer to remain anonymous to the group in posing your question, please remember to type “Anon” either before or after your question. Today’s call will last approximately one hour. The call is being recorded and the full presentation will be archived on the OSTLTS PIM Network web page.

We’ll be conducting a few polls on today’s call, and we have our first poll right now. I’ll introduce the poll question and when I announce that the poll is open you may cast your vote by selecting your response with a mouse click. The first one gives us some idea of who’s participating on the call today. Please indicate your affiliation. Are you with a state health department? A tribal health department? A local health department? A territorial or United States-affiliated Pacific Islands health department? A national public health organization? Or some other organization which we have not previously named? Please continue to cast your votes. This poll is now closed. Our next question is going to give us an idea about how many people are on the line today. So how many people are in the room there with you? Is there more than 10 of you? More than five? Three to five? Two people? Or are you the one and only on the line today? Cast your vote now. All right, this poll is now closed. Thanks for participating. Of course, we’re always going to want to hear your feedback about today’s call, so in addition to these first polls we’re going to have one at the end of the hour where you can tell us what you thought about the call today.

Now, let’s move on to our panel of speakers. After 30 years of public health service in both governmental and academic settings, Jim Pearsol is in his sixth year as chief program officer for ASTHO’s accreditation, performance and quality improvement, survey, research, evaluation, leadership, work force and health informatics portfolio of projects. Deb Koester currently provides support to OSTLTS at CDC on a number of initiatives. She’s obtained her Master’s degree in nursing as a nurse practitioner and prior to that spent many years coordinating clinical research and program evaluation. Her background in public health includes significant work that aligns with NPHII goals including performance management, quality improvement, accreditation readiness, health improvement planning and strategic planning. Deb Wilcox is the director of planning and health care quality at the Vermont Department of Health. She works closely with the department’s performance improvement manager, who is successfully implementing a new performance and management system in the department. And as my colleague Trina Pyron has reminded me, Deb Wilcox is not joining us today. She is ill and she has been replaced by our performance improvement manager, Jessie Baker from Vermont, so with my apologies to Jessie. (Laughter) And then finally Kristin Adams is the director of the office of public health performance management at the Indiana State Department of Health. She oversees accreditation, performance management and quality improvement efforts at ISDH. She was a principal investigator in Indiana for the multi-state learning collaborative grant and is currently the principal investigator for the National Public Health Improvement Initiative Cooperative Agreement from CDC to improve the performance and outcome of ISDH. Jim and company, the floor is now yours. Please talk to us.

Jim Pearsol: Thank you, Melody, and greetings everyone. It’s good to be on the call with you today. We’re looking forward to both presenting some thoughts for your consideration and hearing your questions and comments and your own observations. The kinds of perspectives that we could bring on engaging leadership are many. We’ve covered a few and we’ll look forward to the dialogue when we get there. We’ll make our presentation and then I believe we’ll be opening up for questions. So the first slide here in front of you is the outline and objectives. Our intent is to provide some perspectives on engaging leadership and gaining buy-in and then like David Letterman might do but not nearly as funny, top 10 questions to consider on engaging leadership and gaining buy-in. So the objectives are to develop an understanding of ways in which performance improvement managers can be engaged department-wide, community-wide in leading the way, to understand how these ideas can be adapted to suit the needs of your health department, so what is the particular nuance that if it rings a bell or presents a challenge for you, and then to create a list of possible action items for implementing and improving ways for engaging leadership. We would ask you to take your thoughts and go back to your team and use this presentation to create such a list of action items. Next slide, please.

This is our title slide, perspectives on engaging leadership and gaining buy-in. So let me talk first about context. Next slide, please. Key issues. Demands are increasing while funds are decreasing. There is no surprise there for any one of you on this call. Historically speaking, when we think about emerging areas of practice in public health that were considered emerging in 2001 are now widespread. What am I referring to here? This would be the entire preparedness program that drives much of the work of your department. The creation and implementation of minority health programs in state health agencies particularly. And then the whole increase in flu monitoring and exotic flu preparations, including community engagement, are now widespread and very common kinds of activities. And very few areas of practice are decreasing. Things like arthritis has gone away. Some other disease of the month programs have gone away but not many. And even though we do see some integration, the workload has simply continued to grow in our area of business. The economic recession means increased needs in the population, so the demand not only in terms of programs but in individuals and groups of people with regarding to their needs are affected by this economic recession. Next slide, please.

