Turning Point Revisited: Launching the Next Generation of Performance Management in Public Health

Abstract

Adecade ago, the Turning Point Performance Management Excellence Collaborative (Turning Point)developed the first public health–specific performance management (PM) system, with accompanying resource materials, assisted by the Public Health Foundation. Since then, dramatic advancements in PM and quality improvement activities have occurred in public health. Public Health Foundation gathered data that revealed Turning Point was still relevant but difficult to implement within public health. To reflect recent advances and current challenges, Public Health Foundation refreshed the Turning Point model and related guidance tools and developed new resources to facilitate PM implementation. In addition, a new fifth component, “Visible Leadership,” was added to the 4-quadrant model and the Self-Assessment Tool. In the future, public health organizations should take an active leadership role in innovating and sustaining PM systems, ensuring they become accountable for producing outcomes, leveraging technology advances, and incorporating best practices from all stakeholders.

Performance management (PM) became part of the governmental lexicon in the 1990s when the 103rd Congress of the United States established the Federal Government Performance and Results Act of 1993 for 2 primary purposes: (1) to reduce governmental waste and inefficiency in programs and (2) to bring more attention to program performance and results.¹ This act gave greater impetus to PM, performance-based budgeting, and accountability at all levels of government.² Performance management is defined as the use of performance measurement information to help set agreed-upon performance goals, allocate and prioritize resources, inform managers to either confirm or change current policy or program direction, and report on the success of meeting these goals.³ In the context of public health, PM is described as the practice of actively using performance data to improve the public’s health; this involves the strategic use of performance standards and measures, progress reports, and ongoing quality improvement efforts to ensure that an agency achieves desired results.⁴

Formed as 1 of the 5 collaboratives initiated in conjunction with the Turning Point program^5,6 by the Robert Wood Johnson Foundation in 2000, the Turning Point Performance Management Collaborative developed and disseminated information to public health organizations about how to manage performance. The goal of this collaborative was to transform and strengthen the public health system so that states and communities and their public health agencies could respond to the challenges of protecting and improving the public’s health in the 21st century. Included were representatives from 7 states (Alaska, Illinois, Missouri, Montana, New Hampshire, New York, and West Virginia) and 5 national organizations (Association of State and Territorial Health Officials, Centers for Disease Control and Prevention [CDC], Health Resources and Services Administration, National Association of County & City Health Officials, and Public Health Foundation [PHF]). As a result of this 4-year collaborative, the Turning Point Performance Management Framework (Turning Point Framework) and related guidance were released in 2003 to facilitate public health systems’ efforts to manage performance.

During the past 2 decades, momentum to improve the quality and performance of public health agencies and systems has increased dramatically. National public health initiatives and tools have been developed to facilitate building and improving the public health system (eg, the National Public Health Performance Standards Program,⁷ Mobilizing for Action through Planning and Partnerships,⁸ and the national Turning Point initiative).^9–11 Related initiatives were centered on improving the efficiency and effectiveness of public health agencies (eg, the Multi-State Learning Collaborative and national voluntary accreditation for public health departments^12–15). In 2010, the CDC Office for State, Tribal, Local and Territorial Support began providing support to health departments through the National Public Health Improvement Initiative (NPHII),¹⁶ which provides funding to 73 state, tribal, local, and territorial grantees through the Prevention and Public Health Fund of the Affordable Care Act. It is designed to accelerate the achievement of national public health standards and readiness for accreditation through the Public Health Accreditation Board and support accelerated implementation of PM and quality improvement activities.

Acknowledging recent national initiatives focused on quality improvement, coupled with advancements and changing priorities in the public health field, PHF launched an effort in 2011 to refresh the Turning Point Framework and related guidance. The initial scope of the effort called for validating the value of the model to the field. If continued relevance was demonstrated, then a 3-fold approach was planned:

1. Introduce updates that reflect current challenges and priorities in public health.

2. Refresh guidance and tools, specifically the Performance Management Self-Assessment Tool¹⁷ and From Silos to Systems: Using Performance Management to Improve the Public’s Health (From Silos to Systems),⁴ to make the framework more easily understood and implemented within public health.

3. Collect and add current examples of public health department PM activities.

Methods

To inform the effort, the PHF identified, through an online search, public health PM resources developed within the past decade and gathered resources recommended during interviews with 13 public health accreditation leaders representing national public health organizations and funders (Table 1). Resources developed by individual health departments were not included in the summary table but are available on the PHF PM Web site at www.phf.org/PMtoolkit.

