2. Learning Objectives
• Provide Infant Mental Health Advisory
Board with foundational Continuous
Quality Improvement knowledge and
skills
• Introduce the upcoming self-assessment
survey
3. Performance Management and CQI
• Two components:
–Performance Management: Using data to
improve performance
–CQI (Continuous Quality Improvement):
Involving all stakeholders to examine the
performance of a process and address
identified gaps
4. Four Parts of Performance Management
• Performance Standards help agencies
decide on the right path to take.
• Performance Measures help agencies
follow their path without getting off track.
• Reporting of Progress helps agencies
determine if they have made the right
choices.
• Quality Improvement helps agencies keep
getting better.
5. Performance Standards
Objective standards or guidelines that are used to
assess an organization's performance
Identify relevant standards as described in your
vision, mission, and strategic plan, and those
supported by best practice policies .
Select indicators of performance that align with
each standard that can be tracked over time.
Set targets for the performance of your agency
related to each indicator.
Communicate expectations for performance.
6. Weight Loss Example
• Performance Standards: Looking to the Body
Mass Index chart for an ideal weight range
(standards), and looking to lose two pounds
per week (target) are based on standard
recommendations for weight and weight loss.
7. Performance Measures
• Defining measures for each standard so you
know what data you need. Measures need to be
clearly and logically related to each standard,
feasible to collect over time, within your scope of
influence and consistent (ECMH Data Indicators)
(e.g. % of live births that were preterm in 2013)
• Developing data systems to make sure data are
collected routinely and stored appropriately, and
• Collecting data on a regular and ongoing basis.
8. Weight Loss Example
• Performance Standards: Looking to the Body
Mass Index chart for an ideal weight range ,
and looking to lose two pounds per week are
based on standard recommendations for
weight and weight loss.
• Performance Measures: Recording (collecting
data) weight, calories, and physical activity
(defined measures) in a spreadsheet (data
system) on a set schedule allows you to look
at relevant data over time.
9. Reporting Progress
• Analyze data and compare with their target
• Communicate results broadly to all stakeholders
• Provide context and be targeted to the
audience
• Be routine – reports should be produced on a
schedule to help ensure that results are utilized
• Be created in a way that is straightforward, easy
to produce, and easy to understand, and
• Creates a system that is transparent, which helps
drive monitoring and improvement.
10. Weight Loss Example
• Performance Standards: Looking to the Body Mass
Index chart for an ideal weight range, and looking to
lose two pounds per week are based on standard
recommendations for weight and weight loss.
• Performance Measures: Recording weight, calories,
and physical activity in a spreadsheet on a set
schedule allows you to look at relevant data over
time.
• Reporting of Progress: Examining (analyzing) the
data on a set schedule (routine) allows you to
monitor the data and observe trends.
11. Quality Improvement
• Uses data on how you are performing to drive
activities which lead to true improvement.
• Utilizes stakeholders to address identified gaps
continually improve processes
• Addresses the question: How do we get
better?
12. Weight Loss Example
• Performance Standards: Looking to the Body Mass Index
chart for an ideal weight range and looking to lose two
pounds per week are based on standard recommendations
for weight and weight loss.
• Performance Measures: Recording weight, calories, and
physical activity a spreadsheet on a set schedule allows you
to look at relevant data over time.
• Reporting of Progress: Examining the data on a set schedule
allows you to monitor the data and observe trends.
• Quality Improvement: When the data showed (using
data) that the targeted weight loss of two pounds per
week wasn’t met, adding additional physical activity
(improving process) was tested as an improvement
strategy.