Another way to think about this is in terms of categorical funding. Those of you in state health agencies and in local health departments and tribal health departments are familiar with categorical funding. But what that doesn’t always allow us to prepare for are issues related to social determinants of health, those things we know that sort of underlie our work but were not really particularly funded necessarily to address directly. The fact that we’ve had a fragile and underfunded infrastructure. I want to tip my hat to OSTLTS and the NPHII program for really stepping in and helping fill this gap in our needed services. And then I think the idea of the aging workforce in need of training. The times, they are a-changing, and how we do our business, with whom we do our business, is rapidly evolving. How can we take our different funding streams and address these kinds of issues? And then certainly the question on everyone’s mind in this election year is what’s the story going to be with regard to sustainable funding? We know that there have been efforts to repeal the Affordable Care Act and that has created uncertainty for us. Federal budgets have some uncertainty about them. The whole question about this word, this exotic word called sequestration, managing the deficit; all have with them the challenge of what gets cut in order to create more of a balance with regard to funding of government. And then certainly if you’re working in a state, local or tribal health department you’re already experiencing cuts. I’ve often told the story of the period from 2004 to 2006 when we saw cuts in state health departments and I was worried at that time, and then seeing the ones that you’ve seen are twice what we wrestled with back in those years, and so my heart goes out to you in that regard. So these kinds of key issues are driving some of your thinking about how do I get engaged and make this program work with my leaders? Let’s go to the next slide.

Well, here’s the story. It’s another new normal for public health. That phrase, “the new normal for public health,” comes from 11 years ago when preparedness took off, emergency preparedness was called the new normal as we did 365, 7 days a week, 24 hours a day public health. We are facing this federal, state and local quote, budget pandemic, I would say. And it’s really—if there’s nothing about this is a challenge or an opportunity, I don’t know what better is in terms of rising to the occasion. So we’re using now and seeing new strategies for this new public health. Adjusting public health to health reform. How are we engaging the primary care? How are the patient-centered medical home model integrating with your population-based kinds of work? We’re seeing a National Prevention Strategy. Hopefully we can align around that strategy to really see transformation and change in public health. We have lots of clever approaches like integration in chronic disease as a way to become more efficient and effective in our chronic disease program. The idea of Dr. Frieden’s winnable battles. Very clearly articulated programs that work, that are public health-based and can even help inform policy or policy-makers. Certainly performance accountability and QI are front and center. I think this is a tremendous evolution in public health and this really provided us a great opportunity. The current work coming really out of the Center for Cross-Jurisdictional Sharing funded by RWJ at the Kansas Health Institute really brings to the foreground regionalization and cross-jurisdictional models. Given all the issues I mentioned before, whether that’s around sustainable funding or simply integration and revision of programs, how we share services with our neighbors has really become an important conversation for some. And then health technology data and information is really quite transformative for us. And are we able to convert our surveillance program into something that seamlessly connects with the health care system so that we can look at disease spread and the like in new and novel ways? And then certainly new partnerships. A community transformation grant introduced this. Now, if you think back about how we’ve always talked about public health, we said we’re just one of a piece of the picture of the public health system in the country. Well, this really brings it into sharp focus that we are in a position to really be guided to partner with these kinds of partnerships nationwide. But this is the context that I think we’re in. I’d like to pause on this slide, Melody, for just a second and then turn it over to Kristin first, and then Jessie, to see if there’s any comments you want to make with regard to context of the key issues I presented or this new normal for public health. Kristin?

Kristin Adams: Sure. I think as we, as the Indiana State Department of Health has started to look at things, you know, we are 70% federally funded. So we’re very little on the state side so we are looking at the context of what happens when the federal cuts start coming down the pike. So we’ve started reaching out to new partnerships even across state agencies. So we have a new QI project that’s going to happen between us and Homeland Security to help increase that data and information sharing while also reducing the stress of whose role is what. So, you know, we’re always being challenged right now of how we’re going to move things forward, not necessarily using less people but using people more strategically along with our partners from state agencies to other partners whether it’s a non-profit or another business sector. And so that’s where we’re approaching it.

Jim Pearsol: Great. Thank you. Jessie?

Jessie Baker: Yes. I think your list was very comprehensive. The only thing I would add here in Vermont is some more, similarly to the cross-state agency work referred to earlier. I think with the health reform contract in Vermont and a lot of political will and political energy around local health reform initiatives, we are looking at those state partnerships that we have within our agency, our parent organization, our Agency of Human Services, as well as across the rest of state government to look at how we kind of align our efforts and make sure we’re all working in the same direction around the greater public health.

