The Whatcom County Health Department (WCHD) received accreditation in March 2016. Both the process of preparing to become accredited and feedback from the site visit report helped our department prioritize where to improve our quality improvement (QI) and performance management (PM) systems and processes. Examining and evaluating our QI/PM systems showed that of the six foundational elements necessary to develop a QI culture,employee commitment and empowerment, as well as teamwork and collaboration, werethe areas that needed the most improvement. Understanding that staff participation and engagement is necessary for successful implementation of a PM system, the department prioritized increasing staff capabilities and collaborative participation in the QI/PM processes. To achieve this goal the department decided to improve QI/PM systems and processes that 1) intentionally embedded and integrated staff participation from all levels of the department, 2) had a centralized and standard reporting system, and 3) ensured the reporting system and data collected is accessible to everyone.
To accomplish these changes multiple action steps were implemented, including providing QI training to all staff and ensuring the process of evaluation and measure selection included participation from staff at all levels of the department. In addition, a centralized electronic reporting and monitoring system was developed, and we redesigned the measure reporting and analysis process to be centered on, and inclusive of, staff participation. Increasing staff capabilities and collaborative participation in QI/PM helped strengthen those foundational elements most in need of improvement.
Implementation and progress of QI/PM in the department is overseen by the management team and the performance management specialist, and informed by the work of the programs. Program supervisors and staff review and analyze performance measure values regularly; conclusions and results are entered directly into electronic reporting workbooks. Documentation of “the story behind the results” and actions taken based on measure analysis are maintained and accessible. Our reporting system allows us to monitor reporting timeliness and performance trends throughout the organization and for all performance measures.
Identified improvements are sustained through annual reporting, which helps support continuous assessment and monitoring of program goals, objectives, and operations. The WCHD utilizes the PHAB Standards and Measures to guide policy and program development to help support these efforts; this ensures that we’re following best practices. This updated system allows for top-down and bottom-up participation in performance management. Accreditation requirements contributed to the department’s awareness and examination of processes and the need for developing and documenting the procedures in use. As an organization, we are now more adept at managing QI/PM throughout every level of the department.
We’re most proud of increasing staff participation in our performance management system, which has led to:
Whatcom County Health Department in Bellingham, Wash., was awarded national accreditation through PHAB on March 8, 2016.
About the author: Molly Burkeis Performance Management Specialist and Accreditation Coordinator at Whatcom County Health Department in Bellingham, Wash. Contact her at [email protected].
Other benefits gained as a result of going through the accreditation process: