Minnesota Department of Health
Quality Improvement Plan
UPDATED MAY 2016
QU AL I T Y I M P R O V E M E NT P L AN
Minnesota Department of Health Quality Improvement Plan
Minnesota Department of Health
PO Box 64975
St. Paul, MN 55164-0975
651-201-5000
www.health.state.mn.us
For more information:
Minnesota Department of Health
Health Partnerships Division, Public Health Practice Section
PO Box 64975
St. Paul, MN 55164-0975
651-201-3880
[email protected]
www.health.state.mn.us/divs/opi
Contents
I. Purpose and Scope ........................................................................................................................................................................................ 3
II. Quality Improvement Structure .................................................................................................................................................................... 5
III. Quality Improvement Projects ..................................................................................................................................................................... 6
IV. Goals and Objectives ................................................................................................................................................................................... 7
V. Performance Monitoring and Reporting ...................................................................................................................................................... 8
VI. Training Plan ................................................................................................................................................................................................ 8
VII. Communication Plan .................................................................................................................................................................................. 8
VIII. Evaluation .................................................................................................................................................................................................. 9
IX. Appendices .................................................................................................................................................................................................. 9
Appendix A. MDH Quality Council Definitions ................................................................................................................................................ 10
Appendix B. Organizational QI Maturity at MDH ............................................................................................................................................ 12
Appendix C. Agency Performance Management ............................................................................................................................................ 18
Appendix D. MDH Quality Council Charter ..................................................................................................................................................... 21
Appendix E. QI Project Charter Template ....................................................................................................................................................... 24
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I. Purpose and Scope
The purpose of the Minnesota Department of Health (MDH) Quality Improvement (QI) Plan is to guide the development, implementation,
monitoring and evaluation of quality improvement efforts throughout the organization. The QI Plan provides a framework for the MDH
Quality Council to use to enhance the culture of quality at MDH. It focuses on the central themes of advancing a culture of quality:
leadership; QI structure and infrastructure; continuous process improvement; capacity building; customer satisfaction; QI
communication; and recognition of QI efforts.
The QI Plan outlines MDH’s broad QI goals, as well as specific objectives, and provides a realistic annual work plan for achieving those
goals. As a result of the vision and activities outlined in this plan, MDH will be better able to protect, maintain and improve the health of
all Minnesotans.
Quality Improvement Defined
Quality improvement in public health is the use of a deliberate and defined improvement process which is focused on activities that are
responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable
improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or
processes which achieve equity and improve the health of the community (refer to Appendix A. MDH Quality Council Definitions).
As defined by the MDH Quality Council, quality improvement is about:
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Intentionally and continually looking for ways to do our work better and adapt to change;
Empowering employees to identify and make improvements;
Meeting the needs of our customers; and
Using data and information for decision making.
Culture of Quality Defined
A mature culture of quality is exhibited by an agency when QI is fully embedded into the way business and operations are conducted
across all levels, departments, and programs. Leadership and staff are fully committed to quality and the results of QI efforts are
communicated internally and externally. Even if leadership changes, the basics of QI are so ingrained in staff that root causes of problems
are always identified. - Roadmap to an Organizational Culture of Quality Improvement, National Association of County and City Health
Officials, Fall 2012.
Culture of Quality at MDH
PHAB Perspective
In the post-Accreditation PHAB Annual Report to MDH dated April 2015, MDH was recognized for achieving the Governor’s Continuous
Improvement Award in 2014. Not only was MDH the only state agency to achieve recognition but four MDH quality improvement
projects also received the Governor’s Award for Continuous Improvement. PHAB also praised MDH for having a “very active” Quality
Council and noted that the number of QI projects have increased annually.
In terms of opportunities for improvement, PHAB suggested that it might be beneficial for the agency to identify QI projects that are
administrative in nature and/or that engage additional divisions. Additionally, although MDH offers a three hour QI 101 course, the
agency might consider offering a shorter one-hour online introduction to QI for all staff.
MDH Quality Council Perspective
In the spring of 2014, MDH Quality Council members informally assessed the agency’s QI maturity status based on the Roadmap to a
Culture of Quality Improvement produced by the National Association of County and City Health Officials (NACCHO). They concluded that
MDH’s current culture of quality may be described by the following characteristics:
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Discrete QI efforts are practiced in isolated instances.
Data is used but not consistently across divisions. Data is not used routinely for decision-making.
Staff views QI as extra work.
There is general lack of knowledge across the board about QI.
There is more QI activity and capacity building occurring.
Technical assistance from the Public Health Practice Section is valuable.
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Throughout 2015, Council members’ general view of MDH’s culture of quality remained the same with the exception of QI knowledge
which was recognized as improving across the agency. Council members expressed that several factors were contributing to advancing
the culture of quality, including: more leaders at the division and section level being supportive of QI; an increase in the number of QI
committees or teams at the division level; an uptick in activity around development of performance measures, process improvement and
standardizing processes; and a higher level of ownership of QI (empowerment).
Council members also identified a few key challenges. Staff are still learning about “what is a good fit” for a QI project. There is a need to
increase the understanding of “process.” Divisions need tools to identify and prioritize division-wide QI projects and to develop divisionlevel QI infrastructures. Also, staff don’t always tie QI to their work and are not using QI tools routinely for problem-solving.
QI Maturity Tool
MDH uses a series of ten questions that measure QI maturity through use of an all-employee survey which is conducted every other year.
Results from the MDH QI Maturity Tool indicate an increase in the agency QI Maturity Score between 2011 and 2016 (refer to Appendix
B. Organizational QI Maturity at MDH). The QI Maturity Score corresponds to the aforementioned Roadmap to a Culture of Quality
Improvement.
In order to establish a short-term vision for QI at MDH, Council members were asked what they would like the agency to look like a year
from now in terms of QI. Responses included:
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MDH staff are able to identify their customers and routinely ask customers for feedback.
There is an increase in employee QI aptitude.
There is an increase in the number of QI champions in the department.
Complaints are seen as opportunities for improvement. Every program has a complaints process.
Leaders (at all levels) talk about QI.
Survey respondents don’t have to answer “I don’t know” to the QI questions.
Procedures are documented.