Jim Pearsol: Thank you very much. So in this issue of context, leadership opportunities are present and need to be captured, and especially as we’ve heard here in cross-cutting kinds of ways. So Melody, if we could turn to the next slide. It’s entitled creating value. I’m going to talk about three frameworks within which you can gain leadership buy-in. There are many more. These are not exclusive. They are complementary. But I want you to be thinking about what is the framework you’re appealing to as you try to make the case for this performance improvement work that you’re doing in the agency? So this model of creating value comes from Harvard, a book about creating public value by Mark Moore. In fact, Dr. Judy Monroe when she created OSTLTS used this as a framing concept for why OSTLTS exists. And so this idea of keeping these three points of this triangle in balance. What are we doing to define the value for the public that we serve? Are we producing value for the public? Are we articulating that value? Are we able to attract support and money? Do we have legitimacy with our legislators? Do we have the support in terms of funding based on having articulated that value? And are we able to sustain the operational capabilities that allow us to deliver the value as expected by the legitimacy and support we gained? So if you’re looking for a framework to talk to your leadership about, it’s that balance between these three kinds of things that really are the framework within which performance management occurs. But let’s look at another very obvious one. Next slide, please, Melody.

We now have national public health accreditation with the Public Health Accreditation Board. I know each of you is funded to talk about the ways you are preparing your agencies for accreditation readiness. It’s a delightful blueprint for public health, a framework for how you can put your agency to the test of how are we measuring up. I am particularly enamored of the opportunity that’s in Domain 9, which is really the QI and performance improvement category, and so anything you’re doing in terms of performance improvements council across your agency or a quality improvement plan really is a very concrete way for you to speak to (audio skips) across your agency, not just a single leader of your agency but across the leadership team as a useful device. Next slide, please.

This is just another perspective. Think of this as sort of a tactical approach that complements the previous two slides. This slide called perspectives presents to you what a balanced scorecard really looks like. And they are lenses within which you can view and assess your performance in, quote, a balanced kind of way. So what are you doing to provide customer value, very similar to that public value in the slide two slides before? How do we ensure excellence in our internal processes? Are we getting the work done in an efficient and timely manner in order for the service to be delivered? How do we enable our folks to adapt and grow and change? If I would say one thing about this new normal on public health, it’s it requires an agility by departments, governmental agencies like public health that are usually not thinking of themselves as agile groups, and how we’re preparing our staff to function in that way. And then are we being a good steward of the finances invested in us by our populations that use the legislature as a device for making that happen? You’ll see in the center up there, that vision mission and strategic themes. That’s important though these tactics are really going to be the drivers that help you make the case about how successful you’re being. So these are three different frameworks, these three sets of slides I’ve just presented to you. And I’d like to pause for a second and ask first Kristin and then Jessie, what are your thoughts on frameworks like these as useful tools for engaging leadership and gaining buy-in? Kristin?

Kristin Adams: Yeah. My experience is that you have to—you have to be able to paint the picture. And my staff always asks me, give me the 30,000-foot level and then get me to the 3-foot level. And so I’ve been able to take our performance management system from what we stand for, what our vision and mission is, to what—all the way through all our strategic plan, through our performance matrix that I’ve partnered with our office of management and budget to create because they required it. Everything is tied back to the strategic plan and then it drills all the way down into what are those activities we do day in and day out when you can’t show obesity dropping at a massive rate. What are we doing to at least address those issues? And then it gets down into personal performance. So it gets all the way from the system to personnel. And so you have to be able to point that because everybody has to understand that their job drives the overall good of the agency.

Jim Pearsol: Thanks on point. Jessie?

Jessie Baker: Yes. I agree with what Kristin said. I think in terms of framework, I think the three here that you present are great. I think the real benefit that we’ve had in Vermont is being able to lay out a very clear framework, whether it’s around the triangle, around the creating value system or around a balanced scorecard system, whatever it is, having a very clear, branded, concise framework that you can sell to leaders as their own and then they can go out and sell with their higher-ups or back down with staff, and then filling in the details as you go. So kind of giving people that full picture in the beginning so they know where you’re going and then filling in the smaller, you know, PDSA cycles, accreditation readiness, those details that go along with the larger framework as Kristin alluded to starting with, you know, where you’re going as a health department, your population priorities, all the way down to each individual employee’s performance.

