Performance Management and Quality Improvement Plan

INDI A N A S T A TE D E P A R TMENT O F HE A L T H

PERFORMANCE MANAGEMENT & QUALITY IMPROVEMENT PLA N

JUNE 1, 2018 - JUNE 30, 2020

Of fice of Public Health Performance Management

CONTENTS

Purpose ...... 3 Culture of Quality ...... 3 Language ...... 3 Mission, Vision, Values ...... 3 Assessment of Performance System and Culture ...... 4 Current State and Desired Quality Improvement (QI) Culture ...... 4 Strategies towards Desired QI Culture ...... 5 Structure, Roles and Responsibilities ...... 6 Performance Management Committee ...... 7 Quality Improvement Team ...... 7 Office of Public Health Performance Management ...... 8 QI Coordinator ...... 8 QI Project Teams ...... 9

Performance Management System ...... 9 Performance Management ...... 9 Project Identification and Prioritization ...... 10 Alignment ...... 11 Data Collection, Monitoring and Reporting ...... 11 QI Methodology ...... 12 Regular Communication ...... 12 Evaluation and Sustainability ...... 12 QI Training ...... 13 QI Program Goals and Projects ...... 13 Goals, Objectives and Measures ...... 13 Appendicies ...... 14 Appendix A: Key Terms ...... 14 Appendix B: Culture Assessment ...... 15 Appendix C: ISDH Project Proposal Form ...... 16 Appendix D: Project Tools and Techniques ...... 18 Appendix E: Current Projects ...... 19 Works Cited ...... 19

Purpose

The Indiana State Department of Health (ISDH) is committed to ongoing performance improvement efforts. Perfor- mance management (PM) and quality improvement (QI) techniques are being utilized to varying degrees in the agency, and efforts have not been coordinated and monitored agency-wide. This plan outlines the strategy for implementing a formalized process throughout the agency. ISDH recognizes the importance of PM and QI tools in achieving its mission, vision and values as reflected in the 2018-2020 ISDH Strategic Plan (ISDH-SP). These tools are instrumental to maxi- mizing public health resources to accomplish goals and improve outcomes.

Improving health outcomes in Indiana involves a structured and intentional approach that embraces the measurement of performance and continuously seeks opportunities to improve service delivery and organization effectiveness. The Performance Management and Quality Improvement Plan (PMQIP) sets the foundation for a culture of quality improvement that facilitates systematic activities for improving health of all Hoosiers.

This plan informs staff, divisions and programs on how to access support and resources for improvement activities. Any questions about this plan should be directed to the Office of Public Health Performance Management (ophpm@ isdh.in.gov) or members of the ISDH Quality Improvement Team.

The culture of an organization is the embodiment of the core values, guiding principles, behaviors and attitudes that collectively contribute to its daily operations. Organizational culture is the essence of how work is accomplished.

Culture of Quality Language It is well established that language is a critical element of culture. To develop a culture of quality, it is necessary to develop a common and consistent vocabulary, and a glossary of common terms is provided in Appendix A: Key Terms. Mission, Vision, Values ISDH’s focus on performance and quality begin with its mission, vision and core values as outlined in the ISDH-SP.

Vision: A healthier and safer Indiana

Mission: To promote, protect, and improve the health and safety of all Hoosiers.

Core Values: Integrity, Innovation, Collaboration, Excellence, Dedication

Assessment of Performance System and Culture ISDH regularly assesses its PM system and culture an ongoing basis. ISDH completes a formal assessment every two years using an abridged version of the National Association of County and City Health Officials (NACCHO) Roadmap to a Culture of Quality self-assessment tool. Participants of the survey include executive leadership, managers and supervisors, as well as non-supervisors/front-line staff. The results from the 2018 assessment were used to guide the development of the 2018-2020 PMQIP.

This assessment is grounded in six foundational elements critical to building a culture of quality: Employee Empower- ment, Teamwork and Collaboration, Leadership Commitment, Customer Focus, QI Infrastructure and Continual Process Improvement. ISDH uses these foundational elements as guiding principles to achieve a culture of quality. Current State and Desired QI Culture According to the 2018 assessment, ISDH ranks overall as “Phase 3: Informal or Ad Hoc QI Activities” on the NACCHO Roadmap. This means discrete QI efforts are practiced in isolated instances throughout the agency, often without consistent use of data or alignment with the steps in a formal QI process. According to the roadmap, our agency characteristics are as follows:

“HUMAN” CHARACTERISTICS “PROCESS” CHARACTERISTICS • Staff infrequently share lessons learned. • QI projects may be occurring only at the administrative staff level or at other isolated times. • Staff may view QI as an added responsibility. • Data are still not routinely used in agency operations and • Staff are anxious about implementing QI incor- decision-making. rectly or uncovering negative performance • Discrete QI projects occur but are likely not fully aligned • Staff may be frustrated if efforts do not result in with formal steps of a QI model. immediate improvement • QI is not aligned with the organizations strategic plan or • Basic QI training and resources are more readily performance data. available, but advanced QI training may still be limited. • Multiple failed attempts to improve through QI projects may exist. • Some QI champions are able to lead QI projects and mentor staff. • QI efforts are often stalled due to emerging issues

• Loss of a QI champion often results in regression. • Redundancies and variations in processes still exist.

Please see Appendix B for more results. ISDH aims to foster a QI culture that is fully embedded into the agency (Phase 6), whereby agency leadership and staff are fully committed to quality, and results of QI efforts are communicated in- ternally and externally. As agency leadership changes, QI efforts continue through an established agency QI culture in which staff routinely seek out the root causes and solutions of challenge. They do not assume that an intervention will be effective, but rather they establish and quantify progress toward measurable objectives.

Strategies Toward Desired QI Culture The Quality Improvement Team ranks identified transition strategies to be addressed in the QI plan.

Foundational Transition Strategies Element Employee 3.53 Establish performance expectations and communicate roles for supervisors and work Empowerment team members PM/QI Council provides staff at every level with basic training in PM and QI Staff celebrate QI successes Leaders assess the source of any staff resistance and develop strategies to counter resistance through effective messaging, training and incentives Teamwork and 3.89 QI champions lead functional QI teams in implementing discrete projects sponsored by Collaboration PM/QI Council Leaders provide staff the opportunity to share results achieved through various mechanisms Leadership 3.56 Leaders incorporate QI into the organization’s value statement/guiding principles Leaders communicate key messages to staff and begin to demonstrate concrete examples of messages: 1) QI not about placing blame or punishment; 2) QI is a way to make daily work easier and more efficient; 3) QI is within reach of all staff and will get easier with practice Leaders work with PM/QI Council to develop a plan for the change process using deliberate change management strategies including timelines, costs, short/long term goals, communication and training plans, and implication for staff and stakeholders Leaders work with PM/QI Council to continuously assess the culture of the agency including staff commitment and engagement and sustainability of progress toward building a QI culture Customer Focus 3.02 Identify the agency’s customers and stakeholders to determine where customer satisfaction should be assessed Identify existing customer satisfaction data and data needs QI Infrastructure 3.24 PM/QI Council develops a plan for establishing and implementing a PM system to monitor achievement of organizational goals and objectives PM/QI Council begins to identify areas for improvement based on a gap analysis using performance data Continuous Pro- 3.79 All staff practice using the seven basic tools of quality in daily work to identify root causes cess Improve- of problems, assess efficiency of processes, interpret findings, and correct problems ment The PM/QI Council identifies and sponsors “winnable” QI projects using agency performance data. QI efforts are linked to strategic priorities and identified from performance data to the extent possible. Identify and train all staff on formal QI model, such as PDSA or Lean, and the seven basic tools of quality

Structure, Roles and Responsibilities ISDH recognizes the importance of staff in achieving a culture of quality. Each staff member has critical perspective on how processes can be improved and play a role in implementing a quality culture.