13. Performance Management, Evaluation, and
Continuous Quality Improvement (CQI)
Performance Management Evaluation CQI
Determines current
performance in relation to
standards of performance
Determines whether your
program is doing what it is
intended to do
Determines whether
adjustments to a process are
improvements
Examines performance
data and progress towards
performance goals
Determines whether the
effect is worth the
resources needed to
implement the program
Uses staff expertise to
improve the processes by
which the program is
implemented
Occurs continuously Occurs starting at program
onset, continuing through
program completion
Occurs at specific points in
time when an improvement
opportunity is identified
Examines performance
across the organization
Examines the performance
of a specific program
Examines the performance of
a process
Conducted by all staff
across the organization
Conducted by an outside,
objective evaluator
Conducted by program/
process stakeholders
Identifies gaps between
performance and
standards
Identifies gaps between
activities and goals
Addresses identified gaps
14. CQI: Four Principles
• Continuous Quality Improvement is guided by
four principles:
– Focus on the individuals being served (in our
case, individuals attending professional
development trainings)
– Continually improve all processes
– Involve stakeholders (ECMHAB)
– Mobilize both data and team knowledge to
improve decision-making
15. CQI Process
• The three key questions to keep front and
center during all CQI work are:
– What are we trying to accomplish?
– How will we know that a change is an
improvement?
– What changes can we make that will results in
improvement?
• These questions can be addressed through the
use of a deliberate and defined improvement
process, such as the Plan-Do-Study-Act Cycle
16. PDSA Cycle
• The PDSA cycle is used to improve existing
processes, not to plan or implement new
programs
• Always relies on data to support its decisions
• Both the DSS and ECCS grant are focusing on
professional development. By using CQI, we
can systematically look at how our
professional development activities impact
participants
17. PDSA Cycle: Nine Steps
• Plan-Do-Study-Act Cycle (Steps 1-5)
• Step 1: Identifying a problem
• Step 2: Assembling a CQI team that can address
the problem (ECMHAB)
• Step 3: Identify what the true cause(s) of the
problem may be, map the process to understand
the existing activities that lead to the
problematic issue
• Step 4: Brainstorming and conducting
background research to look for possible
solutions
• Step 5: Working to develop a theory of
improvement that can be tested
18. What is a Process Map?
A process is a series of steps or actions
performed to achieve a specific purpose.
Process map = Visual representation of
steps in a process.
Describes the way things get done.
20. Plan-Do-Study-Act (Step 6)
• Step 6: Test your theory of
improvement
• Implement a small-scale test of
the change to your process.
• Collect, chart, and display data
to determine the effectiveness
of the improvement.
• Document problems,
unexpected observations, and
unintended side effects,
because these occurrences will
aid in the learning process.
21. Plan-Do-Study-Act (Step 7)
• Step 7: Study the Results of your Test
• Use data to determine if the test of your theory was
successful
• Compare the results of your test to the baseline data
• Some questions to consider include:
• Did your test work? What do the data show?
• Did the results match your theory/prediction?
• Are there trends in your data?
• Did you have unintended side effects?
• Is there improvement?
• Do you need to test the improvement under other
conditions?
22. Plan-Do-Study-Act (Steps 8 and 9)
• Step 8: Either standardize your improvement (if
test was successful) or develop a new theory for
improvement (if test was unsuccessful)
• Step 9: Establish Future Plans
– Sustaining change or beginning PDSA again
23. The Self-Assessment Survey
The survey will be used to assess important components
of the grant’s professional development activities:
1. Understanding consumer and capacity
2. Focus on providing high quality professional
development
3. Using CQI principles and processes to optimize
activities
4. Using data to drive decision making
The results of the survey will be used to identify
potential areas that could benefit from a PDSA cycle
Editor's Notes
Performance Management and CQI are distinct processes. While some of the components may overlap, there are marked differences as well.
In the example to follow, we will be using an example based on weight loss.
In our weight loss example, CQI is looking analytically at the process to achieve weight loss. Performance Management is tracking performance.
With the Board’s help and guidance, we will be conducting a survey (introduced later) that will look at areas in our implementation that may benefit from a closer look/improvement process.
Write a narrative first of process (AS IT IS, NOT AS YOU WISH IT WAS). Then, using sticky notes, start to map out how the steps follow one another and flow. Think the process through step by step. There are specific symbols used in process mapping. Add dates/times where you can. Add in data points where available.
After you have the map completed, test the map using different scenarios to see if there are any breaks. You may find some examples of situations where the current system doesn’t work or where steps do not logically flow together. You may be able to identify duplicative effort or needless steps.