Jim Pearsol: Great. Thanks. Melody, let’s go on to the next slide. And really talk about these ideas that Kristin and Jessie have just presented in a little more detail. So the slide in front of you is organizational structure. You know, this is sort of the formal presentation of the department. It has its varying layers and your ability to understand the interplay among those three layers, both in terms of the formal process and I think just as important if not more important the informal pathways that an organizational structure really works and functions. So not just thinking of this as a straight upward or straight downward process, we like to think of this as really more of a matrix kind of model where we know that we have this structure in place but—next slide, please. Engaging leadership and buy-in is really around doing a matrix approach to your engagement. Now this is a lot to ask of you but I have always found in my own career that managing from below is the real skill of professional development rather than managing from above down. And so you’re in that sweet spot. (Laughs) It might not feel like a sweet spot all the time, but you are, with regard to engaging leadership and buy-in. So what is the message at the organizational level? What’s in this for us? I think you’ve heard from Kristin and Jessie saying that it belongs to all of us so that principle of engagement and inclusiveness is quite crucial. With regard to management level, what is it that they are doing to clear the way? I mean, one of the reasons they’re in that position is not to be a gate-locker or keeper but a gateway to how change occurs and what tools, techniques, opportunities are you giving them to sort of make that happen so that systems go more smoothly? And then I think at the individual level that’s absolutely crucial. I’m a firm believer that leadership doesn’t reside in the position ones hold but leadership talents and skills lie within the individual and those individuals can be anywhere within your organization and are waiting for an opportunity to step up and make a difference. So if you conceptually think about these two slides together as sort of vertical and horizontal then you really have come to appreciate that there is a matrix model here to gaining leadership support and buy-in. So next slide, please.

This just begs the question, so where do you fit in your organization? So I want you to ponder that question as we finish up this presentation and come to the Q&A session later and let us know your thoughts. How do I fit in and how do I relate to this matrix model? So next slide, please. Key elements of success. The outcome of the kind of work you’re talking about here should be demonstrate visible leadership by your agency senior staff. You can do a lot but you can’t get all the way there without that articulation of visible support from your leadership about this is the path we’re going. Talk about QI as scalable. It can relate to large policy shift kinds of issues, you know, are we going to modify our restaurant inspection program in a major way, or it can be quite narrow and relate to how do we improve contract processing and train the program staff and the fiscal staff. So QI is quite scalable and work in any kind of problem that you have in front of you both big and small. And it creates a line of sight for everyone. What’s the agency’s part, division, unit and staff role in QI? I need to be able to connect (audio skips) a receptionist in the environmental health program. I need to be able to connect to what the department’s aim is all about and how what I’m doing every day is making that happen. It’s really useful to celebrate and identify champions at every level of the agency. I don’t know, I’ll be interested to hear from you what your view on how you recognize champions and who has taken a problem and turned it around using QI. I mean absolutely, as you already are doing, linked to accreditation readiness and use QI to close gaps and issue documentation you need to make your case for accreditation. So let me pause after these sort of context. This is really about the organization and the matrix model and where you fit and some suggestions for what success indicators might look like. Let me defer here, first now to Jessie and then Kristin after that, to say what is that? What does this look like to you? Where do you fit into your organization and how are you using this kind of approach in your work?

Jessie Baker: Sure, thank you. I think, you know, as my role as a PIM, and I apologize that Deb is not here. She would probably have a different perspective. I really see myself as a resource to management and I think articulating that from the start helped develop that leadership—or that engagement of senior leadership that they saw me as another resource to help them do this work, which got us pretty far. I also was very cautious of articulating in the beginning that performance management as a whole, the framework for establishing are tools to both manage up and manage down, exactly what you said in the beginning, Jim, so that we are equally trying to hold managers accountable to do that work of clearing the path for us as well as hold staff accountable, and when staff can see that these frameworks will be a resource to them as well, I think we really achieve some success in that area. And then in terms of developing champions I think it’s really important to look at staff across your organization that may be doing not performance management work but work that is very closely aligned, whether that’s program evaluators, internal or external grant managers who are trying to do that performance management to their individual project—with their individual project officers and then general planners, and trying to align their efforts to your organization’s performance management framework really gets you some economies of scale.

Jim Pearsol: Super. Kristin?

Kristin Adams: Yeah. I think for me personally, I answer directly to the chief of staff. But I think the biggest message that I could give, it doesn’t necessarily have anything to do with where I sit on an organizational chart but where I sit on a physical location. I am actually right down the hall from the commissioner’s office. He has to walk by me when he comes in and when he departs, so I am a constant reminder that I am here. And as a resource and as somebody who can really provide guidance and work through the strategic plan, through everything that we have developed. I think the other big benefit that we did was we trained every executive staff member and every division director as quality improvement champions. And it’s really—they were the ones who took hold of the strategic plan and said here are the top four projects we want to do. And then we asked for names of lower level staff who really touched those projects day in and day out who could be strong leaders of the green belt and yellow belt. So everyone was trained with the same concept. They all had a say in what the projects were. And of course it all ties back to accreditation and my infamous phrase is, “due to accreditation we need to.” (Laughter) And that manages to really get a lot—it buys the leverage back to executive leadership. So people use me as a resource to say we’re stuck, we need to move this forward. I try and take it back to an accreditation level and say this is a good reason why we need to do this. So I’ve tried to tie it all together and really say I am your resource but I’m also going to be a driving force for you.

Jim Pearsol: Those are excellent comments and we both thank you very much. And I like your example there, Kristin, about tying it back to accreditation, because that makes it concrete about where we go from here. Melody, if you could go to the next slide. Leadership competencies. I just want to use this slide to sum up this conversation about engagement within the organization to say there really is a science around this work. And this is sort of a teaser slide to invite you to look into some of the science of organizational change and quality improvement and performance management, and using in this case Demmings’ System of Profound Change. That systems thinking is really where the solutions are and how can we create the kinds of systems, the pathways, the link to accreditation as was just mentioned, to find our way going. Understanding variability and what processes and how we might make our measurements, let’s say standard error and that sort of thing, and what’s the theory of knowledge that’s sort of driving the change that we want to see occur. You know, it might be around a health care concept. It might be around a disease prevention concept. And linking those kinds of things to this science of performance management is really pretty intriguing to me. And I think that creating the sense of urgency, I think you’ve sort of heard it underlying our comments so far, that there is a real responsibility for the performance improvement manager to create this sense of urgency. So if we go to the next slide, please, Melody.

This is—the title is engagement and buy-in. Some top 10 questions. Like I said, this is not particularly humorous, but what we really tried to do is make these concrete. And I want to tip my hat again to Deb Koester for pulling these questions together, because you’ll see—go to the next slide, please, that says the top 10 questions from leadership. We understand that these are the kinds of questions you’re getting and we want you to ask us or tell us what kinds of answers you’re giving to these questions. Why does leadership engagement and buy-in matter? Who’s your leadership? Good God, why this now and why now? Why do it at all? How does performance management and QI make a difference? What do they do? We’ve already done evaluation, how is this different? So how is this going to help me? How do we make this a success? What do you need from me? And what’s next? So I think always having that answer to what’s next might be the real key question in this list. So let’s go to question 1, Melody. Why does leadership engagement and buy-in matter? I think we know that (audio skips) vision, it clearly creates the mechanism for support. So Kristin didn’t walk in and say I want the office right on the same floor down the hall from the director. Somebody put that in place for her. Ongoing communication and promotion. Custom content. Here’s my message. Give the senior leadership and your staff a way for them to really own the message in their own way. Telling the story from their perspective. This is why I see it this way. This happened to me. And this is why it’s important. And if you get leadership buy-in, you get a lot of staff buy-in. Now I will tell you that experience has taught me that you have 10 percent resistance no matter what you do but that’s a pretty small problem to try to overcome. You’ll see some key messages that you can share with your leadership team listed in this—next slide, please.

Question number 2. Who is your leadership? Make sure you define that. Clearly these are some examples of essential individuals who are driving that, but as we’ve mentioned before, consider both formal and informal leadership, create opportunities, create teams and engage all employee classifications. People want to own this. And then slide, question number 3, Melody. Why this and why now? Because of the challenges we’ve presented right at the beginning, what is the context, the very volatile context we’re working in. This actually provides a little bit of certainty, a little bit of structure, a little bit of concreteness in order to follow a pathway and why we could move forward. But let me pause here and ask Jessie and Kristin if you would like to comment on any one of these three questions. Why does leadership engagement and buy-in matter? Who’s your leadership? And why this and why now? Jessie?

Jessie Baker: Sure. Just to underline the point you made, I think providing—so my leader would be my state health officer and providing him with a framework that he can own and be his and sell up his chain of command is really critical. And I think if you can do that and approach it almost from a dare I say political approach, to me that’s—for us here in Vermont that’s made a huge difference. Our commissioner really sees performance management as his success.

Jim Pearsol: Great. Kristin?

Kristin Adams: Well, and I even think about, just so everyone knows, I’ve only been with the state department of health for about 3 years now, and I’ve been through two state health commissioners and two deputy health commissioners/chief of staff and I’m getting ready to go through a third one because we will have an election. So—and we will get a new governor, just because ours has timed out. But the key is, for me it’s not just executive leadership. It’s all those program managers who are still going to be in place when everybody at the top level will probably leave. So they will be the ones who continue the efforts. I could teach one or two new people. I can’t teach another 40 to be back on the same page. And I won’t have to. The work will continue. So I think that’s a why this, why now, but also really defining who your leadership is. I do have strong buy-in but they’re leaving. So those are things that I have to keep reminding myself.

Jim Pearsol: That’s a very good—very good reminder. Great. Thank you. And I’d like to say the comment of giving something that the chief leader can take up the chain is really quite crucial to this dialogue about engaging leadership. So, Melody, could you go to the slide that talks about question number 4? Why do it at all? Well, I think we’ve talked about this throughout this presentation. It’s the cornerstone of any business is good quality. The department must show impact and change. The need is rising. Accreditation is the driver. Efficiency is an expectation. And it really can easily connect to our core values and mission. So I would encourage you to look at those key messages and consider those as you try and think about addressing this question. Next slide, please. This is question number 5. What does performance management and QI do? It focuses on process not people. I think the real point there is that it is very easy to say so-and-so’s a barrier to this issue. And there may be instances of that, but helping folks understand what the process is in place that can allow us to not let individuals hamper our process and let the process provide us with success. And it allows us to not only do that but create an accreditation application and then talk about impact on dollars, time and health. And we’re just now studying some ROI principles with CDC colleagues. They really give it this concept of really amortization across time. You know, we think about we have to do investments up front, but we can amortize that over time and that helps define the return on investment that one gets for putting some effort into change. And you’ll notice that you have resources from many, many sources, not just the ones listed here that would help you along the way. Let me pause there and ask Kristin and Jessie if you have any comments about why do it all and what does performance management and QI do for you in the agency.

Jessie Baker: This is Jessie. I think one of the things I’ve been really thrilled with about here in Vermont is that—going to this question of why do it at all—it’s about processes not people; however, the people have the pride in what they do, and what I’ve found is especially, you know, capitalize on that idea of what Kristin was sharing, getting to the people actually doing the work. If you give them the tools to improve what they do, they’re proud of what they do. They want to do it as best they can. And if you empower them to be the ones coming up with the ideas, coming up with the improvements, going through the PDSA cycles, they will kind of harness that pride and work really hard through improvement. And I think that that—bringing that tool of improvement to the department kind of answers its own question of why do it at all for the staff.

Jim Pearsol: Great. Kristin?

Kristin Adams: Well, and I stop to think, you know, if you go back to the original slides were under-resourced, they’re being kept more and more, we can’t replace staff. And I sit back and say we’re all tired. And so it does become the point of what can we do to help us become less tired and make things less frustrating. And so I have just started the philosophy within the last couple of weeks, you cannot come and complain to me. You must bring me a problem statement and figure out how we’re going to solve this. So it’s almost define your problem statement and then we’ll do the plan. We can’t just continue to invest in the frustrations. So I think that’s the way I’ve started to flip things on people, to say we have the power to change it, so get me the problem statement and let’s go. And that’s been hard for people to change that mentality.

Jim Pearsol: Great. That’s excellent.

Trina Pyron: Jim, this is Trina here at the CDC. We’ve just got a question on LiveMeeting that I think it might be a good time for you all to address, is how do you explain the benefit of accreditation to your leadership, especially considering these times that you’re discussing right now. And so if you could talk a little bit about that, you know, before you move on to your next question, I think that’d be great.

Jim Pearsol: We’re—I’ll take a first stab and then defer to Kristin and Jessie. You know, in public health we’re in multiple businesses. You know, a comprehensive state health agency has over 120 programs. There are not enough story lines for you to make an impact and tell a story 120 times over that any governor or any member of the public isn’t going to be able to listen and track on and make that be your story line. But if you can pull together in the blueprint kind of way that says we’re in this kind of business and you can go write down the domain and then cite the examples, and then you don’t have to do 120 programs, you can cite a tobacco example or you can cite a maternal and child health example. You begin to have this really handy blueprint that’s quite scalable. You can go down to the measure or stay up at the domain level to articulate the story line. So I think it provides your leader with a chance to say this is the business we’re in, these are the protections we provide, and this is what we’re going to lose if we don’t keep these protections. And I’ll defer to Kristin first and then Jessie to also comment.