Improvements are documented. The Minnesota Office of Continuous Improvement’s Project Reporting and Tracking Tool is used.
The longer-term vision for QI at MDH is achieving the definition of a culture of quality (as described above) and as characterized by the
following “human” and “process” characteristics based on Phase 6 of the Roadmap to a Culture of Quality Improvement:
“Human” Characteristics
“Process” Characteristics
People are highly valued in the organization.
A fully integrated performance-management system is in place.
Ongoing QI trainings and resources are provided.
Progress is routinely reported to internal and external customers.
QI knowledge and skills are strong across majority of staff.
QI competencies and action plans are incorporated in job
descriptions and performance appraisals.
Problems are viewed as “gold” by all staff.
“Top-down” and “bottom-up” approach to QI is prevalent.
QI is integrated into all agency planning efforts, and all efforts
align with strategic goals.
All staff are completely committed to the use of QI to
continuously improve daily work.
Data analysis and QI tools are used in everyday work.
Customer is the primary focus.
Solidarity among staff is strong, and staff turnover tends to be low.
Innovation and creativity is the norm.
The organization is viewed as a QI expert in the field.
Agency operations are outcome-driven.
Return on investment is demonstrated.
Emerging issues are viewed as opportunities to use QI, rather
than reason to avoid QI.
Agency shares successes and contributes to the evidence base of
public health.
Performance Management System Defined
A fully functioning performance management system that is completely integrated into health department’s daily practice includes: 1)
setting organizational objectives across all levels of the department, 2) identifying population indicators and performance measures to
assess progress toward achieving objectives, 3) operationalizing a system to monitor and report progress, and 4) engaging in focused
quality improvement efforts when performance gaps are identified (refer to Appendix A. MDH Quality Council Definitions).
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Performance Management System at MDH
Performance management at MDH is the practice of using data for decision-making by establishing results and standards; using data for
measurement; monitoring and communicating progress toward those results; and engaging in quality improvement activities when
desired progress is not being made. Quality improvement is an essential component of this broader system.
Use of a performance management system not only facilitates the achievement of improved health outcomes, it ties to the agency
mission of protecting, maintaining and improving the health of all Minnesotans. It also relates to the value of accountability—operating
with open communication, transparency, timeliness and continuous quality improvement.
MDH’s Performance Management System is outlined in Policy number – 702.03: Agency Performance Management (refer to Appendix C.
MDH Agency Performance Management Policy). This policy, adopted in May of 2014, requires performance management to occur at
every level of the organization, with all employees having a role in identifying and engaging in continuous quality improvement. The
policy outlines the performance management procedure and specific responsibilities for Deputy/Assistant Commissioners, Division/Office
Directors and for the Public health Practice section.
MDH will realize the following benefits of a performance management system as it matures:
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Alignment of quality improvement initiatives with agency strategic priorities
Increased ability to use data to communicate
Targeted improvement efforts resulting in increased efficiency and effectiveness
Increased customer satisfaction
Ultimately, improved health outcomes for all Minnesotans
II. Quality Improvement Structure
Engaging in continuous quality improvement is expected at all levels across the department. Key roles and responsibilities for QI include:
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The Executive Leadership Team (ELT) will demonstrate support for continuous quality improvement. The ELT is represented on
the Quality Council.
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The Health Directors group will review and provide feedback on Quality Council project priorities at least annually. They may
refer any agency-wide quality improvement opportunities to the Council or other appropriate group or committee for
consideration and/or required action. The Health Directors will also demonstrate leadership support for continuous quality
improvement.
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MDH’s Quality Council will provide support to department leaders for building a culture of continuous quality improvement.
The Council will be a source of leadership and direction for agency-wide quality improvement projects at MDH, as well for
discrete QI projects that can be replicated in other areas. The Council will also provide support and guidance for building
capacity for QI on all levels, communicating and sharing QI activities and resources and recognizing QI work and successes (refer
to Appendix D. MDH Quality Council Charter).
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Budget and staff resources within the Public Health Practice Section will provide consultation, facilitation and training for
quality improvement efforts throughout the department. This includes but will not be limited to: facilitation of the MDH Quality
Council; consultation or facilitation for agency-wide QI projects, as appropriate; design and delivery of QI trainings;
communication of QI activities; and development, housing and promotion of QI resources.
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Division Directors and Assistant Division Directors are expected to have a basic understanding of quality improvement
(definition, purpose, basic concepts), to lead by example, and to foster a culture of quality within their respective divisions. This
may include: assessing and addressing QI training needs; referring priority agency-wide QI opportunities to the Quality Council
or other workgroups; encouraging managers/supervisors and their staff to integrate QI into their daily work; supporting a
division quality councils/teams; and recognizing those who contribute to quality efforts, efficiencies and cost savings. Division
managers are responsible for using performance measures to manage the work of their division.
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Managers/supervisors are expected to have a basic understanding of quality improvement (definition, purpose, basic concepts).
They will lead by example and foster a culture of continuous quality improvement within their sections, units and program
areas. This includes addressing QI training needs; referring any potential cross-section/unit/program QI opportunities to
Division Directors; encouraging staff to use QI tools and integrate QI into their daily work; and recognizing those who contribute
to quality efforts, efficiencies and cost savings. Section/Unit/Program managers and supervisors should use performance
measures to make data driven decisions. They are expected to identify and put forward opportunities for improvement.
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All employees are expected to continually look for ways to do their work better, share those ideas with their colleagues and
supervisors, and to contribute and adapt to change. Employees are expected to participate in quality improvement initiatives,
as needed.
III. Quality Improvement Projects
Quality Council members will review and prioritize ideas submitted as potential quality improvement opportunities at least annually.
Ideas will be submitted by Council members on the Quality Council SharePoint site under Member Ideas Submission. Select ideas will
then be presented to the Health Directors group for feedback and guidance. Priority will be placed on projects that align with the
agency’s strategic priorities, have a significant impact on customers, and are feasible to implement based on resources and timing.
Council members may also identify agency-wide QI opportunities (or opportunities that might involve more than one division) through
one or more of the following sources:
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Requests from leadership groups, such as the Executive Leadership Team or the Health Directors
Accreditation Improvement or Action Plans
Strategic Plan
State Health Improvement Plan
Other agency-wide assessments and surveys, such as the annual employee survey
Agency-wide and division or office performance measure data
Division-level projects that have the potential to be replicated
Implementation of Agency-Wide QI Projects
Agency-wide QI projects may be sponsored by a Council member or non-member and led by staff in the appropriate division or office.
Staff from the Public Health Practice Section and/or Agency Project Planning will offer project consultation and/or facilitation, as
requested and as appropriate.
Project teams are expected to:
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Document the answers to the questions:
o What are we trying to accomplish?
o How will we know that a change is an improvement?
o What changes can we make that will result in an improvement?
