DESCHUTES COUNTY HEALTH SERVICES
Title: Quality Management Policy—Public Health
Program Area(s): Public Health All Programs
PURPOSE: To establish the scope, structure and functions of the Deschutes County Health
Services Public Health (DCPH) Quality Management Program.
Organizational Goals for Public Health Quality Management
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Acknowledge the ongoing work of DCPH staff and incorporate performance management
into our daily work.
Engage staff at all levels in the quality management process and culture.
Utilize a process for reporting on achievement of goals, objectives, and measures.
Define quality management training plan and standards for staff
Develop a performance management system that encourages sound judgment, meaningful
improvement, and collaboration among staff.
Establish a systematic process for assessing customer satisfaction with public
health services.
Identify areas that will benefit from quality improvement, review processes and systems,
develop improvement strategies, evaluate impact of strategies, and make recommendations
to DCPH leadership to maximize resources and expertise.
Provide guidance, support, and resources to program managers, supervisors, coordinators
and line staff to measure and report on program performance.
Assist programs in demonstrating program effectiveness and efficiencies, and in meeting
goals, objectives, and regulatory or reporting requirements.
Increase accountability through consistent performance reporting.
Develop quality improvement initiatives consistent with the organization’s mission, vision,
and values.
POLICY: It is the policy of DCPH to invest in a culture of continuous quality improvement and
compliance and integrate quality management into daily practice at all levels of the department.
PROCEDURES:
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ROLES (Public Health Accreditation Measure 9.2.1A)
All public health staff have a role in quality management efforts. From front line staff to the
Public Health Advisory Board, all levels of the organization will participate in developing,
establishing, utilizing, and updating the quality management program for the organization.
A. Public Health Advisory Board (PHAB)
The PHAB is comprised of members that represent DCPH community stakeholders,
panel providers, and other members as assigned. The PHAB meets on a monthly basis
and maintains records and minutes of all meetings. The role of the PHAB is to:
• Review program performance areas as identified and reported on in the PH Quality
Improvement Work Plan (QIWP);
• Formulate policy recommendations on operational and programmatic issues
B. Public Health Quality Council (PHQC) (Measure 9.1.2A)
The purpose of the PHQC is to identify key indicators of performance. The PHQC
consists of no more than ten members from DCPH leadership and line staff representing
the various public health programs in the department. Members of the PHQC shall be
appointed by the DCPH leadership. Ad hoc members will be added as necessary. The
PHQC meets on a monthly basis and maintains records and minutes of all meetings.
Major functions of the PHQC include:
• Define the division’s performance improvement priorities, actions, and measures.
• Review program performance areas using Deschutes County’s Quarterly
Performance Report.
• Limit quality improvement priorities and initiatives to no more than 6 at one time to
ensure adequate resources.
• Review regulatory requirements, agreements, and any local or regional requirements
and assure that public health programs are in full compliance.
• Establish and monitor goals, quality indicators, set performance measures and
benchmarks.
• Identify corrective actions needed to assure standards for performance and
opportunities for improving services, along with outcomes of corrective interventions
and overall performance.
• Develop, implement, monitor, evaluate and revise the QIWP.
• Oversee and direct all quality work. Mandate and form committees or workgroups as
needed.
• Direct, sponsor, and charter departmental and division quality improvement projects.
• Review critical incident reports, emergency safety intervention documentation,
grievances and other documentation as applicable
C. Staff
Staff involvement at all levels is essential to the success of the quality management
program and to ensure that quality improvement is completely integrated into
organizational daily practice. Per Public Health Accreditation Board Standards and
Measures, “Staff ownership is required because implementation of a performance
management system is successful only when staff is involved in early and continuous
decision making” (Measure 9.1.1A). All public health staff will be trained with the
appropriate tools to identify, plan, and implement quality improvement efforts. DCPH
staff is responsible for:
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Working with program teams or across programs, and with supervisors and
managers to identify areas for improvement and suggest improvement projects to
address those areas, including meeting state requirements.
Participating as program representatives on workgroups to conduct quality
improvement projects.
Report quality improvement training needs to the Quality Improvement Specialist or
Leadership staff.
D. DCPH Leadership
DCPH Leadership Team involvement and investment in quality improvement is vital to
the success of the quality management program. The Leadership Team will be
responsible for:
• Establishing and updating the quality management program (Measure 9.1.1A)
• Appointing program representatives to the Quality Council
• Orienting all staff to Quality Council process, plan, and resources
• Developing a work plan and priorities for each program
• Reviewing progress of work plans on an annual basis with teams
• Initiating problem solving processes or improvement projects based on program
requirements, priorities, and deficiencies.
E. Quality Improvement Specialist (QIS)
The role of the PH QIS is to facilitate the quality management program within the
organization through training, consultation, and technical assistance. The QIS
coordinates and facilitates the Quality Council meetings, and ensures that improvement
efforts are completed efficiently and that all participants have the appropriate training
and tools following common quality improvement methods. The QIS will produce
performance reports and communication as necessary to the Public Health Advisory
Board and DCPH Leadership.
REPORTING AND COMMUNICATION
DCPH will report on achievement of goals, objectives, and measures set by the performance
management program (Measure 9.1.3A). This includes written goals, objectives, and
timeframes for measurement as well as a process for monitoring performance.
A. Annual Report
The Annual Report is a summary of the QIWP activities and results, including the
Quarterly Performance Reports. The report represents activity from July 1 through June
30and is prepared and presented by the assigned QIS to applicable boards and
committees. Program managers shall distribute the report to supervisors and staff.
B. Performance Boards
Snapshots of department performance shall be reported on Performance Boards to
convey to all staff vital information about DCPH performance and improvement efforts.
They are designed to connect all staff work to the performance of the organization, foster
curiosity and build staff investment in a culture of quality. These boards shall be posted
in locations convenient for staff viewing. Quality committees have oversight of
frequency, duration and type of data posted on each board. The QIS shall keep these
boards up to date.
C. DCHS Newsletter
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Quality improvement will be a regular section in the DCHS Monthly Newsletter sent to all
staff.
D. Quarterly Performance Report
The QIWP quarterly report is a summary of the QIWP activities and results (i.e.,
snapshots). The material includes any quality improvement, assurance or performance
management projects recommended, planned, or underway. Quantitative and quality
data will be used to create graphs, charts, tables and written analysis and
recommendations. The quarterly reports will be presented by the assigned Quality
Improvement Specialist to applicable boards and committees. Program Managers shall
distribute the reports to supervisors and staff.
QUALITY IMPROVEMENT PRIORITIES (Measure 9.2.1A)
DCPH will refer to the following when determining quality improvement priorities:
• Administrative Responsibilities: inefficiencies related to organization administrative
processes such as information systems, finance, payroll processes, business office
functions, hiring and orientation, safety, etc.
• Post Incident Debriefs: Debrief reports related to public health events (epidemiologic
outbreaks, emergency preparedness exercises) reviewing protocols, compliance
procedures, laws and regulations, efficiency, communication, response efforts, etc.
• Customer Service: Through client and customer satisfaction surveys or other methods,
DCPH will determine client needs for services and improvement of care delivery. These
priorities will become quality improvement initiatives, and a client satisfaction survey will
be assessed on a routine basis for all public health programs and services. (Measure
9.1.4A)
• HIPAA Compliance Findings: The Public Health Registered Health Information
Technician will inform the Quality Council of issues regarding HIPAA policies, training,
confidentiality, potential confidentiality breaches, data sharing, security, and retention
policies.
• Deschutes County Internal Auditor Findings: Audits and reports from the Deschutes
County Internal Auditor regarding business functions will be reviewed and updated to
report progress in complying with suggested operational changes. Deficiencies will be
considered as quality improvement initiatives.
• Program Evaluation, Triennial Review Findings: On a routine basis, DCPH programs are
evaluated by the State of Oregon for level of compliance with State regulations and
minimum standards. The deficiencies highlighted in the evaluation findings will be
addressed through the quality management program and prioritized for correction.
• Strategic Plan: The DCHS Strategic Plan objectives and goals will be considered when
determining priorities for quality improvement efforts.
• Public Health Accreditation Evaluation: In preparation for public health accreditation,
Leadership Team will evaluate the capacity to meet the standards, measures, and
documentation requirements and prioritize deficiencies as quality improvement initiatives
as appropriate.