Kristin Adams: Well, this is Kristin and I think that’s been a message that we’ve tried to say is (a) this is a framework for the agency. It gives us direction. It gives us those sets of standards. It gives us a common language across the nation instead of you do this, we do it that way, we do it another way. But I think when you also start telling administration—and I’m referring to the governor’s office and to state budget agency—when you have departments of education that are accredited and you have your jails are accredited, and then you say oh, the overseeing body of public health is your state agency or your local health department and you don’t have an accreditation program, they’re almost appalled. So I think it’s a level of education that there is now a new system. There was never a system. And now we have mission and vision and strategies on how we’re going to do this. And I think when you start looking at health care costs right now, you know, everybody’s trying to figure out how we’re going to control these and how we’re going to bring business into the state with a healthy population. And we have several communities who they’ve lost businesses because of the health of the population.

Jim Pearsol: Jessie?

Jessie Baker: Sure. So my kind of elevator pitch about accreditation, I definitely tap into that competitive nature. Why are hospitals accredited and we’re not, etc.? That usually gets people’s juices flowing. You know, just the basic statement of we need to hold ourselves to national standards and demonstrate that we’re using the tax dollars—taxpayer dollar wisely is usually pretty effective, and then finally and most importantly here in Vermont and I know this is a huge luxury for us, and it’s actually in our health reform state legislation that we seek public health accreditation. So we are legally obligated to move forward with it. And again, that’s connected to our bigger culture of health reform here in Vermont.

Jim Pearsol: Great. Thank you guys. Thank you, Trina, for introducing that question. I’d like to now turn to question number 6 and turn it over to my colleague, Deb Koester, who will take us through questions 6 through 10.

Deb Koester: Great. Thanks, Jim. Well, Melody, as we move to the next slide and question number 6, if you haven’t had this question, and it comes up not infrequently. We’ve also touched on it a couple of times today. How is performance management and QI different than program planning and evaluation? Why do we need to do both? Perhaps another opportunity for an elevator speech, but you know, for you all to think about how do you articulate how QI and that ongoing monitoring and improvement processes that are aimed at really accomplishing performance improvement are different than the periodic program planning and evaluation or the program evaluation that we do to really evaluate how well a system is working, how well a program is working and meeting its goals. But this is also an opportunity as we talked about the broader concept of performance throughout today’s presentation, what does performance management mean in your agency? Jim and Kristin and Jessie have all touched on that. What does that mean at all levels within your organization? Because it really does cross all levels whereas program planning and evaluation could be much more focused. They talked about the matrix model and the three levels. It really is also focused on efficiency and effectiveness and what those being integrated as key NPHII goals and the work that you’re doing, you’re well aware of that. And Kristin touched on also how do we align performance management and quality improvement efforts with the agency’s strategic plan?

As we move to the next slide for question number 7, what’s in it for me, not necessarily meant to—with performance management and quality improvement to certainly compete with leadership priorities or be additional, but how do you take performance management and quality improvement in your agency and align that with leadership priorities and align that with state health priorities and integrate performance management and quality improvement concepts and methodologies into those? How do you demonstrate return on investment and cost quality? How do you demonstrate the impact of the work that you are doing around quality improvement, around performance improvement across your agency? Because that’s really your opportunity to articulate the results, the impact and the difference that you are making. And as well, what’s in it for me? The organization of culture, that opportunity for the leadership to really carry that message across the agency to the agency with you in your role and how quality improvement and performance management, there is a role of, as Kristin mentioned, for everyone in the agency and deriving quality in all of the services. I’ll stop there for Kristin and then Jessie and then finish up the last couple of questions.

Kristin Adams: I think my biggest thing is that we have to have a dedicated focus, and so when you take that quality improvement piece, it’s really about making everybody’s life better. And also just making sure that everybody has a statement to the best of their capacity that if there’s a problem, they identify it. They have a role in helping fix it.

Jessie Baker: This is Jessie. Going—in terms of question number 7 and aligning to leadership priorities and other priorities, I think one of the opportunities of our work is also just to align—to as much as we can align efforts and demonstrate how things are connected so how the state—how state health improvement plans, strategic plans, healthy people, accreditation, quality improvement, how these all are connected and not individually new work but are all—together form this bigger framework that I talked about at the beginning.

Deb Koester: Thank you. And then moving on to question number 8. How do we make this a success? Even knowing what those required resources are, understanding the communication plan, the strategy that you have for moving things forward, the implementation and evaluation plans, hopefully a new way of thinking for some folks. And definitely a culture change. But very specific sort of the cost, the time for leadership. What are the expectations? What is the best and worst case scenario? What should they be expecting? What is the role I’m going to look at? So how do we make this a success? And then moving on to the next slide. What do you need from me? And you can see at the very bottom of the slide those top 5 enablers of performance management and quality improvement, and why those are certainly support from the leadership and the management. So having their approval, having their ongoing support, certainly establishing a start date, and then how that leadership can message to the organization. However, leadership is anyone in the organization that can carry that message about the importance of integrating performance management/quality improvement into everyone’s work.

