Feedback on Performance Management and QI Plan

Wed, 03/30/2016 - 10:52 -- azsnyder

Hi All,

I started at Anne Arundel County Department of Health about 2 months ago, and I'm working on both PHAB accreditation and QI. We are shooting to finalize the document submission by January 2018. I've started talking with other health departments who've gone through both accreditation and the QI implementation process to get a feel for their experiences and timelines. I've developed a workplan (link below) of what I think our process and timeline should look like, and I would love feedback. Do you think this is realistic? Are there any steps I may have missed? 

Just as background, our Department conducted a program-level assessment intitaive about two years ago, so most programs have goals, objectives and measures already (but many need to be updated). We currently have no centralized data reporting system or standardized QI activities. 

Thanks in advance for any feedback,

AZ Snyder

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Submitted by Georgianna on


You've done an excellent job of identifying the tasks and establishing a workable timeline.  Two thoughts:

You have the completion of your QI Plan prior to analysis of data from your PMS reporting.  It's how we did it too, but the pitfall is that your QI Plan isn't responsive to the PMS.  Unfortunately if you push development of the QI plan out to respond to issues illuminated by your PM data, then it pushes your accreditation timeline out significantly, since you have to also demonstrate an annual review of the QI Plan.  This cycle we are striving to line these processes up to be more mutually supportive.

My second thought is that that if these concepts are new to the culture of your your org, then your staff may struggle with it a bit.  I discovered that there was a huge spectrum of understanding when I started receiving the proposed performance measures from program staff.  A lot of patience and repetition and examples and one-on-one time may be needed to get everyone speaking the same language.

Best of luck in your new position, and keep us updated!

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Georgianna Wood
Accreditation Coordinator
Humboldt County DHHS Public Health

Submitted by azsnyder on

Thank you Georgianna! It's reassuring to hear from someone who's done the same thing. The last thing I want to do is stress staff and cause resistance to a process that is going to help them do their job in the long run. I think that I need to build in more time for one-on-one support for program managers, which is something I didn't take into account originally. 

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Submitted by gkroberts on

Hi and congrats on your new position! You have done a great job with this gantt chart to try and plan the big picture of PM and QI. A lot of accreditation coordinators could benefit from this! Here are a few thoughts:

  • I agree with Georgianna that there was a lot of one-on-one time needed with program managers to help them understand and develop their personal program goals.
  • When developing your PM goals and objectives, try and allign them with strategic/agency goals to begin with so that you don't have to go back and add to them. I only mention this because on your timeline, it says you are approving program goals before looking at strategic goals. We did it this way, and realized we had to go back and add goals reflecting strategic/agency goals to the programs.
  • It might help to draft your PMS system description earlier, when you do PM orientation or training. It helped everyone to understand how the PM system worked as a whole and alligned with the other plans (CHA, CHIP, Strategic Plan, QI Plan, Workforce Development Plan, etc).
  • Don't be discouraged during your first quarter of PM implementation. It will be a rocky road but make sure you continue to spend time with the program managers during this period as well, if they need your support. Otherwise, they may get discouraged. One thing we realized was that creating the goals/objectives, was much different than actually collecting and reporting the data.
  • For QI projects, remember to start small and celebrate the small win(s). Using this to share and gain support from other staff members will help others buy into the concept. I mentioned this because you have listed that each bureau will select a project and do an additional agency-wide project.
  • During phase 5 or 6, in addition to the QI suggestion boxes, I would also recommend focusing on QI communication such as creating an intranet page, newsletter section (Q-tips) to highlight QI projects/happenings.  

Please keep us updating throughout your journey! We can all benefit from shared experiences. Good luck!

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Gurleen Roberts, MPH
Director of Quality Management
Cobb & Douglas Public Health
Marietta, GA

Grace Gorenflo's picture
Submitted by Grace Gorenflo on

Georgianna and Gurleen have made some great suggestions.  Some additional thoughts:
For your PMS, consider pilot testing the reporting tool before it is launched.  Also, see this community forum thread for ideas on a tracking system:

A great resource to introduce performance management systems can be found on the Public Health Center for Excellence website:  Specifically, check out the “QI in Five” tab for 2 11-minute webinars on performance measures and performance management systems.  This site has a number of other valuable resources on QI and performance management.

Georgianna and Gurleen also had some great suggestions about change management strategies to bring employees along with th.ese new systems.  It could be helpful for you to develop a change management plan and embed that in the workplan.

Finally, it is important to have teams engage in quality improvement initiatives as soon as possible after receiving training and therefore I encourage you to modify the schedule so teams do the QI work while the information from the training is still relatively fresh.

Thanks for sharing your workplan – I’m sure this will be helpful to many others!

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