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TRAINING (Measure 9.2.1A)
An initial overview of quality improvement, this policy, and improvement methods and tools
will occur at a PH All Staff meeting and utilizing the communication methods described
above. In addition, the QIS will work with the Leadership Team to ensure that all staff and
quality improvement workgroups have the appropriate training regarding methods and tools
to determine root causes of issues, identify solutions, and measure data to determine
improvements. Review of this policy and training materials will be included in the
department’s new employee orientation.
The PH Quality Council will participate in periodic training and presentations related to
performance management to ensure an understanding of the use of methods and tools most
effective in monitoring and analyzing objectives and measures (Measure 9.1.5A).
The QIS will attend applicable quality improvement trainings related to public health,
accreditation, and health quality improvement practices. As quality improvement is a
growing aspect of public health operations and services, the QIS will stay informed and
educated with the most current quality improvement practices to ensure that DCPH is
utilizing the most current tools and methods available and meeting necessary public health
standards and practices.
To keep staff informed and trained and keep quality improvement as a priority, the QIS will
conduct an annual PH All Staff training of quality improvement methods/tools and review
successful improvement initiatives.
METHODS
There are a variety of quality management and improvement methods and activities that
guide and assist quality management processes. These methods include but are not limited
to:
1. DCPH Quality Improvement Work Plan (QIWP)
Created by the Public Health Quality Council for yearly monitoring and evaluation of
goals specified for the primary quality domains as outlined by the Public Health
Accreditation Board.
2. DCPH Self-Assessment
Per Public Health Accreditation Standards (Measure 9.1.2A), DCPH will complete a
performance management self-assessment to determine the extent to which
performance management practices are being utilized within the organization. DCPH will
utilize The Performance Management Self-Assessment Tool from the Turning Point
Performance Management National Excellence Collaborative as recommended by the
Accreditation Board. This self-assessment focuses on four components of performance
management: performance standards, performance measurement, reporting of
progress, and quality improvement process. Through this tool, the department will
evaluate capacity and effectiveness as an organization to access and utilize the
necessary resources, skills, accountability, and communications for each of the four
components. This self-assessment will be completed at the implementation of the quality
management program and repeated at six months and one year following to determine
progress and adoption of the Quality Management Program.
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QUALITY MANAGEMENT PROGRAM EVALUATION AND REVISIONS
The Public Health Quality Council will annually review and suggest necessary revisions to
this Quality Management Program. When reviewing, the PHQC will refer to Oregon
Administrative Rules, Deschutes County contract with the Central Oregon Health Board,
Deschutes County Health Services Strategic Plan, Public Health Accreditation Board
guidelines, and internal priorities.
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Appendix A
QUALITY TERMS & DEFINITIONS1 (Measure 9.2.1A)
1. Performance Measurement: Measurement of capacities, processes, or outcomes
relevant to the assessment of a performance indicator. Measurement assesses
achievement of standards and objectives.
2. Public Health Accreditation Standards & Measures: The Public Health Accreditation
Board accreditation standards and measures define the expectations for all public health
departments that seek to become accredited.
http://www.phaboard.org/wp-content/uploads/PHAB-Standards-and-Measures-Version1.0.pdf
3. Program Evaluation: A systematic collection of information about the activities,
characteristics, and outcomes of programs to make judgments about the program or
improve program effectiveness. A tool for making informed decisions about future
program development.
4. Quality Management Program: Framework for assessing and improving clinical,
operational and financial performance of DCHS.
5. Quality Improvement: Continuous process that identifies problems, examines
solutions to those problems, and regularly monitors the solutions implemented for
improvement.
6. Quality Assurance: Set of planned and systematic actions necessary to provide
confidence that a service meets regulatory and quality expectations.
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Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook 2012
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Appendix B
DESCHUTES COUNTY HEALTH SERVICES
Quality Improvement Objective and Performance Measures Submission Form
Title of Project:
Program Area Reporting:
Reported By:
Initial Report to Quality Council Date:
1. What is the identified issue that you would like to work on?
2. How did you determine that this was an issue (background)?
3. What is your specific objective and timeframe for improving the identified area, such as
“increase x by 10% by (date)”? This should be your one, overall objective for the project.
4. What activities/improvement theories are you considering to meet the objective of the
project?
5. What tools/data sources do you have available to measure data to track the improvements?
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——— Reporting
- - - - - Consultation
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