And then the last question, number 10. What’s next? Leading the leadership there’s only two or three action items that you really, really need them to do and focus on, and then knowing that you can handle the rest. That you’re, you know, that’s your role across the agency. And I think Kristin and Jessie have both really articulated their role as a resource in their role as a PIM within the agency. And then go ahead and move to the bonus question on strategies during leadership transitions. We touched on that a little bit. Right now we’re getting close to the hour so I want to stop there for Jim and Kristin and Jessie, any additional comments before we go to questions. Trina for you.

Jim Pearsol: Yeah. You’re going to have leadership transition and I think Kristin spoke to that, the way you’re preparing for that, Kristin, is really a smart strategy. Let me ask Jessica if there is anything you’d like to add.

Jessie Baker: No. I’d love to hear people’s questions.

Melody Parker: All right. Thanks you guys, everyone. Thank you ever so much. We only have a few minutes left for questions. I believe we can go ahead and open up the lines. Our operator Kelly will be opening the lines, so again, please remember to mute your phone or press star 6 as all the lines are open. At this time I am going to—we’ve already started with one of our LiveMeeting question we asked earlier question earlier. And are the lines open now?

Kelly: They should be, yes.

Melody Parker: Are there any burning questions from our group for our presenters today?

Debra Tews: This is Debra Tews in Michigan and I have a comment, if I may.

Melody Parker: Go ahead, Deb. Thanks.

Debra Tews: You bet. I just wanted to let all of you know that this has been the most practical, helpful presentation to date from my perspective on the Performance Improvement Managers Network. They’ve all been good, so I’m not taking issues with past ones. But I found this one especially helpful. As of September 1st we have a brand new Michigan department of community health director and we will soon be having a brand new public health administration director, and so I had seen this presentation before but it’s taking on much greater and new meaning for me now. So thank you for the timeliness.

Emily Brown: Hi. This is Emily Brown from the Nevada State Health Division. I was just curious what your perspective was on the funding issue. I know that that’s often a driving force for doing anything for health departments, and what strategies have you used for promoting accreditation when it’s not officially required and there’s no direct funding tied to completing it. Thank you.

Jim Pearsol: Well, when it—go ahead.

Kristin Adams: This is Kristin, and this has been a commitment that we—that ISDH’s leadership has been willing to make. It’s one of those things. I’m currently funded through the public health block grant so I’m not even funded on this project, but it really is to build the infrastructure to this and to do all that performance management work. When public health block grant was slated to be cut, all of my leadership said we will move you to state dollars. So I think, you know, you need to start working that process now. What happens when, what happens if. And we’ve been talking about this for two years of what happens when. So we have a plan in place. We have that contingency. I’ve been lucky. Both sets of funding have continued on and we just wait the next day.

Jessie Baker: This is Jessie. Again, going back to looking at specifically the NPHII funding and performance management in general as tools and resources to staff and managers to improve the work that they’re already doing. If you can put that culture into place, then looking at the funding from NPHII as a resource to the department, that’s, you know, that funding is directly tied to accreditation. I think that was the real service OSTLTS did for us in making it such an articulated requirement so we can go back to our stakeholders and say no, we actually are getting funding to do this and here are the tools that this funding is enabling to help.

Melody Parker: Thank you so much everyone. I’m sorry (background noise drowns out). We don’t have time for any more questions. I do apologize for that. If you do have follow-up questions for our presenters today, by all means please forward them to and we’ll be happy to pass them on. I want to thank everyone for their participation on today’s call. We do have one final poll for you. You can quickly go with this. How would you rate this webinar overall? Excellent, good, fair or poor? And as you’re answering that poll I’d like to tell you that we hope that you’ll join us on October 25th for our next call, where we’ll hear about new tools available from our NPHII/CBA partner organizations. Also looking a bit towards the future, the Thanksgiving holiday means that there will not be a November call, and due to the timing of the winter holidays, the December call will be held on the third Thursday of the month instead of the usual fourth Thursday. That will be on December 20th. Don’t forget that you can view and download these calls and companion materials from the PIM Network web conference call series on the OSTLTS PIM Network website. Again, everyone, thank you so much for your time today. We’ll see you again on the October PIM Network webinar call. Thanks so much.

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