TABLE 1.

Public Health Performance Management Resources Referenced

Peer-reviewed publications

Madamala K, Sellers K, Beitsch LM, Pearsol J, Jarris P. Quality improvement and accreditation readiness in state public health agencies. J Public Health Manag Pract. 2012;18(1):9–18.

Beitsch LM, Leep C, Shah G, Brooks RG, Pestronk RM. Quality improvement in local health departments: results of the NACCHO 2008 Survey. J Public Health Manag Pract. 2010;16(1):49–54.

Riley W, Beitsch L, Parsons H, Moran J. Quality improvement in public health: where are we now? J Public Health Manag Pract. 2010;16(1):1.

Riley W, Moran J, Bialek R, et al. Defining quality improvement in public health. J Public Health Manag Pract. 2010;16(1):5.

Leep C, Beitsch LM, Gorenflo G, Solomon J, Brooks RG. Quality improvement in local health departments: progress, pitfalls, and potential. J Public Health Manag Pract. 2009;15(6):494–502.

Baker SL, Beitsch L, Landrum LB, Head R. The role of performance management and quality improvement in a National Voluntary Public Health Accreditation System. J Public Health Manag Pract. 2007;13(4):427–429.

Web site resources

Centers for Disease Control and Prevention. Performance management and quality improvement public health journey. http://www.cdc.gov/stltpublichealth/performance/Journey.html. Published 2012.

Public Health Accreditation Board. Accreditation materials. http://www.phaboard.org/accreditation-process/accreditation-materials. Published 2012.

National Institute of Standards and Technology. Are we making progress as leaders? http://www.nist.gov/baldrige/publications/progress_leaders.cfm. Published 2011.

Robert Wood Johnson Foundation. The quest for exceptional performance: crosswalk PHAB and Baldrige. http://www.crosswalkphabbaldrige.org. Published 2012.

Milhon K. A short history of performance management in public health 1988–2010. http://nnphi.org/CMSuploads/AShortHistoryofPerformanceManagementinPublicHealth.pdf. Published June 14, 2011.

Thielen L. Improving the Public’s health systematically: public health and performance management systems. MLC Topical Brief. http://nnphi.org/uploads/media_items/mlc-performance-mgt-systems-topical-brief.original.pdf.

Archived conference calls and webinars

Centers for Disease Control and Prevention. Drawing connections: linking the tools in your toolbox. In: Public Health Agency & Systems Improvement Webinar Series. http://nnphi.org/CMSuploads/WebinarSummary8.7.12.pdf. Published 2012.

Centers for Disease Control and Prevention. Learning about established performance improvement offices in health departments. In: 2011 PIM Network Conference Calls and Webinars. http://www.cdc.gov/stltpublichealth/pimnetwork/events_2011.html. Published 2011.

National Association of County & City Health Officials. Introduction to building a performance management system. In: Performance Improvement Technical Assistance Webinar. http://www.naccho.org/topics/infrastructure/accreditation/upload/PITA-Call-Notes_April2012.pdf. Published 2012.

From November 2011 to March 2012, PHF gathered initial input on how the Turning Point Framework and related guidance were being used, how they could be improved, and what should be considered for revision. Input was gathered through conversations with 16 NPHII performance improvement managers (PIMs) from 12 state health departments, 3 large local health departments, and 1 tribal health board. The PIMs providing input self-identified as having taken steps to implement PM influenced by the Turning Point Framework. PHF obtained additional feedback from November 2011 to January 2013 through responses to a series of discussion questions posted on the PIM Network phConnect Community group.¹⁸ In addition, state public health departments whose stories were included in From Silos to Systems were contacted for updated information on PM practices, focusing on how practices had evolved over the past decade.

In March 2012, PHF convened a “think tank” meeting comprising members from the original Turning Point Performance Management Collaborative, PIMs, PM experts, and professionals representing national organizations involved in public health accreditation and quality improvement. The stated objectives for the Performance Management Think Tank (Think Tank) meeting were to:

1. reflect on current issues relevant to PM in public health;

2. recommend ways to refresh the PM framework that address current challenges, include innovative practices, improve usability, and link the materials to current public health priorities such as health department accreditation;

3. recommend ways to update existing related PM tools (Performance Management Self-Assessment Tool and From Silos to Systems) or to develop new tools to make the framework more readily understood and applied within public health; and

4. identify resources, examples, and references that may be important to consider and/or include in the refreshed materials.

PHF sought additional guidance from national public health partner organizations (American Public Health Association, Association of State and Territorial Health Officials, National Association of County & City Health Officials, and the National Networks of Public Health Institutes). It also solicited feedback on draft materials from 2 PM workshops at the NPHII Grantee Meeting in May 2012. Additional input on the draft materials was requested through publication on the PHF Web site, the PHF E-News electronic newsletter,¹⁹ discussion during a national webinar hosted by the CDC and the National Networks of Public Health Institutes in August 2012,²⁰ and a scientific session at the 2012 American Public Health Association Meeting and Exposition on October 31, 2012.

Results

Initial findings

Think Tank discussions and outreach generated key insights about the current role of PM in public health. Initial interviews with PIMs and national partner organizations confirmed that the Turning Point Framework remains relevant today and is being used by public health departments. This finding was validated in an Agency, Systems, and Community Health Improvement Webinar Series that the PHF conducted in December 2011.²⁰

Nonetheless, consistent knowledge gaps were noted between understanding the PM framework and applying it. Of 59 interview participants, although 5% said the PM framework was useful and that they applied it to everyday practice, the majority (77%) reported that they were aware of the Turning Point Framework but did not apply it regularly.²¹ A smaller percentage (18%) found it difficult to use or had never heard of the framework.²¹ In addition, at 2 PHF-facilitated PM sessions at the NPHII Grantee Meeting in May 2012, participants also reported that a gap existed between familiarity with the framework and actual application of it. Further discussions with health departments revealed that those with experience building a PM system used the Turning Point Framework as a guide and adapted it to fit their organization’s existing PM infrastructure. In addition, many reported that they were influenced by other PM resources, including the Baldrige framework,²² Results-Based Accountability,^23,24 and Balanced Scorecard.²³

Feedback from the field also included requests for several enhancements that could improve the value and utility of a refreshed Turning Point Framework:

1. Provide guidance on how to begin PM implementation and apply it systematically.

2. Share more stories from health departments that have implemented a PM system framework successfully.

3. Show evidence of the benefits of PM to garner leadership support.

4. Encourage PM application that reflects individual organizational needs, fiscal limitations, and other realities.

5. Update to include language about public health accreditation and other current public health initiatives.

6. Improve usability of the Performance Management Self-Assessment Tool (eg, electronic platform, scoring instructions, and interpretation guidance).

7. Expand the implementation section of From Silos to Systems (eg, more guidance on what types of groups can use the tool, provision of sample standards and measures).

8. Update citations within the document and make them easier to locate.

As a result of these discussions and input gathered from the Think Tank, a number of initial refresh themes for updating the Turning Point Framework emerged and were posted for comment on the PHF Web site.²⁵ In addition, suggestions for successful PM application in public health were developed (Table 2). The updated Turning Point Framework diagram and related guidance, as well as newly developed tools to support the application of the framework, are described later.

TABLE 2.

Turning Point Framework Refresh Recommendation and Considerations for Successful Performance Management Application

Turning Point refresh recommendations Update the Turning Point Performance Management System Framework diagram and guidance on its use Add language about public health accreditation and other current public health initiatives in the refreshed From Silos to Systems guidance and Performance Management Self-Assessment Tool Improve usability of the Performance Management Self-Assessment Tool Develop a 1-page “Case for Performance Management” emphasizing the benefits of performance management to garner leadership support and educate health department staff Build an online performance management toolkit in which refreshed materials, case stories, related resources, updated references, etc, will reside and serve as a living repository for public health performance management resources Migrate a refreshed From Silos to Systems to an online toolkit Gather and share state, tribal, local, and territorial health department stories of performance management framework applications Write an article for a peer-reviewed journal on performance management in public health

Considerations for successful performance management application Become familiar with existing performance management frameworks (eg, Turning Point, Malcolm Baldrige) Borrow, adapt, and tailor frameworks, tools, and resources to fit the organization’s needs Involve all staff, broad system partners, and leadership early on in discussions of performance management Assess periodically the extent to which core elements are already in place and what needs improvement and then prioritize the elements not in place and build systematically Align performance management-related activities with the organization’s mission, vision, and strategic directions Integrate performance management into core operations at multiple organizational levels, including the program, organization, and system levels Instill a culture of learning, quality improvement, and transparency around performance management Train staff routinely to ensure that the performance management components are understood and monitored routinely Identify organizational champions who can mentor and keep momentum going Measure, celebrate, and communicate progress

Public Health Performance Management System Framework

The PHF released the refreshed Public Health Performance Management System Framework (Figure 1) in 2013, including updates of the 4 main components of the original Turning Point Framework and a new fifth component. In the revised framework, the 4 main components are displayed in a circle rather than a square to reflect the inherent cyclical nature of the process, consistent with continuous improvement. Double-headed arrows were incorporated into the circumference to emphasize that there could be multiple starting points for PM (ie, an organization need not wait until all the components are in place to begin managing its performance). The PHF added the fifth component, Visible Leadership, defined as senior management in the organization being visibly committed to (1) cultivating a culture of quality, (2) aligning PM practices with the organization’s strategic goals, (3) weighing customer experiences in program decisions or system changes, and (4) fostering transparency about organizational performance.^25,26 Visible Leadership includes 4 subcomponents: Culture of Quality, Customer Focus, Strategic Alignment, and Transparency.

FIGURE 1.

2003 and 2013 Turning Point Performance Management Frameworks

Performance Management Self-Assessment Tool

The updated Turning Point Performance Management Self-Assessment Tool includes new assessment questions about Visible Leadership and a description of how different target groups can benefit from using the tool. PHF added explanations for the components at the head of each section to facilitate understanding and use of the tool. In addition, Web site links, references, and definitions were updated.²⁶ PHF decided against adding accreditation-related questions to avoid duplication of or confusion with current accreditation preparation tools. However, to showcase how PM complements accreditation, a case example of how a health department added a section related to accreditation preparation is shown in Table 3. User guidance also was added to encourage customization to fit the needs of each organization undertaking the self-assessment; the guidance included information on where to find examples of how health departments have adapted the tool.

TABLE 3.

HDHHS Modified Self-Assessment Tool: Case Example

Background: With funding from CDC’s National Public Health Improvement Initiative, the HDHHS assessed its use of performance management and quality improvement. The purpose of this activity was to collect baseline data to determine whether the health department’s programs and divisions used standards or measures, reported progress, or implemented elements of quality improvement outside of specific funding requirements.

Methods: The HDHHS Performance Improvement Accreditation Team, in the Office of Surveillance and Public Health Preparedness, selected the Turning Point Self-Assessment Tool and adapted it into an electronic data collection tool (via SurveyMonkey) to enable widespread staff participation in the assessment. HDHHS added an accreditation readiness section and open answer space to allow the programs and divisions to share the following: (1) ideas for performance improvement; (2) interest in participating in the agency’s accreditation workgroup; (3) the public health accreditation domains their program or division addressed; and (4) whether they could provide supporting documentation, examples, and a list of community partners.

Key Findings: Preliminary results indicated that all programs used standards or measures and elements of quality improvement to some degree. Weaknesses were identified in sharing information, using quality improvement tools to improve processes, and documenting quality improvement activities. One challenge identified was that the HDHHS divisions did not routinely share information due to existing program silos in the agency. As a result of the self-assessment, data have been used to inform the Performance Improvement and Accreditation Team’s training curriculum and quality improvement initiatives. HDHHS will also work toward breaking down silos and improving information exchange through future training and engagement throughout programs and divisions. For example, the Performance Improvement and Accreditation Team discussed partnering with the Department Labor Management Cooperation Council to promote public health accreditation, performance improvement and workforce development, and communication across programs and divisions. In collaboration with the HDHHS’s Quality Council, the Performance Improvement and Accreditation Team plans to transform the current performance management system into a dynamic database to track accreditation documentation and outcomes-based initiatives of the department and of the Houston mayor’s office.

Conclusion: HDHHS found that (1) sustaining leadership accountability, (2) maintaining momentum to ensure that planning is done systematically, and (3) aligning activities with strategic plans were critical to successfully maintain the HDHHS performance management system. Moreover, the involvement of the Performance Improvement and Accreditation Team in the strategic planning process ensured that elements of performance management, quality improvement, and public health accreditation would be woven into the department’s strategic efforts for the next three years.

For more information, visit the PHF Web site at http://www.phf.org/resourcestools/Documents/Houston_PM_Application_Overview.pdf.

Abbreviations: CDC, Centers for Disease Control and Prevention; HDHHS, Houston Department of Health and Human Services.