Develop a Project Charter that outlines how the team will operate and what it will accomplish (refer to Appendix E. QI Project
Charter Template)
Use project management principles
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Use a proven QI methodology, such as Plan-Do-Study-Act, Lean or Six Sigma
Document key steps of the process
Report results to the Council
Share documents, tools, lessons learned, etc. with others throughout the department
Develop a brief project summary
Division/Office-Level QI Projects
In order to integrate QI at all levels of the agency, each division and office is responsible for identifying, implementing, monitoring,
evaluating and documenting QI projects. The Quality Council requests that all quality improvement activities are documented in the
MNCI Project Reporting and Tracking Tool. The purpose of this documentation is to assess the spread of QI throughout the department
and state government, identify QI expertise and experience, create a mechanism for connecting with others engaged in QI, identify
projects that have department or state-wide significance and assist in communicating and celebrating successes. Public Health Practice
Section staff and Agency Project Planning staff are available to provide additional support and technical assistance as needed.
Quality improvement projects at all levels will be encouraged to follow “project management” principles to provide structure to the
activity. This helps ensure clear purpose and scope, commitment of necessary resources, specified timeframes, expected level of effort,
management sponsorship and support, clear decision/implementation authority, and anticipated outcomes.
To ensure success, QI project teams should include individuals at various levels including “frontline” staff, program managers, division
directors, and other staff or stakeholders. A QI project team may be developed to address a single project or the team may be in place on
a long-term basis to address a series of related QI projects over time.
IV. Goals and Objectives
In order to assess and monitor progress in advancing the culture of quality at MDH, the Quality Council updates the QI Plan annually.
Within the QI Plan are goals, objectives and an annual work plan. Goals are established based on results from the QI Maturity Tool,
Council members’ vision for quality improvement at MDH, and on recommended transition strategies from the NACCHO Roadmap to an
Organizational Culture of Quality.
The following goals and objectives were based on several themes related to creating and sustaining a culture of quality: leadership, QI
structure, continuous process improvement, capacity building, customer satisfaction, communication and recognition.
Goal 1
Goal 2
Leadership at all levels communicates the importance and value of quality improvement internally and externally (with
stakeholders).
1a.
The Commissioner recognizes quality improvement efforts at two or more all-employee events by December 31, 2016.
1b.
Each Assistant Commissioner communicates one or more quality projects from their bureau at a Town Hall meeting or
other forum or through another medium by December 31, 2016.
1c.
Eighty percent of managers and supervisors queried report using at least one suggestion or recommendation from the QI
Talking Points with their staff in the past year by December 31, 2016.
Quality improvement is institutionalized into MDH’s structure.
2a.
Goal 3
Goal 4
The Quality Council QI Plan aligns with the new MDH Governance structure by March 31, 2016.
All staff at MDH will have an understanding of QI concepts and practices, including the use of data to make decisions.
3a.
Twenty-five percent of MDH staff from each division will have completed the MDH QI 101 training by December 31, 2016.
3b.
Develop and implement a strategy to train leaders on their QI role by December 31, 2016.
3c.
Develop and distribute a tip sheet for QI teams on how to share QI successes and lessons learned by June 30, 2016.
3d.
Explore a quality improvement certificate program for MDH staff by June 30, 2016.
3e.
Share a minimum of four successful experiences of using data for QI on the intranet by December 31, 2016.
MDH seeks and uses feedback from customers for continuous quality improvement.
4a.
Share a minimum of one QI project that used customer feedback for metrics at the Performance Measures User Group by
December 31, 2016.
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Goal 5
MDH values and recognizes staff quality improvement efforts.
5a.
Recognize all MDH submitted nominations for the Governor’s CI Awards through the intranet by January 31, 2016.
5b.
The Commissioner personally recognizes team members from all MDH submitted nominations for the Governor’s CI
Awards by February 15, 2016.
5c.
Representation from the Executive Office is present at a minimum of two quality improvement project celebrations by
December 31, 2016.
5d.
Each Quality Council member shares at least one QI success from their division on the intranet by December 31, 2016.
In order to achieve the above goals and objectives, the Quality Council will develop a detailed annual work plan which will be available on
the Quality Council SharePoint site.
V. Performance Monitoring and Reporting
A.
The Council will review the QI Plan and related processes annually to ensure they remain adaptive to change and meet the
needs of all who are impacted by QI efforts. The evaluation will include comparison of actual results to objectives outlined in
Section IV. Analysis of gaps in performance will inform the annual plan updating process.
B.
The status and results of quality improvement projects managed by the Council will be reported to the Health Directors, as
dictated by the Health Directors’ project reporting procedures.
C.
The Council Chair will present an annual summary to the Health Directors which summarizes:
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Progress on achieving QI Plan Objectives and related work plan activities and measures
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Achievement on the comprehensive QI Maturity Score and data from the ten questions that comprise the QI Maturity
Tool
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Additional Council performance measures, if available
VI. Training Plan
Developing staff capacity and competency to engage in continuous quality improvement is an essential component to building a culture
of quality. In addition to objectives 3a, 3b, 3c, 3d, and 3e in Section IV, the Quality Council will support the following activities:
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Encourage offices and divisions to consult with Public Health Practice Section staff for QI training, consultation and technical
assistance needs.
Offer QI 101 and Process Improvement Measurement training quarterly through ELM.
Encourage and promote QI trainings to MDH staff and managers/supervisors which are offered by external partners, such as
through the Minnesota Office of Continuous Improvement.
Encourage networking and learning from others through the MDH Performance Measures User Group and the MNCI CI
Community of Practice.
VII. Communication Plan
Clear and consistent communication about QI is also critical to building a culture of continuous quality improvement throughout the
agency. In addition to the objectives outlined within Goal 5 in Section IV, the Council will engage in the following strategies and actions:
Recognizing Quality Improvement Efforts
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Acknowledge QI efforts and successes through Star Honors, Team Galaxy Awards and announcements on the MDH intranet
homepage.
Provide recognition of QI efforts from the Commissioner and the Assistant Commissioners at all-employee events/forums and
through other venues.
Oversee MDH’s nomination process for the Governor’s Continuous Improvement Awards. Acknowledge these QI projects on
the MDH intranet homepage.
Publicize and archive completed QI projects in the MNCI Project Reporting and Tracking Tool.
Documenting QI Project Activity
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Request that agency-wide QI projects are documented on a one-page project summary upon project completion.
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Strongly encourage division and office-level projects to develop a project summary and document activities in the MNCI Project
Reporting and Tracking Tool.
Reporting Regularly on QI Efforts and Achievements
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Provide an annual Quality Council status report to the Health Directors.
Invite QI project (agency-wide and division/office/program specific) leads to present project summaries to the Quality Council
upon project completion.
Share results of QI efforts with the MDH Performance Measures User Group and at MNCI CI Community of Practice meetings.
Enhancing, Maintaining, and Promoting QI Resources and Tools
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Promote QI tools, resources, and trainings through links from the MDH Intranet home page to the MDH external webpage for
QI: MDH: Quality Improvement & Performance Management.
Organizing and Sharing QI Documents on SharePoint
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Use the Quality Council SharePoint site to store documents from the Quality Council.
VIII. Evaluation
The effectiveness of the QI Plan will be measured by the following methods:
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Monitoring the MDH QI Maturity Score
Assessing the achievement of QI Plan goals and objectives
Assessing the completion of the annual Quality Council Work Plan and the status of work plan performance measures
IX. Appendices
Appendix A: MDH Quality Council Definitions
Appendix B: Organizational QI Maturity at MDH
Appendix C: Agency Performance Management Policy
Appendix D: MDH Quality Council Charter
Appendix E: QI Project Charter Template
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Appendix A. MDH Quality Council Definitions
UPDATED JANUARY 2016
Accreditation: According to the Public Health Accreditation Board (PHAB), Accreditation is defined as:
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The development of a set of standards, a process to measure health department performance against those standards, and
some form of reward or recognition for those agencies meeting the standards.
The periodic issuance of credentials or endorsements to organizations that meet a specified set of performance standards.
A voluntary conformity assessment process where an organization or agency uses experts in a particular field of interest or
discipline to define standards of acceptable operation/performance for organizations and measure compliance with them. This
recognition is time-limited and usually granted by nongovernmental organizations.
Alignment: Alignment is the consistency of plans, processes, information, resource decisions, actions, results and analysis to support key
organization-wide goals. Source: Baldrige National Quality Program. (2005).
Competencies: Core competencies are fundamental knowledge, abilities, or expertise associated in a specific subject area or skill set.
Source: Nash DB, Reifsnyder J, Fabius RJ, and Pracilio VP. (2011). Population Health: Creating a Culture of Wellness. Sudbury, MA: Jones
and Bartlett.
Continuous Quality Improvement (CQI): Continuous Quality Improvement (CQI) is an ongoing effort to increase an agency’s approach to
manage performance, motivate improvement, and capture lessons learned in areas that may or may not be measured as part of
accreditation. The primary goals are to improve the efficiency, effective-ness, quality, or performance of services, processes, capacities,
and outcomes. Source: Centers for Disease Control and Prevention, National Public Health Performance Standards Program and Public
Health Foundation. (2007). Acronyms, Glossary, and Reference Terms.
Customer Satisfaction: Customer satisfaction is a measure of how products and services supplied by an organization meet or surpass
customer expectations. Customer satisfaction is the number of customers, or percentage of total customers, whose reported experience
with an entity, its products, or its services (ratings) exceeds specified satisfaction goals. Source: Farris PW, Bendle NT, Pfeiffer PE,
ReibsteinDJ. (2010). Marketing Metrics: The Definitive Guide to Measuring Marketing Performance. Upper Saddle River, NJ: Pearson
Education, Inc.
Data: Data are factual information (as measurements or statistics) used as a basis for reasoning, discussion, or calculation. Data are
information in numerical form that can be digitally transmitted or processed. Source: Merriam-Webster Online. Data – Definition and
More. Online: http://www.merriam-webster.com/dictionary/data.
Goals: The term “goals” refers to a future condition or performance level that one intends to attain. Goals can be both short- and longerterm. Goals are ends that guide actions. Quantitative goals, frequently referred to as “targets,” include a numerical point or range.
Source: Baldrige Performance Excellence Program. (2002). Goals. Baldrige Business, Public Sector, and other Nonprofit Glossary. Online:
http://www.baldrige21.com/BALDRIGE_GLOSSARY/BN/Goals.html.
Lean: Lean refers to a collection of principles and methods that focus on the identification and elimination of non-value added activity
(waste) involved in producing a product or delivering a service to customers. Source: James Womack, Daniel Jones, and Daniel Roos
coined the term “lean” in their 1990 book, The Machine that Changed the World, to describe the manufacturing paradigm (often referred
to as the Toyota Production System).
Mission: A mission statement is a description of the unique purpose of an organization. The mission statement serves as a guide for
activities and outcomes and inspires the organization to make decisions that will facilitate the achievement of goals. Source: Centers for
Disease Control and Prevention, National Public Health Performance Standards Program and Public Health Foundation. (2007). Acronyms,
Glossary, and Reference Terms.
Objectives: Objectives are targets for achievement through interventions. Objectives are time limited and measurable in all cases.
Various levels of objectives for an intervention include outcome, impact, and process objectives. Source: Turnock, BJ. (2009). Public
Health: What It Is and How It Works. 4th ed. Sudbury, MA: Jones and Bartlett.
Performance Management: Performance Management uses data for decision-making, by setting objectives, measuring and reporting
progress toward those objectives, and engaging in quality improvement activities when desired progress toward those objectives is not
being made.
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. Source: Public Health
Accreditation Board. (2011). Standards and Measures Version 1.0. PHAB: Alexandria, VA. Online: http://www.phaboard.org/wpcontent/uploads/PHAB-Standards-and-Measures-Version-1.0.pdf.
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Performance Measure: Data that determines progress toward a specific program, service, product or process target. Performance
measures indicate how much, how well and at what level products and services are provided to customers. Measures may be expressed
in a number, percent or other standard unit.
Plan-Do-Study-Act (PDSA): PDSA refers to the process of continual improvement and learning proposed by Walter Shewhart and
espoused by W. Edwards Deming. The letters stand for Plan, Do, Study, and Act. The four stages of the PDSA cycle: Plan – the change to
be tested or implemented; Do – carry out the test or change; Study – data before and after the change and reflect on what was learned;
Act – plan the next change cycle or full implementation. Also sometimes called Plan-Do-Check-Act (PDCA).
Program Evaluation: Program evaluation is defined as the systematic application of social [or scientific] research procedures for assessing
the conceptualization, design, implementation, and utility of social [community] intervention programs. Source: Rossi PH, Freeman HE,
Lipsey MW. (1999). Evaluation: A Systematic Approach (6th ed.). Sage: Thousand Oaks, CA.
Quality Assurance: Quality Assurance consists of planned and systematic activities implemented in a quality system so that quality
requirements for a product or service will be fulfilled. Source: American Society for Quality.
Quality Improvement (QI): Quality improvement in public health is the use of a deliberate and defined improvement process, such as
Plan-Do-Check-Act, which is focused on activities that are responsive to community needs and improving population health. It refers to a
continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability,
outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community.
Source: Riley WJ, Moran JW, Corso LC, Beitsch LM, Bialek R, and Cofsky A. (2010). Defining Quality Improvement in Public Health. Journal
of Public Health Management and Practice 16(1), 5-7.
Quality Improvement Plan: The Quality Improvement Plan is a basic guidance document indicating how the department will manage,
deploy, and review quality throughout the organization. The main focus is on how we deliver our products and services to our customers
and how we ensure that we are aligned to their needs. The Quality Improvement Plan describes the processes and activities that will be
put into place to ensure that quality deliverables are produced consistently. Over time, the Quality Improvement Planning, business
planning, and strategic planning will integrate themselves into one aligned document. Initially, however, the Quality Improvement Plan
needs to be separate to give it the proper focus and attention throughout the organization. Source: Kane T, Moran JW, and Armbruster S.
(2010). Developing a Health Department Quality Improvement Plan. Public Health Foundation. Online:
http://www.phf.org/resourcestools/documents/developing_a_quality_improvement_plan.pdf.
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. Source: Swayne LE, Duncan WJ, and
Ginter PM. (2008). Strategic Management of Health Care Organizations. Jossey-Bass: New Jersey.
Training: Training for the public health workforce includes the provision of information through a variety of formal, regular, planned
means for the purpose of supporting the public health workforce in maintaining the skills, competencies, and knowledge needed to
successfully perform their duties. Source: Institute of Medicine. (2003). Who Will Keep the Public Healthy? National Academies Press:
Washington, DC.
Values: Values (and principles) describe how the work is done, what beliefs are held in common as the basis for the work. Source: Public
Health Accreditation Board.
Vision: Vision is a compelling and inspiring image of a desired and possible future that a community seeks to achieve. A vision statement
expresses goals that are worth striving for and appeals to ideals and values that are shared among stakeholders. Source: Bezold, C. (1995).
On Futures Thinking for Health and Health Care: Trends, Scenarios, Visions, and Strategies. Institute for Alternative Futures and the
National Civic League: Alexandria, VA.
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Appendix B. Organizational QI Maturity at MDH
Overview and History
MDH uses 10 questions to measure quality improvement (QI) maturity, as recommended by Minnesota’s public health practice-based
research network. These 10 questions span three key domains of quality improvement: organizational culture, capacity/competency, and
alignment/spread.*
Organizational Culture
1.
2.
3.
4.
Staff members are routinely asked to contribute to decisions at my public health agency.
When trying to facilitate change, staff has the authority to work within and across program boundaries.
The key decision makers in my agency believe quality improvement is very important.
MDH currently has a pervasive culture that focuses on continuous quality improvement.
Capacity/Competency
5.
6.
7.
The leaders of my division use basic methods for evaluating and improving quality, such as Plan-Do-Study-Act.
My public health agency has a quality improvement plan.
MDH currently has a high level of capacity to engage in quality improvement efforts.
Alignment/Spread
8.
Job responsibilities for many individuals responsible for programs and services at my division include those specific to
measuring and improving quality.
9. Customer satisfaction information is routinely used by many individuals responsible for programs and services in my public
health agency.
10. MDH currently has aligned our commitment to quality with most of our efforts, policies and plans.
MDH began to use these 10 questions to monitor organizational QI maturity through annual surveys of all employees, beginning in 2011.
In 2013, Minnesota community health boards began reporting annually on these questions through the Local Public Health Planning and
Performance Measurement Reporting System (PPMRS).
MDH Surveys, 2011-2016
Date
Responses (Count)
Response Rate
Agency Culture and QI Efforts
June 2011
1,111
73%
Employee Engagement and Quality Maturity
Sept. 2012
990
65%
MDH Employee Survey
Feb. 2014
1,136
80%
MDH Employee Survey
Feb. 2016
1.174
79%
The initial goals of the survey were to broaden assessment of QI maturity beyond the top officials to include all employees, and to
establish state and local baseline QI maturity scores. The QI maturity score is calculated based on responses to the 10 questions above.
QI Maturity Score
The QI maturity score corresponds to the Roadmap to an Organizational Culture of Quality Improvement produced by the National
Association of County and City Health Officials:
Score
Meaning
0.0-2.9
Low QI: No knowledge, not involved, starting to get involved
3.0-3.9
Medium QI: Ad hoc QI
4.0+
High QI: Borderline formal QI, formal QI, QI culture
*
These 10 measures are a representative subset of a much more extensive 37-item survey developed, tested, and administered
nationally to top public health officials as a way to measure the QI maturity of individual health departments. For more information, see:
Joly BM, Booth M, Mittal P, et al. (2012). Measuring quality improvement in public health: The development and psychometric testing of
a QI maturity tool. Eval Health Prof 35(2): 119-47.
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The QI maturity score (as of now) is simply being used to measure progress of MDH (and the LPH system) in increasing organizational QI.
A target has not been set for MDH.
MDH organizational QI maturity score, 2011-2016
5.00
High QI
(4.0+)
4.00
3.00
3.20
3.10
2.00
2.70
Medium QI
(3.0-3.9)
Low QI
(0.0-2.9)
2.28
1.00
MDH QI Score
0.00
2011
2012
2013
2014
2015
2016
MDH Employee Survey Results
Organizational Culture: All Questions
Organizational culture question responses (strongly agree or agree),
MDH all-employee surveys, 2011-2016
100%
Staff members are routinely asked
to contribute to decisions at my
public health agency
75%
70%
56%
50%
50%
49%
37%
45%
35%
43%
When trying to facilitate change,
staff has the authority to work
within and across program
boundaries
The key decision makers in my
agency believe QI is very important
25%
MDH currently has a pervasive
culture that focuses on continuous
QI
0%
2011
2012
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Organizational Culture: Breakdown by Question
Staff members are routinely asked to contribute to decisions at my public health agency,
MDH all-employee surveys, 2011-2016
100%
75%
6%
20%
25%
50%
25%
6%
8%
29%
25%
10%
21%
24%
25%
26%
40%
42%
43%
I don't know
Disagree/
strongly disagree
Neutral
49%
0%
2011
2012
2014
2016
Strongly agree/
agree
When trying to facilitate change, staff has the authority to work within and across program boundaries,
MDH all-employee surveys, 2011-2016
100%
75%
50%
25%
19%
17%
26%
32%
18%
37%
2011
16%
15%
22%
18%
22%
19%
22%
I don't know
Disagree/
strongly disagree
Neutral
30%
38%
45%
2012
2014
2016
0%
Strongly agree/
agree
The key decision makers in my agency believe quality improvement is very important,
MDH all-employee surveys, 2011-2016
100%
15%
13%
18%
5%
15%
56%
53%
61%
70%
Neutral
2011
2012
2014
2016
Strongly agree/
agree
75%
12%
50%
25%
I don't know
21%
10%
15%
27%
0%
Disagree/
strongly disagree
MDH currently has a pervasive culture that focuses on continuous quality improvement,
MDH all-employee surveys, 2011-2016
100%
15%
16%
15%
75%
23%
50%
26%
24%
25%
15%
11%
23%
35%
43%
50%
2012
2014
2016
0%
2011
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I don't know
Disagree/
strongly disagree
Neutral
Strongly agree/
agree
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Capacity/Competency: All Questions
Capacity/competency question responses (strongly agree or agree),
MDH all-employee surveys, 2011-2016
100%
75%
50%
68%
The leaders of my division use basic
methods for evaluating and
improving quality, such as PDSA
48%
My public health agency has a QI
plan
37%
MDH currently has a high level of
capacity to engage in QI efforts
36%
28%
25%
22%
0%
2011
2012
2014
2016
Capacity/Competency: Breakdown by Question
The leaders of my division use basic methods for evaluating and improving quality, such as Plan-Do-StudyAct, MDH all-employee surveys, 2011-2016
100%
75%
50%
25%
I don't know
48%
40%
38%
38%
10%
14%
15%
15%
13%
10%
15%
21%
Disagree/
strongly disagree
Neutral
28%
29%
28%
37%
2011
2012
2014
2016
0%
Strongly agree/
agree
My public health agency has a quality improvement plan,
MDH all-employee surveys, 2011-2016
100%
75%
58%
0%
17%
14%
50%
25%
23%
31%
8%
12%
47%
56%
2012
2014
18%
11%
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Disagree/
strongly disagree
68%
Neutral
2016
Strongly agree/
agree
22%
2011
I don't know
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MDH currently has a high level of capacity to engage in quality improvement efforts,
MDH all-employee surveys, 2011-2016
100%
75%
50%
24%
23%
17%
12%
23%
20%
25%
20%
10%
21%
36%
42%
48%
2012
2014
2016
0%
2011
I don't know
Disagree/
strongly disagree
Neutral
Strongly agree/
agree
Alignment/Spread: All Questions
Alignment/spread question responses (strongly agree or agree),
MDH all-employee surveys, 2011-2016
100%
Job responsibilities for many
individuals responsible for programs
and services at my division include
those specific to measuring and
improving quality
75%
51%
50%
49%
35%
33%
25%
Customer satisfaction information is
routinely used by many individuals
responsible for programs and
services in my public health agency
36%
29%
MDH currently has aligned our
commitment to quality with mostof
our efforts, policies, and plans
0%
2011
2012
2014
2016
Alignment/Spread: Breakdown by Question
Job responsibilities for many individuals responsible for programs and services at my division include
those specific to measuring and improving quality, MDH all-employee surveys, 2011-2016
100%
75%
50%
35%
38%
16%
14%
16%
17%
30%
2011
2012
25%
12%
8%
16%
18%
Disagree/
strongly disagree
45%
51%
0%
MINNESOTA DEPARTMENT OF HEALTH
I don't know
Neutral
25%
33%
25%
2014
16
2016
Strongly agree/
agree
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Customer satisfaction information is routinely used by many individuals responsible for programs and
services in my public health agency, MDH all-employee surveys, 2011-2016
100%
I don't know
75%
39%
41%
50%
15%
16%
17%
17%
25%
33%
33%
16%
12%
18%
22%
Disagree/
strongly disagree
Neutral
29%
25%
29%
36%
2011
2012
2014
2016
0%
Strongly agree/
agree
MDH currently has aligned our commitment to quality with most of our efforts, policies, and plans, MDH
all-employee surveys, 2011-2016
100%
75%
50%
23%
22%
25%
22%
8%
21%
16%
11%
35%
42%
49%
2012
2014
2016
23%
25%
0%
2011
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I don't know
Disagree/
strongly disagree
Neutral
Strongly agree/
agree
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Appendix C. Agency Performance Management
Policy number – 702.03
Effective date – 5/13/2014
Policy
Consistent with organizational best practices, MDH engages in performance management at all levels of the agency. All MDH employees
have a role in identifying and making continuous improvements that allow MDH to effectively fulfill its mission. This policy specifically
addresses the following:



Agency performance
Division/Office performance
Section/Unit/Program performance
Rationale: Use of performance management not only facilitates the achievement of improved health outcomes for all Minnesotans, it is
good business practice. It uses results from both population indicators and from program performance measures to drive improvement.
Benefits of performance management include:




Organizational alignment and the ability to identify, examine and address issues with department-wide implications;
Increased ability to use data to communicate successes and tell our story
Specific improvement projects resulting in increased efficiencies
Increased customer satisfaction
Standard
Performance management at MDH is the practice of using data for decision-making by establishing results and standards; measuring,
monitoring and communicating progress toward those results; and engaging in quality improvement activities when desired progress is
not being made. Performance management includes the following components:




Results and Standards – Where do we want to be?
Measurement – How will we know?
Monitoring and Communication Progress – How well are we doing?
Quality improvement – How will we improve?
Agency Performance

The Executive Office and Health Steering Team (HST) are responsible for monitoring agency performance.

The Executive Office and HST will maintain a set of key agency performance measures. Those performance measures are
intended to monitor performance on topics that are agency wide in nature (e.g., the MDH strategic plan, creating a culture of
quality within MDH, timeliness of employee performance evaluations) or that pertain to a topic of particular significance.
o
MDH will maintain a current organizational strategic plan; at a minimum the department will engage in a strategic
planning process every five years, as outlined in the Public Health Accreditation Board (PHAB) Standards and
Measures. The strategic plan will include objectives and measures to track progress towards the objectives.
Responsibility for implementation and reporting on activities and measures within the strategic plan will be assigned
to a responsible individual or the chair/convener of an appropriate committee or group.
o
Divisions/Offices will submit up to seven performance measures to the Executive Office/HST on an annual basis.
Those measures will be reviewed for potential inclusion in the set of key agency performance measures and/or
strategic plan.

At a minimum, progress on key agency performance measures will be reviewed biannually and opportunities for improvement
identified.

MDH’s key agency performance measures and the results of the biannual review will be communicated to employees.

Identified opportunities for improvement will be referred to the MDH Quality Council, appropriate HST subcommittee, or other
appropriate MDH group or committee. Opportunities for improvement will be prioritized and acted upon as outlined in MDH’s
Quality Improvement Plan.
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Division/Office Performance

Division/Office Directors are responsible for monitoring the performance of their divisions/offices and are expected to actively
use performance measures to manage the work of the division/office.

It is expected that staff at all levels are engaged in the development and monitoring of performance measures.

When selecting performance measures, customer satisfaction should be considered.

The person in the Executive Office with oversight responsibility for a division/office is responsible for reviewing division/office
performance annually. The purpose of this review is to provide the Executive Office with information about division/office
performance, reasons for performance and future opportunities for improvement. The review is also to ensure accountability
with this policy.

Identified opportunities for improvement should be acted upon internally or referred to the MDH Quality Council or other
appropriate MDH group or committee.
Section/Unit/Program Performance

Section/Unit/Program managers and supervisors should use performance measures to make data-driven decisions. They should
also engage their staff in the development and monitoring of performance measures. At a minimum, managers and supervisors
are expected to adhere to the performance management expectations of their respective divisions/offices.

All managers, supervisors and staff are expected to identify and put forward opportunities for improvement.
Results

The Executive Office and HST will establish the population result(s) to which all MDH activities should contribute.

The Executive Office and HST will also establish and monitor a set of indicators that quantify the result(s); these indicators will
be reviewed annually.

The results and indicators will be made available and posted on the agency’s website.
Coordination and Support

The Public Health Practice Section will support performance management at MDH by providing training and technical
assistance; developing reporting templates and resources; and providing facilitation and coordination of organizational efforts.

MDH will charter a Quality Council who will establish and maintain a Quality Improvement (QI) Plan. The Quality Council will
integrate performance management into the QI Plan and the Council’s operations.

In the spirit of continuous improvement, the director of the Public Health Practice Section will initiate an annual performance
management assessment and engage the Executive Office, HST and the Health Operations Team to update this policy as necessary.
Key Terms
Result: A condition of well-being for children, adults, families or communities.
Indicator: A measure that helps quantify the achievement of a result.
Performance Measure: A measure of how well a program, agency or service system is working. Performance measures can be
categorized into three main categories:



How much did we do?
How well did we do it?
Is anyone (the customer) better off?
Quality Improvement: The use of a deliberate and defined improvement process & the continuous and ongoing effort to achieve
measurable improvements. MDH has adopted the following principles of continuous quality improvement:




Intentionally and continually looking for ways to do our work better and adapt to change
Meeting the needs of our customers
Empowering employees to identify and make improvements
Using data and information for decision-making
Public Health Accreditation Board (PHAB): PHAB is a non-profit entity which was formed in 2007 to oversee national public health
department accreditation.
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PHAB Standards and Measures Version 1.0: These are the official standards, measures, and required documentation for PHAB national
public health department accreditation.
Procedure
Division/Office Director
1.
2.
3.
4.
5.
6.
Establish processes and set expectations for division/office performance management including performance measure
development, data collection, monitoring, and identification of opportunities for improvement.
Initiate the division/office performance management process; review and modify as necessary, no less than annually.
Prepare for and participate in an annual review of division/office performance initiated by Deputy Commissioner/Assistant
Commissioner.
Submit up to seven performance measures to the Public Health Practice Section by June 1 each year.
Participate in agency performance management activities (i.e., key performance measure selection and monitoring) through HST.
Assign staff to collect data and report on performance measures/indicators as appropriate.
Public Health Practice Section
7.
Collect and organize division/office performance measures and other relevant performance measures (i.e., from strategic plan
or past agency-wide QI initiatives) for consideration by the Executive Office/HST.
8. Present performance measures to the Executive Office/HST and facilitate a process for key agency performance measure
selection in July of each year.
9. Facilitate the selection of indicators.
10. Facilitate the strategic planning process.
11. Establish a reporting schedule and coordinate the collection and presentation of performance measure data and analysis to the
Executive Office/HST.
12. Initiate an annual assessment of the agency’s performance management activities.
Deputy Commissioner/Assistant Commissioner
13. Review the performance of each division/office on an annual basis.
14. Participate in agency performance management activities (i.e., key performance measure selection and monitoring) through HST.
15. Approve key agency performance measures, strategic plan objectives and associated measures, agency results and associated
indicators and any other metrics used to monitor department performance.
Responsible Manager(s)
Chelsie Huntley, Public Health Practice Section
Contact Person(s)
Chelsie Huntley, Public Health Practice Section
Revision Dates
5/13/2014
Related Policies, Information, and Standards
This policy is consistent with the Public Health Accreditation Board, Results Based Accountability, the Association of State and Territorial
Health Officials’ (ASTHO) Performance Management Position Statement, and Results Management at MMB.
More information, tools and resources can be found on the Public Health Practice Section’s intranet site.
Agency Signature
/s/Jim Koppel
James G. Koppel
Deputy Commissioner
PO Box 64975
St. Paul, MN 55164-0975
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Appendix D. MDH Quality Council Charter
1. Purpose of the Council
The Quality Council (Council) is chartered to support department leadership in building a culture of continuous quality improvement
throughout the organization. The Council provides leadership and direction for department-wide quality improvement (QI) efforts at the
Minnesota Department of Health (MDH). The Council will also provide leadership support and guidance for: building capacity for QI on all
levels; communicating and sharing QI improvement activities and resources; and recognizing QI efforts and successes.
2. Goals





MDH has a sustainable quality improvement (QI) culture that promotes continuous QI efforts at all levels of the organization.
Staff has knowledge and skills necessary to build and sustain a departmental QI culture.
MDH has a customer-focused approach to work activities.
QI efforts are recognized, acknowledged and celebrated.
Successful QI initiatives are broadly implemented.
3. Council Responsibilities and Scope
The Council will advise MDH leadership by:





Developing and implementing MDH’s QI plan.
Evaluating QI projects and providing recommendations to the Health Directors for broader implementation.
Advising the Public Health Practice Section on QI training needs and requirements.
Developing operational procedures to support QI efforts.
Recognizing and promoting QI efforts and successes.
4. Council Structure
Membership
The Council will attempt to include one representative from each of the agency divisions and offices. Membership will consist of a
combination of director-level staff, managers/supervisors and non-managerial staff.
EX OFFICIO MEMBERS
Representation from the MDH Executive Office
FACILITATION
Staff from the Public Health Practice Section
Membership Terms
One member per division/office will serve on the Council. Membership is based on recommendations from Division/Office Directors.
Members will serve a minimum of two years. No more than half of the Council members will rotate off the Council in a given year. New
member orientation will be provided by the Public Health Practice Section and the Council Chair on an individual or group basis.
Leadership
Leadership will be provided by the Quality Council Chair. If the Quality Council Chair is not able to attend a meeting, the chair assigns
either the Quality Council Chair-elect or the past Quality Council Chair to conduct the meeting.
The Quality Council will nominate a chair and chair-elect in December. The Commissioner, Deputy Commissioner, or Assistant
Commissioner of Operations will approve nominations before the end of the calendar year. The chair and chair-elect will each serve for a
period of one calendar year beginning in January. The chair-elect will assume the chair role after one year (as a chair-elect).
Council leadership is responsible for reporting to the Health Directors, chairing meetings and assisting the Public Health Practice Section
with planning meeting agendas.
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Staffing
Public Health Practice Section staff facilitate Council meetings and provide both administrative and technical support. Administrative
support includes but is not limited to: drafting agendas, recording, securing meeting rooms, distributing materials and delivering
communication, as needed. Technical support includes drafting an annual QI Plan update and work plan based on Council input and
providing consultation, training and facilitation to the Council, as needed.
5. Council Meetings
The Council will meet every other month for one and half hours per meeting. Additional meetings may be scheduled for specific working
sessions or tasks, as needed. Meetings are scheduled by Public Health Practice staff. Members should communicate with the Chair if they
are unable to attend meetings. The Council Chair is responsible for sending meeting summaries to Council members after meetings.
6. Guiding Principles
The Council will operate using the following principles:







It will ground its work on fostering a culture of continuous quality improvement (CQI) and promoting the use of QI methods and
tools.
Its decisions will be data-driven and evidence-based, but it will also use and respect people’s knowledge and experience.
It will make the customer perspective central to its decision-making and strive to consistently meet or exceed customer
expectations.
Its processes will be transparent, collaborative and inclusive.
It will foster engagement and accountability with all persons involved in the CQI effort.
It will focus on learning and improvement rather than judgment and blame.
It will value prevention and problem solving over correction.
7. Team Norms
The Council will establish, at a minimum, team norms for communication issues, decision-making, participation, attendance,
confidentiality, and preparedness for meetings.
Ground Rules were established on July 10, 2013, and include:












Be on time for meetings.
Do your homework.
Be clear about expectations for homework/preparation.
Distribute agendas to the team in advance of the meeting (target 1 week).
Ask the group ahead of time if there are any agenda items to add.
Stick to the agenda.
Bring information to and from the Council.
Decisions will be made by consensus.
Keep an open mind.
Be respectful.
Operate in the spirit of improvement. Practice what we preach. Be in the mindset of continuous change.
If members need to miss a meeting, a decision will be made on an ad-hoc basis whether to send a substitute or not.
8. MDH QI Plan
The purpose of the Minnesota Department of Health (MDH) Quality Improvement (QI) Plan is to guide the development, implementation,
monitoring and evaluation of agency-wide efforts to build a culture of continuous quality improvement throughout the organization. This
includes supporting both “big QI” efforts such as engaging our customers, as well as “little qi” efforts such as decreasing the number of
hand-offs in a targeted process.
The QI Plan outlines MDH’s broad QI goals and objectives and provides a realistic work plan for achieving those goals. As a result of these
efforts, MDH believes it will better be able to protect, maintain and improve the health of all Minnesotans.
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9. Performance Monitoring and Reporting
Refer to Section V. Performance, Monitoring and Reporting.
10. Communication Plan
Refer to Section VII. Communication Plan.
Charter Action
Date
By
Approved
1/4/2012
HST
Updated
6/25/2013
Chair, Council staff
Updated and approved
8/7/2013
Council
Updated and approved
8/14/2014
Council
Approved
9/3/2014
HST
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Appendix E. QI Project Charter Template
QI Project Charter
Date/Version
Project Name
Division/Section/Unit/Program
Executive Sponsor
Project Lead
Project Description/Statement of Work
Business Case/Statement of Need (Why is this project important now?)
Describe/Insert Data Indicating a Performance Gap (Include all quantitative and qualitative data available. If data is not
available, indicate how and when baseline data will be collected).
Customers
Customer Needs/Requirements
Project Definition
Project Goals
(Specific, Measureable, Achievable,
Relevant, Time-bound)
Project Scope
(Indicate the first step and the last step
in the process and also what is out of
scope)
Project Deliverables
Cost/Budget/Resources Needed
Project Constraints/Risks (Elements that may restrict or place control over a project, project team, or project action)
Implementation Plan/Milestones (Due dates and durations)
Communication Plan (What needs to be communicated? When is communication needed? To who? How?)
Change Management/Issue Management (How decisions will be made? How changes will be made?)
Customer Focus/Engagement (Describe how you plan to engage customers in the improvement project)
Project Team: Roles, Responsibilities
Team Member
Role/Position
MINNESOTA DEPARTMENT OF HEALTH
Anticipated Project Responsibilities
24
M AY 2 0 1 6
QU AL I T Y I M P R O V E M E NT P L AN
Stakeholders: Roles, Needs/Requirements
Stakeholders
Role/Position
Stakeholder Needs/Requirements
Sponsor Sign-off
Name
MINNESOTA DEPARTMENT OF HEALTH
Date
25
M AY 2 0 1 6