Agency Roles and Responsibilities All individuals working for ISDH  Staff members identify and suggest QI projects, participate in and implement improvement activities.  Identify and suggest areas of improvement or opportunities for development  Develop and participate in QI projects and activities  Participate in QI trainings

 Incorporate PM/QI concepts and principles into daily work  Demonstrate familiarity with QI plan All staff  Collect and manage quality and performance improvement data  Document and report on the process of QI projects and activities  Collaborate across divisions and programs to share knowledge  Be open to trying new ways to improve processes  Ask questions utilize mentorship and coaching

Supervisors/Managers oversee the day-to-day implementation or QI projects and activities, as well as support the staff and provide access to training opportunities  Carry out ISDH responsibilities

 Identify staff QI training needs and provide access to training opportunities  Orient staff to QI process and QI Plan  Present proposals for QI projects and activities to directors 

sors/Managers Ensure QI projects and activities align with division/office strategic plan  Complete written reports of QI project results

Supervi  Initiate, implement and ensure oversight of QI projects and activities  Support staff in QI and data collection efforts  Recognize and reward staff for participating in QI efforts

Senior leadership is comprised of the commissioner, chief medical officer, deputy commissioner, chief of staff, assistant commissioners and identified operational support directors

 Carry out the responsibilities of ISDH  Foster a culture of quality within the agency  Allocate and request necessary resources and funding to sustain and implement QI activities  Ensure QI efforts align with the SP or fulfill gaps/needs  Approve and sponsor QI projects/activities Senior Leadership Senior  Prioritize agency and commission wide QI projects and activities  Coordinate oversight of QI projects and activities with QI Team  Communicate QI efforts and success to governing entity. QI leaders (formal and informal) supporting the robust infrastructure.  Define QI vision

 Incorporate quality into policies, plans, procedures and culture  Provide ongoing QI training opportunities, mentoring and coaching

QI Leaders  Address questions and concerns about QI

 Lead agency QI projects

The governing entity (governor’s office and executive board) provides guidance to advise senior leadership regarding quality improvement efforts. They receive periodic updates on

the progress.  Support a culture of quality within the agency  Provide guidance and advice to senior leadership regarding QI efforts  Review progress and findings of QI efforts  Communicate constituents’ concerns and comments to senior leadership Governing Entity Governing  Communicate QI success stories to constituents  Fund QI efforts

Performance Management Committee

The Performance Management Committee (PMC) will monitor the ISDH-SP identified goals to inform QI Team of improvement opportunities.

Quality Improvement Team

Annually, the QI Team considers members for invitation to the team based on: stated interest, schedule availability, membership diversity and division representation. The QI Team makes all reasonable attempts to incorporate staff from different disciplines, backgrounds, divisions and commissions to ensure diverse staff are represented. Member-

ship requires a one-year commitment. At the end of that year, members may elect to remain on the team or withdraw. Specific responsibilities include:

» Provide support, guidance and objectivity for agency QI activities

» Guide selection of QI projects, monitor progress, and oversee implementation of goals and strategies

» Ensure QI projects results are communicated to appropriate internal staff and external stakeholders

» Provide project updates and reports to governing entity

» Sponsor or participate on QI Project Teams and assist in identification of team leads

» Review, monitor and report progress toward plan goals and objectives annually

» Review and contribute to PMQIP amendments and revisions

» Monitor QI metrics

Office of Public Health Performance Management

The health commissioner and deputy health commissioner empower the ISDH Office of Public Health Performance Management (OPHPM) to provide operational leadership of PM and QI efforts within the agency. OPHPM provides oversight of the SHA, SHIP, ISDH-SP, and PM, QI, workforce development and overall Accreditation activities as outlined by Public Health Accreditation Board (PHAB). OPHPM is responsible for the convening of the Accreditation Team (A-Team), Sub-Domain teams, Strategic Planning Committee (SPC), Performance Management Committee (PMC), and Quality Im- provement Team (QI Team). OPHPM serves as a repository of tools, information and ideas. With the support of OPHPM, it is up to each program to fully integrate quality improvement in the way ISDH delivers the best public health services.

Quality Improvement Coordinator

OPHPM staffs the QI Coordinator who coordinates agency PM and QI efforts to ensure appropriate agency plans cross- link to support and strengthen a culture of quality and performance. The QI coordinator chairs the QI Team to facilitate sustained knowledge and guidance and to provide consistent coordination of improvement activities across the agency.

Specific duties include:

» Serve as subject matter expert for QI and PM

» Develop agenda, meeting materials, minutes and facilitate QI Team meetings

» Maintain QI projects documentation

» Engage and involve QI Team in all PMQIP updates and revisions

» Maintain communication protocols for staff to suggest QI initiatives

» Coordinate with executive leadership for internal and external customer communication as needed

» Maintain database of QI training records and staff training certificates

QI Project Teams QI Project Teams are composed of staff who investigate proposed QI initiatives to plan and test potential solutions. Their responsibilities include:

» Complete all appropriate documentation for each QI project

» Report progress to QI Team at appropriate intervals

» Demonstrate commitment to regularly monitor progress

» Promote progress and project results at staff and governing meetings as appropriate

» Share success at annual opportunity

Performance Management System Performance Management The ISDH defines public health performance management as the practice of using data to improve the public’s health. This involves strategic use of performance measures and standards to establish performance objectives and targets; regular measurement monitoring toward objectives; and engaging in quality improvement activities when desired progress is not achieved. Establishing a PM system is a proven way to enhance performance and achieve desired results. Each employee has a role in creating an ideal work environment and should actively engage in problem solving and improvement. Improving individual and program performance will increase our capacity to positively impact our customers.

An organization with a culture of performance management and quality improvement achieves employee empowerment, teamwork and collaboration, visible leadership, customer focus, strategic alignment and continual improvement. ISDH has adopted the following model of Performance Management adapted from the Turning Point National Excel- lence Collaborative on Performance Management including the following components:

• Visible Leadership – commitment of executive leadership to a culture of quality that aligns performance management practices with mission, taking into account customer feedback, and enabling transparency. • Performance Standards – establishment of organizational standards, goals and targets to improve public health practice • Performance Measurement – development, application and use of performance measures to assess achievement of standards • Reporting Progress – documentation and reporting of progress in meeting standards and targets then sharing such information through regular feedback • Quality Improvement – using performance data for decisions to improve policies, programs and outcomes; managing change; and creating a learning organization.

ISDH leadership and OPHPM engage staff at all levels of the organization in the development and maintenance of the PM system through a Strategic Planning Committee (SPC). The SPC follows a six-step strategic planning process to identify agency measures: 1) Organize; 2) Set mission and vision; 3) Scan environment; 4) Strategize; 5) Develop work plans; 6) Evaluate; and 7) Revise as needed.

Agency-level performance measures are established under the ISDH-SP priorities and objectives. It is the division and programmatic performance management is the responsibility of directors, managers, supervisors, coordinators and front-line staff following the State of Indiana Performance Management Policy found here: https://www.in.gov/spd/ files/perf_management_policy.pdf.

Project Identification and Prioritization

Various types of continuous quality improvement (CQI) projects will be conducted, ranging from minor changes to existing processes, Rapid Improvement (Kaizen) Events, Lean A3 Problem Solving, Model for Improvement, or Plan-Do- Check/Study-Act (PDCA/PDSA) depending on size and scope of projects.

Projects may be identified in a number of ways, including, but not limited to:

» Staff suggestion for improvement idea submitted to leadership or QI Team, surveys, and other avenues

» Identification from agency plan implementation or reports (State Health Assessment/State Health Improve- ment Plan, Workforce Development Plan, etc.)

» Identification of possible process improvement through review of ISDH-SP performance data

» Stakeholder feedback and external performance assessments

» As identified by governing entity

Project selection and prioritization criteria (see Appendix C for Project Identification form) will include, but not limited to:

» Alignment with ISDH mission, vision and strategic plan

» Staff QI knowledge

» Potential impact of solution

» Program, organization and staff timelines

» Stakeholder input

» Clearly defined process with SMART target for improvement identified

» Manageable scope

Alignment

The 2018-2020 ISDH-SP serves as the focal point for the ISDHs PM system. The ISDH-SP states the agency’s mission, vision, and strategic goals serving as a roadmap for the ISDH over the next three years. Ensuring strategic priorities and objectives are met requires use of continuous data collection and monitoring. If metrics are not successfully met, agency QI processes can be utilized to discover root causes and possible solutions.

The 2017-2018 Workforce Development Plan highlights training goals and capacity for agency staff supporting developing in QI, PM and other topics supporting a culture of quality.

Data Collection, Monitoring and Reporting

ISDH will use tools available and familiar to staff, such as MS Office Suite applications, ArcGIS, and Tableau, to record and track performance management data. The PMC will work with staff to create and standardize data recording processes:

1. Programs submit data monthly or quarterly (as defined by the indicator)

2. Epidemiology Resource Center Data Analysis Team analyzes data and sends results to the QI Coordinator

3. QI coordinator document results, reviews data for completeness and prepares report

4. QI coordinator shares report with executive leadership and ISDH staff each quarter and the executive board annually.

5. Identified data also shared with the public through ISDH regular website updates, QI coordinator, and Data Analysis Team.

6. Measures NOT on target will be recommended for review by the QI Team.

Currently, identified measure owners are responsible for ensuring performance data collection processes are in place to track and regularly update data used to measure progress to goals. Data will be collected from a variety of sources. Performance measures are tracked using a template developed by the ERC Data Analysis Team. The SPC facilitates the identification and assessment of agency level goals and measures. The PMC will monitor the measures on a regular basis to assess potential QI opportunities.

After gathering data, PMC will analyze to determine if progress toward goals has been made. Identified owners will assess: 1) whether measure is on track; 2) whether measure has been met; 3) why objective was/was not met, action steps if needed; and 4) which QI trainings, tools or processes may help meet objective.

All QI Project Teams will complete appropriate documentation to be shared with staff and stakeholders. Documentation includes a description of the process, tools used, outcomes and lessons learned. Project storyboards will be displayed as appropriate.

QI Methodology

The ISDH will use a deliberate and defined process to identify and solve critical issues based on the ISDH-SP performance reports, customer feedback, and/or Culture of Quality self-assessment, and make improvements using Lean and PDSA methodologies and tools identified in Appendix C. The overall process steps include: 1. Identify/Select quality improvement project(s) 2. Designate a quality improvement project team 3. Develop an aim/challenge statement is developed 4. Develop measures 5. Identify gaps 6. Identify solution/change ideas 7. Test solution/change ideas 8. Sustain improvement 9. Share results

Regular Communication

Clear and consistent communication of QI and PM efforts is critical to building and sustaining a culture. Besides informing leaders and staff of QI practices and improvement efforts in the agency, it can help increase engagement and buy-in and facilitate progress toward building a QI culture. OPHPM will work with the executive team and Office of Public Affairs to ensure regular communication occurs.

OPHPM will ensure regular communication that includes:

 Regular reports on progress toward ISDH-SP goals and objectives

 Staff QI efforts acknowledged through monthly staff newsletter, posting on website and intranet, staff meetings and other communication mediums

 Storyboard for completed projects posted publicly and shared annually

 Completed documentation is archived and available in the QI shared network folder

 Update given at least annually to the governing entity provided by Executive Leadership or QI Team

 OPHPM hosts an annual Open House to share projects

 Share nationally as appropriate

Evaluation and Sustainability

The QI Team will evaluate the PMQIP annually. The evaluation determines if the plan is being followed and if any improvements or revisions are necessary. This evaluation includes a summary of the progress toward goals and objectives as well as activities conducted during the previous year.

The plan will be fully evaluated and revised every three years following the revision of the ISDH-SP to ensure this plan aligns with the ISDH strategic mission and vision.

QI Training The ISDH regularly seeks to build its capacity for process improvement to advance the operational and strategic aims of the organization. A strong process capability will improve the quality and efficiency of the primary services that ISDH offers, facilitate programs that further the health of Indiana residents, and strengthen the case for public health accreditation.

Beginning in 2016, OPHPM, in partnership with Purdue Healthcare Advisors, facilitated the first cohort of Lean training. As a result, five staff members at various levels are poised to conduct their own Lean work in the agency. Additionally, the partnership has resulted in three completed Rapid Improvement Events, improving processes in three distinct areas of the agency. To continue building QI culture, seven additional staff (Cohort 2) received training later in 2017. (See Appendix D: Current Projects)

Regular training is provided to employees, typically through external sources. ISDH is identifying opportunities for regular training and internal curriculums to build sustainable training programs.

QI Program Goals and Projects Goals, Objectives and Measures The 2018-2020 ISDH-SP identifies the following PM/QI-related strategic priorities

Strategic Goal 2: Promote and provide transparent public health data Strategy Objectives Target Indicator Owner Use a performance Though 2020, ensure 100% % strategic mea- OPHPM, Casey Kinderman management system to strategic metrics are re- sures reported monitor achievement of ported as identified in the Regulatory and Policy Com- organizational objective ISDH-SP pliance (RPC), Barb Killian

Beginning Q4 of 2018 9 reports # published IS- OPHPM, Casey Kinderman through 2020, create DH-SP progress quarterly reports for me reports

Strategic Goal 5: Improve organizational health and be an employer of choice Strategy Objectives Target Indicator Owner Foster a culture Achieve PHAB accreditation by Fully PHAB Accreditation OPHPM, of organization Q4 2020 and maintain compli- Demonstrat- status Patricia Truelove excellence ance ed RPC, Barb Killian Track the number of divisions/ TBD (need # division/programs OPHPM, programs completing/partici- baseline) completing/ participat- Casey Kinderman pa-ting in QI activities through ing in QI activities 2020

Assess the number of QI proj- 30 Count of QI projects OPHPM, ects annually through 2020 Casey Kinderman Move the agency from Phase Phase 4 Assessment results, OPHPM, 3 to Phase 4 on the Culture of response rate Casey Kinderman Quality Self-Assessment by 2020. 13

Appendicies Appendix A: Key Terms

Accreditation – Accreditation for public health departments is defined as: 1) The development and acceptance of a set of national public health department accreditation standards; 2) The development and acceptance of a standardized process to measure health department performance against those standards; 3) The periodic issuance of recognition for health departments that meet a specified set of national accreditation standards; and 4) The periodic review, refining and updating of the national public health department accreditation standards and the process for measuring and awarding accreditation recognition.

Best Practices – The best-known way to do something. Best practices are a) recognized as consistently producing results superior to those achieved with other means; b) can be standardized and adopted/replicated by others; and c) will produce consistent and measurable results. Replication required the adoption in a different process, area, or organization such that the results of the origi- nal application can be reliably reproduced. Best practices will evolve to become better as improvements are discovered.

Change Management – A structured approach to transitioning an organization from a current state to a future desired state.

Core Competencies – The key knowledge, skills and abilities required to succeed in performing a role.

External Customer – Stakeholders outside the organization that have requirements to satisfy but are dependent on the organization.

Improvement Activity – A systematic quality improvement activity or a project that includes an aim (goal) statement; a work plan with tasks, responsibilities and timelines; intervention strategy(ies); and measures for tracking change.

Internal Customer – Stakeholders within the organization or between organizations that have requirements to satisfy to deliver the service to the external customer.

Leaders – Anyone who directs the work of others, including senior managers, chiefs, directors, middle managers, supervisors and governing entities.

Lessons Learned – Knowledge generated through a formal method of exploring and understanding after doing something.

Learning Community - A group formed to advance the collective knowledge around a particular topic area in a way that supports the growth of knowledge among individual members of the group. Learning communities often include members that exhibit a diversity of skills, experience and expertise; have an objective of continually advancing collective knowledge, skills and abilities; and support mechanisms for sharing what is learned.

Performance Management System – A fully functioning performance management system that is completely integrated into health department daily practice at all levels includes: 1) setting organizational objectives across all levels of the department; 2) identifying indicators to measure progress toward achieving objectives on a regular basis; 3) identifying responsibility for monitoring progress and reporting; and 4) identifying areas where achieving objectives requires focused quality improvement processes.

Performance Measures – A quantitative tool to help understand, manage and improve what organizations do. Performance measures let us know: how well we are doing; if our processes are in statistical control; if we are meeting our goals; if and where improvements are necessary; if our customers are satisfied. They provide us with the information necessary to make intelligent decisions about what we do. A performance measure is composed of a number and a unit of measure. The number gives us a magnitude (how much) and the unit gives the number a meaning (what). Performance measures are always tied to a goal or an objective (the target)

Public Health Accreditation – A voluntary national program developed to measure health department performance against an established set of nationally recognized, practice-focused and evidence-based standards. This program is overseen by PHAB and modeled on the Ten Essential Public Health Services.

Quality Improvement (QI) – A formal, systematic approach (such as plan-do-check-act) applied to the processes underlying public health programs and services in order to achieve measurable improvements

Strategic Plan – A strategic plan results from a deliberate decision-making process and defines where an organization is going. The plan sets the direction for the organization and, through a common understanding of the mission, vision, goals and objectives, provides a template for all employees and stakeholders to make decisions that move the organization forward.

SWOT Analysis – A strategic planning method used to evaluate the Strengths, Weaknesses, Opportunities and Threats to determine strategic objectives. Strengths are characteristics of organization that give it an advantage over others; Weaknesses are characteristics that place the organization at a disadvantage relative to others; Opportunities are elements that the organization could exploit to its advantage; Threats are elements in the environment that could cause trouble for the organization. The analysis associates the internal and external data to develop strategies.

Value – Activities for which the customer is willing to pay for such as the product, service, and information

Waste – Anything that adds cost or otherwise consumes resources without adding value.

Appendix B: Culture Assessment

Organizational Culture of Quality Self Assessment Tool

Organization: Indiana State Department of Health Date: February 14th, SUB- FOUNDATIONAL FOUNDATIONAL STRATEGY PRIORITY SUB-ELEMENT TOPIC TOPIC SCORE ELEMENT SELECTED TRANSITION STRATEGIES TO IMPLEMENT DURING THIS PLANNING CYCLE ELEMENT ELEMENT SCORE Level SCORE 1.1.1 Creating Establish performance expectations and communicate roles for supervisors, and work Expectations and Getting Feedback 3.60 team members medium

1.1.2 Providing Resources 4.34 PM/QI Council provides staff at every level with basic trainings in PM and QI medium 1.1 Enabling 1.1.3 Empowering Performance Individuals and Teams 3.36 3.67 Staff celebrate QI successes high 1. Employee 1.2.1 Assessment and 3.53 Leaders assess the source of any staff resistance and develop strategies to counter Empowerment Identification of Gaps 3.51 resistance through effective messaging, training and incentives in progress 1.2.2 Deployment and

Execution of Plans to Close Gaps 3.54

1.2 Knowledge, Skills 1.2.3 Materials and and Abilities Methods to Develop KSAs 3.18 3.40 2.1.1 Vision, Values, and Goals 4.06 2.1.2 Roles and Relationships 3.85

2. Teamwork and 2.1.3 Procedures and QI champions lead functional QI teams in implementing discrete projects sponsored by 3.89 Collaboration 2.1 Team Performance Performance 4.10 4.02 QI/PM council high 2.2.1 Awareness and Use of Communities 3.96 2.2.2 Sharing and Leaders provide staff the opportunity to share results achieved through various 2.2 Communities Collaboration 3.60 3.76 mechanisms high 3.1.1 Establishing the Leaders incorporate QI into the organizations value statement/guiding principles Environment 3.65 high Leaders communicate to staff key messages and begin to demonstrate concrete

examples of messages: 1) QI not about placing blame or punishment; 2) QI is a way to make daily work easier and more efficient 3) QI is within reach of all staff and will get

easier with practice medium 3.1.2 Modeling Behavior 3.62 3.1.3 Coaching the 3.1 Culture Organization 3.22 3.52 3. Leadership 3.56

Leaders work with PM/QI council to develop a plan for the change process using deliberate change management strategies including timelines, costs, short/long term

3.2.1 Providing Resources 3.51 goals, communication and training plans, and implication for staff and stakeholders high

Leaders work with PM/QI council to continuously assess the culture of the agency

3.2.2 Providing Structure 3.48 including staff commitment and engagement and sustainability of progress toward in progress 3.2 Resourcing and 3.2.3 QI Training & Structure Development 3.85 3.60 4.1.1 Customer Data Identify the agency's customers and stakeholders to determine where customer Collection and Analysis 3.09 satisfaction should be assessed (may be identified in SP) next plan cycle 4.1.2 Use of Customer

4.1 Understanding the Data 3.05 Identify existing customer satisfaction data and data needs next plan cycle

Customer 4.1.3 Culture 3.07 3.06

4.2.1 Understanding the

Value Stream 2.60

4.2.2 Adding Value for 4. Customer Focus 4.2 Satisfying the Customers by improving 3.02 Customer through the Value Streams 2.43 Value Stream 4.2.3 External Use 2.23 2.47 4.3.1 Understanding Customer's Future Needs 3.78 4.3.2 Re-prioritizing

4.3 Reprioritizing and Existing, and Developing Creating Programs and New, Programs and Services Services 3.35 3.53

5.1.1 Strategic Planning Process5.1.1 Strategic Planning 4.18 5.1.2Process Strategic Plan 4.18 5.1 Strategic Planning Implementation5.1.2 Strategic Plan 3.45 4.00 Implementation 3.45 5.1 Strategic Planning 5.2.1 Performance 4.00 Measures5.2.1 Performance and Standar ds 3.04 5.2 Performance 5.2.2Measures Data andAnalysis Standards & 3.04 Measurement5.2 Performance Reporting5.2.2 Data Analysis & 2.91 3.00 Measurement 5.3.1Reporting Collecting and 2.91 3.00 5.3.1 Collecting and 5. Quality Improvement Analyzing Data for QI Plan Analyzing Data for QI Plan 3.00 3.24 5. QualityInfrastructure Improvement Development Development 3.00 3.24 Infrastructure 5.3.2 Developing the PM/QI Council develops a plan for establishing and implementing a PM system to PM/QI Council develops a plan for establishing and implementing a PM system to Annual5.3.2 Developing QI Plan the 2.96 monitor achievement of organizational goals and objectives high Annual QI Plan 2.96 monitor achievement of organizational goals and objectives 5.3 Annual Quality 5.3.3 Achieving Annual PM/QI Council begins to identify areas for improvement based on a gap analysis using Improvement5.3 Annual Quality Planning Improvements5.3.3 Achieving Annual 2.64 2.88 performancePM/QI Council data begins to identify areas for improvement based on a gap analysis using medium Improvement Planning Improvements5.4.1 Impact of Admin & 2.64 2.88 performance data Functional5.4.1 Impact Processes of Admin (i.e.& HR,Functional Finance, Processes Legal, IT) (i.e. 3.05 5.4 Administrative and Functional5.4 Administrative Process and and HR, 5.4.2 Finance, Supporting Legal, IT)QI 3.05 5.4.2 Supporting QI SystemsFunctional (e.g. Process HR) and Strategies 3.18 3.10 Strategies Systems (e.g. HR) 3.18 3.10 All staff practice using the seven basic tools of quality in daily work to identify root 6.1.1 Selecting causes of problems, assess efficiency of processes, interpret findings, and correct Appropriate QI Methods 4.15 problems low 4.15 The PM/QI council identifies and sponsors "winnable" QI projects using agency

6.1 Selecting and 6.1.2 Applying QI Methods performance data. QI efforts are linked to strategic priorities and identified from Applying Methods Effectively 3.81 3.94 performance data to the extent possible. low 6.2.1 Defining 3.81 3.94 Improvement Objectives Identify and train all staff on formal QI model like PDSA; or Lean; and the seven basic and Aim Statements 4.12 tools of quality medium 6.2.2 Analyzing Current 4.12 Work Processes to determine Root Causes 4.27 6.2.3 Identify Potential 4.27 Improvements and Develop Improvement Hypotheses 3.89 3.89 6.2 Planning for Process Improvements 6.2.4 Develop a Test Plan 3.95 4.04 6.3.1 Test the 3.95 4.04 Improvement Hypothesis 4.15 6.3.2 Study and Analyze 4.15 the Results 4.24 6. Contiinual Process 6.3 Testing Potential 4.24 3.79 Improvement Solutions 6.3.3 Act on Findings 4.00 4.18 6.4.1 Gathering 4.00 4.18 3.79 Knowledge from Subject Matter Experts 3.27 6.4.2 Extracting Learning 3.27 from Experiences 3.33 6.4 Extracting Lessons 6.4.3 Implementing and 3.33 Learned Sharing Learning 3.11 3.21 6.5.1 Identifying, 3.11 3.21 Validating, and Documenting Best Practices 3.80 3.80 6.5 Sharing of Best 6.5.2 Sharing and Practices Replicating Best Practices 3.90 3.83 6.6.1 Developing 3.90 3.83 6.6 Effectively Standardized Work 4.15

Installing Standardized 6.6.2 Teaching and Using 4.15 Work Standardized Work 3.65 3.83 6.7.1 Managing Work 3.65 3.83 6.7 Process Process Performance 3.18

Management, Results 6.7.2 Continually 3.18 and Continual Improving Work Improvement Processes 3.67 3.48 3.67 3.48

TOTAL SCORE: 3.61 NACCHO Roadmap to a Culture of Quality Phases NACCHO Roadmap to a Culture of Quality Phases Total Score Roadmap Phase

<2 Phase 1: No Knowledge of QI 2-2.9 Phase 2: Not Involved with QI Activities 3-3.9 Phase 3: Informal or Ad Hoc QI

4-4.9 Phase 4: Formal QI in Specific Areas of the Organization 5-5.9 Phase 5: Formal Agency-Wide QI

6 Phase 6: Culture of Quality

Appendix C: ISDH Project Proposal Form INDIANA STATE DEPARTMENT OF HEALTH (ISDH) Quality Improvement (QI) Project Proposal

To initiate a quality improvement project proposal or idea, complete this Quality Improvement Project Proposal form. There are two (2) parts to complete: project application and screening criteria. Completed forms and any questions can be submitted to the Quality Improvement Coordinator at [email protected].

PROJECT INFORMATION: Application

Project Name

Program(s) Impacted

Employee Name (or name of person responsible/process owner) Assistant Commissioner AC Approved? (AC) YES Proposed makeup of QI Project Team

Stakeholders and Customers impacted by this project (Describe Impact)

Requested month(s) to have event. (Note: the average prep time required for a Rapid Improvement Event is up to 2 months.)

PROJECT INFORMATION: Application

Program or Activity:

What Are We Trying to Accomplish? (A brief statement of the problem, its impact and SMART Aim)

SMART AIM: (See intranet for SMART Aim Worksheet)

How Will We Know That a Change is an Improvement? (Potential measures of success, including implications for future improvements building off of this project)

What Changes Can We Make That Will Result in an Improvement? How did you identify this opportunity, with what data, from what source(s)? (Please provide a brief description of the problem with any data currently available)

PROJECT INFORMATION: Project Screening Criteria

How does this process relate to the agency’s strategic priorities?

(Please check all that apply and provide a brief description)

☐Decrease disease incidence and burden

☐Improve response and preparedness networks and capabilities

☐Reduce administrative costs through improving operational efficiencies

☐Better use of information and data from electronic sources to develop and sponsor outcome driven programs

☐Improve relationships and partnerships with key stakeholders, coalitions, and networks throughout the State and the nation

For Internal Quality Improvement (QI) Team Use Only Date Received by OPHPM Date Reviewed Lean Practitioner (LP) Assigned

Appendix D: Project Tools and Techniques

Aim Statement – A brief statement clarifying the goal or purpose of a quality improvement project. Statements answer questions about what the organization is seeking to accomplish, target population and specific numerical values to achieve.

Cause and Effect Diagram – A problem-solving technique used to understand the underlying causes of a specific issue and determine effective solutions. The visual, diagram-based technique establishes the relationship of how all possible causes combine to produce the effect. Cause and Effect Analysis is similar to Root Cause Analysis although broader in concept in that CEA drives practitioners to look for multiple cause and effect relationships rather than a single root cause.

Check Sheet – A tool used to record and compile data as it occur, so that patterns and trends can be identified.

Control Chart – A tool used to monitor performance over time by identifying and distinguishing common and special causes of variation.

Flow – An advanced improvement method that seeks to improve work process capacity or throughput and reduce cycle time. It accomplishes this via performing tasks one at a time (vs. batch processing), balancing the work content between people, reducing wait time between process steps, and performing tasks as they are needed.

Gemba Walk (or Genba) – Go and see where the work is accomplished; the action of going to see the actual process, understand the work, ask questions and learn.

Histogram – A graphical tool used to summarize frequency distributions over time.

If, Then Statement – A proposed explanation which is unproven. A hypothesis must be tested in to be validated. Proposed improvement solutions that are derived from analysis are hypotheses that must be tested to be shown to be correct.

Kaizen (rapid improvement event) – An improvement method for making rapid process improvements. Typical application consists of: prior planning followed by fully executing the process improvement cycle over a period of days; performed at the sub-process level or where the work is done (“gemba”); focused on making improvements by detecting and eliminating waste.

Lean – A collection of principles and methods that focus on identification and elimination of waste in producing a product or deliv- ering service to customers.

Mistake-Proofing – An improvement method for minimizing human error within work processes.

Pareto Chart – A tool used to identify problems that offer the greatest potential for improvement by showing their relative frequency or size in a descending bar graph.

Plan-Do-Study-Act (PDSA) – A continuous quality improvement model for improving a process. Similar to the scientific method, PDSA steps involve the development of a hypothesis (Plan), an experiment or intervention (Do), evaluation or data analysis (Study/ Act).

Process Mapping – An improvement method in which a process is depicted graphically with relevant data that enables understanding and analysis for improvement. Includes methods such as Value Stream Mapping and Sub-Process/Swim Lane Mapping.

Scatter Diagram – A graphical tool used to identify the possible relationship between the changes observed in two different sets of variables.

Standardized Work – Documented methods which define how work is done. Standardized work reflects the best-known way to do something and is documented in a way that enables it to be effectively used while work is performed, resulting in decreased variation and a basis for continual process improvement.

Visual Management – A technique for enabling people to effectively manage their work through easily seen and understood visual indicators which make an abnormal condition stand out by: a) showing the current condition; b) showing what the standard is; and c) linking to an action.

Appendix E: Current Projects

SCOPE SOLVE SUSTAIN

Project Reviewed Challenge SIPOC Team Event Participant "Live" 30 Day 60 Day 90 Day 6 Month 1 Year Division Project Proposal Owner Sponsor Facilitator Proposal SIPOC Completion Metrics Target Gaps Solutions Action Plan by QIT Statement Confirmed Date Satisfaction Survey Date Update Update Update Update Update Received Date ISDH EXAMPLE 1/1/2015 Eden Bezy Pam Pontones 2/1/2015 Casey Kinderman Complete Complete Complete 3/1/2018 Yes Complete Complete 4/1/2017 Complete Complete Complete Complete 6/1/2018 Complete Complete Complete Complete Complete EPH Commercial Sewage Review Process Mike Metler Dr. Lovchik TRAINING n/a Complete Complete Yes Complete Complete 10/17/2016 Complete Complete Complete Complete Complete Complete Complete In Progress Finance Accounts Payable Stephanie Rencher Joe Fistrovich TRAINING n/a Complete Complete Yes Complete Complete 12/5/2016 Complete Complete In Progress Not Started Commissioner Grant Opportunities Ann Alley Pam Pontones TRAINING n/a Complete Complete Yes Complete Complete 2/22/2017 Complete Complete In Progress Not Started Not Started Not Started Not Started Not Started LHH Lead Reporting Dave McCormick Dr. Lovchik TRAINING n/a Complete Complete Yes Complete Complete 5/22/2017 Complete Complete In Progress Not Started Not Started Not Started Not Started Not Started LHH Lead Case Coordination Dave McCormick Dr. Lovchik Denise Wright n/a Complete Complete Yes Complete Complete 6/19/2017 Complete Complete In Progress Not Started Not Started Not Started Not Started Not Started VR Vital Records Data Sharing Anne Reynolds Terry Whitson Eric Vance n/a Complete Complete Yes Complete Complete 7/17/2017 Complete Complete Complete Complete Complete Complete In Progress Not Started Labs Media Labs Inventory Ryan Gentry Dr. Lovchik Patricia Truelove n/a In Progress Complete Yes Complete Complete 7/10/2017 Complete Complete In Progress Not Started Not Started Not Started Not Started Not Started CDPCRH Breast and Cervical Cancer 8/11/2017 Keylee Wright Art Logsdon Brian Busching In Progress In Progress In Progress No In Progress Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started ORC Personnel Policies Barb Killian Not Started Not Started Not Started No Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Commissioner IT Helpdesk 12/17/2017 Chris Mickens Trent Fox In Progress In Progress Not Started No Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started OPHPM Internship - Student Seeking Pam Pontones In Progress Not Started Not Started No Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started OPHPM Internship - Staff seeking Pam Pontones In Progress Not Started Not Started No Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started OPHPM Welcome to ISDH Pam Pontones Not Started Not Started Not Started No Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started MCH NBS Biosurveillance Megan Griffee In Progress Not Started Not Started No Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started MCH NBS Labs/APHL Not Started Not Started Not Started No Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Admin Printing Not Started Not Started Not Started No Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started MCH Youth Risk Behavior Survey In Progress Not Started Not Started No Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started DEP Invoicing Not Started Not Started Not Started No Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started WIC WIC Sharepoint Not Started Not Started Not Started No Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started EPH EPH In Progress Not Started Not Started No Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started Not Started

Works Cited

Centers for Disease Control and Prevention. 2013. Evaluation Guide: Writing SMART Objectives. Department of Health and Human Services, Atlanta: CDC Division for Heart Disease and Stroke Prevention.

Duranti. n.d. “Language as Culture.”

Health, Washington State Department of. Rev. 2013. “Washington State Department of Health Quality Improvement Plan.”

Michigan Local Public Health Accreditation Program. 2012. “Quality Improvement: Screening Criteria.”

National Association of County & City Health Officials. 2009. “Accreditation Coalition Quality Improvement Subgroup Consensus.”

Performance Management Collaborative. 2003. “The Turning Point Performance Management System.”

Public Health Accreditation Board. 2011. Acronyms and Glossary Terms Version 1.0. http://www.phaboard.org/wp-content/uploads/ PHAB-Acronyms-and-Glossary-of-Terms-Version-1.0.pdf.

Public Health Foundation. 2005. From Silos to Systems. Prepared for the Performance Management National Excellence Collabora- tive.

Public Health Foundation. 2013. Performance Management and Quality Improvement. http://www.phf.org/focusareas/pmqi/pages/default.aspx.

Swayne, Duncan, and Ginter. 2008. Strategic Management of Health Care Organizations. New Jersey: Jossey Bass.

The Performance Management Collaborative. 2003. The Turning Point Performance Management System. http://www.turningpoint- program.org/Pages/perfmgt.html.

18 Extended ISDH Performance Management and Quality Improvement Plan

June 2020-2021 The agency made intentional steps to assist in the mental health of its employees. This included contracting Documentation will include but is not limited to a description of the process, record of quality improvement with professionals to offer one-on-one sessions with a staff member from the Eskenazi Mobile Crisis Team; tools used outcomes, and lessons learned. In addition, to support the transparency of public health data the providing a crisis counseling support line for anyone on-site or remote; provide additional break areas for Metric Team will also be responsible for the creation of an internal and external-facing interface that those in the office to have an area to decompress; hanging signs to remind staff to get up and move, eat, provides stakeholders the ability to see the life cycle of a measure that outlines the agency’s culture of and take breaks; and reminding staff of the other resources available via the Anthem Employee Assistance performance management, status of all or individual measures, importance of the measure(s), involved Program (EAP). stakeholders, and the point of contact for the measure. Data-Driven: Mission & Vision Statement This extension will allow us the requisite amount of time needed to gather the data required to fully Vision statement: A healthier and safer Indiana understand the changes in culture since the plan was first established. ISDH has established a precedence Mission statement: To promote, protect, and improve the health of administering the Culture of Quality Assessment every two years and beginning July 2020 will be and safety of all Hoosiers. administering a Data Utilization and Performance Management Assessment. The Quality Improvement Team and ISDH Metrics Team will support administration of the assessments, analyze the results and Purpose: create goals and transition strategies to support the agency moving forward. The Indiana State Department of Health established the 2018-2020 Quality Improvement and Performance Additional Goals: Management (i.e. QI/PM) Plan on June 1, 2018. It sunsets on June 30, 2020. This document is intended to The Office of Public Health Performance Management (OPHPM) applied for a grant with the Association extend the current QI/PM plan until January 2021 to allow for more in-depth and accurate data collection. of State and Territorial Health Officials (ASTHO). The Indiana State Department of Health hopes to use the History: Capacity Building-Technical Assistance opportunity to update its current Performance Management cycle In 2017 the Indiana State Department of Health (ISDH) partnered with the National Association of County where the identified measure owners are responsible for inputting performance data, and it’s the sole and City Health Officials (i.e.NACCHO) to conduct a Culture of Quality assessment. This assessment was responsibility of the quality improvement – performance management coordinator to ensure that the originally intended for local health departments to gauge their continuous improvement culture. ISDH processes are in place, the system is functioning, and actively track the data to ensure the progress of adapted it to fit the needs of our agency. The results gained were used to provide the agency with data that agency goals. helped inform the transition strategies and goals found within the 2018-2020 Quality Improvement and Data are collected from a variety of sources throughout ISDH but the data utilization has been obsolete. Performance Management Plan. The transition strategies and goals found within the QI/PM plan was also ISDH’s capacity around performance management and how to utilize its outputs is fairly underutilized. The created and aligned with the 2018-2020 agency Strategic Plan. staff are hesitant to participate in a culture of actively tracking data due to lack of education, opportunity, To begin the process of implementing performance management processes into the agency, the agency and fear of the results. Public health is derived from using evidence-based practices and data-driven used the Strategic Plan as the basis for applying agency performance measures such as teaching staff information to make credible decisions on how best to serve the public. To support our program areas and about baselines, identifying measures of growth, and creating trackable (SMART) activities. At the time of create a system in which staff are actively engaged in data-framed conversations, ISDH needs to solidify a conception, the agency began outlining and defining each strategic plan measures and priorities. During this feedback loop for staff to track their defined measures or standards, analyze them, and identify how to time, the agency was also tracking agency strategic priorities through Excel spreadsheets. In 2019 the communicate this analysis back to the agency. With the guidance of ASTHO and our state and territorial agency purchased licenses to a VMSG platform that staff now use to track and store their activities and peers that are also participating in this opportunity, Indiana hopes to create a sustainable culture of progress to objectives daily. performance management that becomes habitual for day-to-day operations. ISDH plans to solidify the creation of the ISDH Metrics Team and with the guidance of the CBTA Major Event: opportunity to implement strategies and systems that support the infrastructure for an active performance Indiana reported in March 2020 it first case of the COVID-19 (novel coronavirus). A state of emergency was measurement culture. Our long-term goal of this process is that the ISDH Metrics Team will monitor the issued later the same month and ISDH activated the agency’s Continuity of Operations Plan to lead the measures on a quarterly basis to identify any areas of success, areas needing improvement and areas of COVID-19 response. ISDH executive staff, as well as the governor’s office, rolled out several dynamic concern. Specifically, the team will assess: 1) whether a measure is on track 2) whether the measure has changes to the agency’s day-to-day operations to address the safety of staff. Many of ISDH’s staff were been met; 3) why the objective was/was not met 4) action steps if needed; and 4) which quality switched to remote work and the agency was closed to the public. Because of this, the staff began to improvement trainings, tools or processes may help meet objective. If a measure is deemed as an area communicate in different ways. Many meetings were held through Microsoft Teams, a digital meeting of concern the Metrics Team will partner with the Quality Improvement Team to determine what quality platform included in Office 365. Other means of huddles and meetings were conducted via WebEx and chats. improvement tools could be implemented. All quality improvement project teams will complete appropriate documentation to be shared with staff and stakeholders.

TMENT OF HEALTH The agency made intentional steps to assist in the mental health of its employees. This included contracting Documentation will include but is not limited to a description of the process, record of quality improvement with professionals to offer one-on-one sessions with a staff member from the Eskenazi Mobile Crisis Team; tools used outcomes, and lessons learned. In addition, to support the transparency of public health data the providing a crisis counseling support line for anyone on-site or remote; provide additional break areas for Metric Team will also be responsible for the creation of an internal and external-facing interface that those in the office to have an area to decompress; hanging signs to remind staff to get up and move, eat, provides stakeholders the ability to see the life cycle of a measure that outlines the agency’s culture of and take breaks; and reminding staff of the other resources available via the Anthem Employee Assistance performance management, status of all or individual measures, importance of the measure(s), involved Program (EAP). stakeholders, and the point of contact for the measure. Data-Driven: This extension will allow us the requisite amount of time needed to gather the data required to fully understand the changes in culture since the plan was first established. ISDH has established a precedence of administering the Culture of Quality Assessment every two years and beginning July 2020 will be administering a Data Utilization and Performance Management Assessment. The Quality Improvement Team and ISDH Metrics Team will support administration of the assessments, analyze the results and Purpose: create goals and transition strategies to support the agency moving forward. The Indiana State Department of Health established the 2018-2020 Quality Improvement and Performance Additional Goals: Management (i.e. QI/PM) Plan on June 1, 2018. It sunsets on June 30, 2020. This document is intended to The Office of Public Health Performance Management (OPHPM) applied for a grant with the Association extend the current QI/PM plan until January 2021 to allow for more in-depth and accurate data collection. of State and Territorial Health Officials (ASTHO). The Indiana State Department of Health hopes to use the History: Capacity Building-Technical Assistance opportunity to update its current Performance Management cycle In 2017 the Indiana State Department of Health (ISDH) partnered with the National Association of County where the identified measure owners are responsible for inputting performance data, and it’s the sole and City Health Officials (i.e.NACCHO) to conduct a Culture of Quality assessment. This assessment was responsibility of the quality improvement – performance management coordinator to ensure that the originally intended for local health departments to gauge their continuous improvement culture. ISDH processes are in place, the system is functioning, and actively track the data to ensure the progress of adapted it to fit the needs of our agency. The results gained were used to provide the agency with data that agency goals. helped inform the transition strategies and goals found within the 2018-2020 Quality Improvement and Data are collected from a variety of sources throughout ISDH but the data utilization has been obsolete. Performance Management Plan. The transition strategies and goals found within the QI/PM plan was also ISDH’s capacity around performance management and how to utilize its outputs is fairly underutilized. The created and aligned with the 2018-2020 agency Strategic Plan. staff are hesitant to participate in a culture of actively tracking data due to lack of education, opportunity, To begin the process of implementing performance management processes into the agency, the agency and fear of the results. Public health is derived from using evidence-based practices and data-driven used the Strategic Plan as the basis for applying agency performance measures such as teaching staff information to make credible decisions on how best to serve the public. To support our program areas and about baselines, identifying measures of growth, and creating trackable (SMART) activities. At the time of create a system in which staff are actively engaged in data-framed conversations, ISDH needs to solidify a conception, the agency began outlining and defining each strategic plan measures and priorities. During this feedback loop for staff to track their defined measures or standards, analyze them, and identify how to time, the agency was also tracking agency strategic priorities through Excel spreadsheets. In 2019 the communicate this analysis back to the agency. With the guidance of ASTHO and our state and territorial agency purchased licenses to a VMSG platform that staff now use to track and store their activities and peers that are also participating in this opportunity, Indiana hopes to create a sustainable culture of progress to objectives daily. performance management that becomes habitual for day-to-day operations. ISDH plans to solidify the creation of the ISDH Metrics Team and with the guidance of the CBTA Major Event: opportunity to implement strategies and systems that support the infrastructure for an active performance Indiana reported in March 2020 it first case of the COVID-19 (novel coronavirus). A state of emergency was measurement culture. Our long-term goal of this process is that the ISDH Metrics Team will monitor the issued later the same month and ISDH activated the agency’s Continuity of Operations Plan to lead the measures on a quarterly basis to identify any areas of success, areas needing improvement and areas of COVID-19 response. ISDH executive staff, as well as the governor’s office, rolled out several dynamic concern. Specifically, the team will assess: 1) whether a measure is on track 2) whether the measure has changes to the agency’s day-to-day operations to address the safety of staff. Many of ISDH’s staff were been met; 3) why the objective was/was not met 4) action steps if needed; and 4) which quality switched to remote work and the agency was closed to the public. Because of this, the staff began to improvement trainings, tools or processes may help meet objective. If a measure is deemed as an area communicate in different ways. Many meetings were held through Microsoft Teams, a digital meeting of concern the Metrics Team will partner with the Quality Improvement Team to determine what quality platform included in Office 365. Other means of huddles and meetings were conducted via WebEx and chats. improvement tools could be implemented. All quality improvement project teams will complete appropriate documentation to be shared with staff and stakeholders. The agency made intentional steps to assist in the mental health of its employees. This included contracting Documentation will include but is not limited to a description of the process, record of quality improvement with professionals to offer one-on-one sessions with a staff member from the Eskenazi Mobile Crisis Team; tools used outcomes, and lessons learned. In addition, to support the transparency of public health data the providing a crisis counseling support line for anyone on-site or remote; provide additional break areas for Metric Team will also be responsible for the creation of an internal and external-facing interface that those in the office to have an area to decompress; hanging signs to remind staff to get up and move, eat, provides stakeholders the ability to see the life cycle of a measure that outlines the agency’s culture of and take breaks; and reminding staff of the other resources available via the Anthem Employee Assistance performance management, status of all or individual measures, importance of the measure(s), involved Program (EAP). stakeholders, and the point of contact for the measure. Data-Driven: This extension will allow us the requisite amount of time needed to gather the data required to fully 2018-2020 Goals and Objectives understand the changes in culture since the plan was first established. ISDH has established a precedence Strategic Goal Objectives Description of Materials Metric Status of administering the Culture of Quality Assessment every two years and beginning July 2020 will be administering a Data Utilization and Performance Management Assessment. The Quality Improvement Strategic Goal 2: Use a performance Though 2020, ensure strategic 100% of metrics have been Team and ISDH Metrics Team will support administration of the assessments, analyze the results and Promote and management metrics are reported as identified integrated into ISDH’s provide system to monitor in the ISDH SP create goals and transition strategies to support the agency moving forward. Performance Management. Purpose: transparent achievement of The Indiana State Department of Health established the 2018-2020 Quality Improvement and Performance Additional Goals: public health organizational Management (i.e. QI/PM) Plan on June 1, 2018. It sunsets on June 30, 2020. This document is intended to data objective The Office of Public Health Performance Management (OPHPM) applied for a grant with the Association extend the current QI/PM plan until January 2021 to allow for more in-depth and accurate data collection. of State and Territorial Health Officials (ASTHO). The Indiana State Department of Health hopes to use the Use a performance Beginning Q4 of 2018 through 6 of 9 reports are completed management system 2020, create quarterly reports. History: Capacity Building-Technical Assistance opportunity to update its current Performance Management cycle to monitor achieve- In 2017 the Indiana State Department of Health (ISDH) partnered with the National Association of County where the identified measure owners are responsible for inputting performance data, and it’s the sole ment of organizational and City Health Officials (i.e.NACCHO) to conduct a Culture of Quality assessment. This assessment was responsibility of the quality improvement – performance management coordinator to ensure that the objective originally intended for local health departments to gauge their continuous improvement culture. ISDH processes are in place, the system is functioning, and actively track the data to ensure the progress of agency goals. Foster a culture Achieve PHAB accreditation by The site visit was held in Febru- adapted it to fit the needs of our agency. The results gained were used to provide the agency with data that of organization Q4 2020 and maintain compliance ary 2020, and ISDH is awaiting a helped inform the transition strategies and goals found within the 2018-2020 Quality Improvement and Data are collected from a variety of sources throughout ISDH but the data utilization has been obsolete. excellence decision from the June 2020 Performance Management Plan. The transition strategies and goals found within the QI/PM plan was also ISDH’s capacity around performance management and how to utilize its outputs is fairly underutilized. The PHAB Meeting. created and aligned with the 2018-2020 agency Strategic Plan. staff are hesitant to participate in a culture of actively tracking data due to lack of education, opportunity, and fear of the results. Public health is derived from using evidence-based practices and data-driven Foster a culture Track the number of In 2018, there were 21 divisions To begin the process of implementing performance management processes into the agency, the agency of organization divisions/ programs that participated in QI activities; used the Strategic Plan as the basis for applying agency performance measures such as teaching staff information to make credible decisions on how best to serve the public. To support our program areas and excellence completing/participating in in 2019, there were 31 divisions Strategic Goal 5: about baselines, identifying measures of growth, and creating trackable (SMART) activities. At the time of create a system in which staff are actively engaged in data-framed conversations, ISDH needs to solidify a QI activities through 2020 who participated in QI activities; Improve and as of June 2020, 16 divisions conception, the agency began outlining and defining each strategic plan measures and priorities. During this feedback loop for staff to track their defined measures or standards, analyze them, and identify how to organizational have participated in QI activities. time, the agency was also tracking agency strategic priorities through Excel spreadsheets. In 2019 the communicate this analysis back to the agency. With the guidance of ASTHO and our state and territorial health and be agency purchased licenses to a VMSG platform that staff now use to track and store their activities and peers that are also participating in this opportunity, Indiana hopes to create a sustainable culture of an employer of performance management that becomes habitual for day-to-day operations. choice Foster a culture Assess the number of QI projects In 2018 there were 6 projects; progress to objectives daily. of organization annually through 2020 in 2019 there were 18 projects, ISDH plans to solidify the creation of the ISDH Metrics Team and with the guidance of the CBTA excellence in 2020 there have been 3 Major Event: opportunity to implement strategies and systems that support the infrastructure for an active performance projects, 27 cumulatively for Indiana reported in March 2020 it first case of the COVID-19 (novel coronavirus). A state of emergency was measurement culture. Our long-term goal of this process is that the ISDH Metrics Team will monitor the the strategic plan lifecycle. issued later the same month and ISDH activated the agency’s Continuity of Operations Plan to lead the measures on a quarterly basis to identify any areas of success, areas needing improvement and areas of COVID-19 response. ISDH executive staff, as well as the governor’s office, rolled out several dynamic concern. Specifically, the team will assess: 1) whether a measure is on track 2) whether the measure has Foster a culture Move the agency from Phase 3 to Using transition strategies and changes to the agency’s day-to-day operations to address the safety of staff. Many of ISDH’s staff were been met; 3) why the objective was/was not met 4) action steps if needed; and 4) which quality of organization Phase 4 on the Culture of Quality the weighted algorithm of the switched to remote work and the agency was closed to the public. Because of this, the staff began to excellence Self-Assessment by 2020. Culture of Quality Assessment improvement trainings, tools or processes may help meet objective. If a measure is deemed as an area we gauged the agency’s communicate in different ways. Many meetings were held through Microsoft Teams, a digital meeting of concern the Metrics Team will partner with the Quality Improvement Team to determine what quality progression and likelihood of platform included in Office 365. Other means of huddles and meetings were conducted via WebEx and chats. improvement tools could be implemented. All quality improvement project teams will complete appropriate moving from a Phase 3 to 4. The documentation to be shared with staff and stakeholders. latest scoring was 4.05 which means on the next Culture of Quality Assessment administered in July 2020 we should achieve this goal.

By December 31st, 2020, the ISDH Metrics Team will create an outlined process and structure to be defined within the Performance Management Plan. Action Step (concrete activity/task Timeline Resources Needed (consider internal (DOH) and external (ASTHO, other)) that can be assigned to 1-2 people) (by when) • People/stakeholders – IMT Team; Leadership; OPHPM Staff Meet with ISDH Metric Members • Time – 2 hours 2/7/20 • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; Leadership; OPHPM Staff Develop Subcommittees • Time – 2 hours (30mins during meeting) 2/14/20 • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Schedule Meetings for the • Time – 2 hours 2/17/20 Subcommittees • Tools/inputs – Assessment, Agenda, Materials Edit the current Performance • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Management Section of the QI/PM • Time – 10 hours 3/30/20 Plan • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee; Agency; Create an Extension Plan for Accreditation Team Current QI-PM (Adjusted for 4/30/20 • Time – 2 hours COVID-19) • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Review Final Edits of Extension Plan • Time – 2 hours 5/15/20 (Adjusted for COVID-19) • Tools/inputs – Assessment, Agenda, Materials Submit Final Product to OPA for • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Review and Graphics (Adjusted for • Time – 3 hours 5/20/20 COVID-19) • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee; Agency; Submit Final Product to OPA for Accreditation Team 5/30/20 Publishing (Adjusted for COVID-19) • Time – 3 hours • Tools/inputs – Assessment, Agenda, Materials Extension Plan Published on ISDH • People/stakeholders – Agency; Hoosiers 6/24/20 Nerve Center (Adjusted for COVID- • Time – 1 hour

19) • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Create a Strategy for Edits (use • Time – 2 hours 4/1/20-7/15/20 Team Planner feature to delegate) • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Peer Review the Document • Time – 1 hours 5/15/20 – 7/30/20 • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Administer Performance • Time – 1o hours 7/1/20-7/20/20 Management Assessment to ISDH • Tools/inputs – Assessment, Agenda, Materials

Introduce Data from Performance • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Management Assessment of ISDH • Time – 1 hours 7/15/20-8/15/20 to inform transition strategies and goals for 2021-2024 • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Peer Review the Document • Time – 1 hours 8/15/20 – 9/15/20 • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Review Final Edits of Extension Plan • Time – 2 hours 9/15/20-10/15/20 • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Submit Final Product to OPA for • Time – 3 hours 10/31/20 Review and Graphics • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee; Agency; Submit Final Product to OPA for Accreditation Team 11/15/20 Publishing • Time – 3 hours • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee; Agency; Accreditation Team Final Document Agency Reveal 12/1/20 • Time – 3 hours • Tools/inputs – Assessment, Agenda, Materials Notes:

• ASSUMPTIONS – We will have more staff that are willing to participate; normal project work will resume post-COVID response • SUSTAINBILITY – Leadership support; need for accreditation; documentation of the process Updates: With COVID-19 Response taking priority over our work we had to adjust our timelines to accommodate our new normal.

Short Term Goal 2: By June 30th, 2021, ISDH will have the SHA/SHIP tracking process integrated into our Performance Management system that ISDH, state agencies, and external partners can use to track state health flagship priorities. Action Step (concrete activity/task Timeline Resources Needed (consider internal (DOH) and external (ASTHO, other)) that can be assigned to 1-2 people) (by when) Meet with ISDH Metric Members • People/stakeholders – IMT Team; Leadership; OPHPM Staff • Time – 2 hours 2/7/20 • Tools/inputs – Assessment, Agenda, Materials Develop Subcommittees • People/stakeholders – IMT Team; Leadership; OPHPM Staff • Time – 30 mins 2/14/20 • Tools/inputs – Assessment, Agenda, Materials Schedule Meetings for the • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Subcommittees • Time – 1 hours 2/17/20 • Tools/inputs – Assessment, Agenda, Materials Train staff on VMSG Utilization • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee • Time – 2 hours 8/6/20 • Tools/inputs – Assessment, Agenda, Materials Create a Strategy for Identifying • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee owners of the SHA/SHIP • Time – 2 hours 9/1/20 • Tools/inputs – Assessment, Agenda, Materials Create a method for contacting the • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee identified owners • Time – 1 hours 9/15/20 • Tools/inputs – Assessment, Agenda, Materials Collect the data • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee • Time – 2 hours 9/20/20 - 9/30/20 • Tools/inputs – Assessment, Agenda, Materials Analyze the data • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee 10/1/20 - • Time – 30 hours 11/30/20 • Tools/inputs – Assessment, Agenda, Materials Create data visualization tool of the • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee 12/1/20 – 2/28/20

data • Time – 2 hours • Tools/inputs – Assessment, Agenda, Materials Communicate this with the agency • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee; Agency; about processes Accreditation Team 3/1/21 – 3/30/20 • Time – 2 hours/week • Tools/inputs – Assessment, Agenda, Materials Ensure that the process is included • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee; Accreditation in the next SHA/SHIP cycle Team 4/1/20 – 6/30/20 • Time – 2 hours • Tools/inputs – Assessment, Agenda, Materials Updates: With COVID-19 Response taking priority over this work we will continually revisit our timeline to adjust as needed.

Short Term Goal 3: By EOY (December 31, 2020), ISDH in conjunction with the Metrics Team will have a system to assess and analyze our culture of data utilization. Action Step (concrete activity/task Timeline Resources Needed (consider internal (DOH) and external (ASTHO, other)) that can be assigned to 1-2 people) (by when) Identify a Performance • People/stakeholders – IMT Team; Leadership; OPHPM Staff Management Assessment for State • Time – 2 hours 3/1/20 Health Departments • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; Leadership; OPHPM Staff Adapt the Performance • Time – 30 mins 3/10/20 Management for ISDH • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; Leadership; OPHPM Staff Continue to meet and discuss • Time – 30 mins 3/10/20 • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Administer a Performance • Time – 1 hours 7/1/20 – 7/20/20 Management Self-Assessment. • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Advertise/Promote the assessment • Time – 1 hours 7/1/20 – 7/20/20 throughout the agency • Tools/inputs – Assessment, Agenda, Materials Close the survey and develop a • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee 7/20/20-7/30/20 strategy for data analysis • Time – 2 hours

• Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Analyze the data and identify a • Time – 1 hours 8/1/20-8/15/20 current state/transition strategies • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Communicate this information • Time – 2 hours 8/15/20 – 8/30/20 with the PM Plan Sub. Committee • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Create a communication plan for • Time – 30 hours 8/30/20- 10/31/20 promotion in the agency • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Communicate outcomes with the • Time – 2 hours 8/30/20- 10/31/20 agency • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Evaluate the process and adjust • Time – 2 hours 11/1/20 • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Communicate metric tools and • Time – 2 hours 11/1/20 - ongoing resources to agency • Tools/inputs – Assessment, Agenda, Materials • People/stakeholders – IMT Team; ISDH-ASTHO Subcommittee Begin preparing for the next • Time – 2 hours 12/1/20 - ongoing administration of the assessment • Tools/inputs – Assessment, Agenda, Materials Updates: With COVID-19 Response taking priority over this work we will continually revisit our timeline to adjust as needed.