From Silos to Systems: Using PM to improve the public’s health

The Think Tank participants and other respondents found the content in From Silos to Systems remains germane, but they recommended that it be placed in a more accessible online format. They also suggested an expanded implementation section including more guidance, with information on who should use the tool and sample standards and measures. Migration of From Silos to Systems to a Web site allows users to navigate the content more easily and will enable the addition of new PM application examples and educational materials as they emerge. The PHF plans to make available an online phf.org/PMtoolkit containing current resources and tools, including the updated From Silos to Systems and tips on how to assess one’s current public health PM system.

New materials developed

PHF developed Talking Points: Achieving Healthy Communities Through Performance Management Systems,²⁷ based upon recommendations from the Think Tank. The purpose of this 1-page document is to describe the benefits and relevance of PM in public health to foster support and buy-in among leadership, workforce, and communities. As part of the PM toolkit, PHF also developed a short slide set designed to introduce PM to new users.

PHF is collecting 1-page overviews of PM applications in public health and making them available on the PHF Web site.²⁸ The initial intent of this activity was to showcase examples of Turning Point Framework applications in state, tribal, local, and territorial public health departments to align with the refresh work. However, conversations with health departments revealed other PM frameworks that were useful to public health. Accordingly, these models are showcased on the PHF Web site as well. Each 1-page overview introduces a recent application of PM in a public health agency. A story is accompanied by a figure displaying the PM application, a brief description of its use by the health department, a list of resources needed for successful implementation, a summary of the model’s value, and contact information to facilitate communication with the health department providing the information. For example, New York State Department of Health adapted the Turning Point Framework for its Performance Management Framework (Figure 2), integrating its terminology and elevating the role of quality improvement as the foundation for the other components.

FIGURE 2.

New York State’s Performance Management Framework

Discussion and Recommendations

The Turning Point refresh effort was designed to promote discussion on the framework’s relevance in today’s environment. Refresh recommendations were intended to showcase greater emphasis on PM, as well as inform Public Health Accreditation Board’s refinement of Domain 9 accreditation standards. Moreover, the revised model will be useful in supporting health departments’ efforts to prepare for and maintain voluntary public health accreditation. Public Health Accreditation Board Standards & Measures, Version 1.0, Measure 9.1.2A, requires the health department to provide evidence of a completed PM self-assessment reflecting the extent PM is practiced.²⁹ It further states that the health department may develop its own PM assessment or use existing models, such as the Performance Management Self-Assessment Tool. Furthermore, the refresh was intended to stimulate efforts to effectively and efficiently manage organizational performance and facilitate the sharing and adoption of PM best practices.

The Think Tank participants recognized that the 4 central components of the original Turning Point Framework remain important, yet they felt that those components could not be implemented successfully without making Leadership an explicit fifth component. As a consequence, Visible Leadership and its subcomponents (Culture of Quality, Customer Focus, Strategic Alignment, and Transparency) were added to the framework to strengthen the 4 original core PM components.

As a result of interviewing PIMs about success factors and challenges related to the application of PM systems in public health, PHF recognized that no single PM framework, approach to adaptation, or technology solution was accepted as the ideal solution. The PIMs were better able to identify PM concepts and importance as they received more PM training during the first 2 years of the NPHII program, and as they gained experience with applying PM in their work. This change over time may explain the results of 2 recent ASTHO surveys profiling state health departments, in which the percentage of states reporting a formal PM plan in place declined in 2010 compared with 2007.^30,31 It is possible that the data reflect a more limited or less rigorous understanding of PM concepts in 2007. Just as in the case of the PIMs, when more information and examples of PM were made available, leading to a fuller understanding among states about what constitutes a PM system, states may have realized that in fact PM had not been implemented.

A number of PIMs providing input on the Turning Point Framework refresh efforts expressed a desire for a jumpstart shorter Performance Management Self-Assessment Tool and a simple low-cost technology solution to PM implementation. The Think Tank also indicated that a shorter self-assessment tool with automated scoring could facilitate rapid initial assessment. After weighing the pros and cons of developing a shorter tool, PHF felt that such a “shortcut” tool could actually dissuade organizations from dedicating the resources needed to examine PM comprehensively and commit leadership and resources to a systematic effort.

In the future, public health agency management will need to make integration of PM into daily practice the norm. The revised Turning Point Framework offers a roadmap going forward for PM implementation. There is consensus that it is less important which quadrant or component you begin with—it is more important that you begin. Leadership should also recognize that implementation may be uneven across the public health agency. Building first from the strength of the organization is a reasonable point of departure.

Performance management has great potential to transform public health when it successfully aligns with the mission, vision, and strategic directions of the organization. Currently, many organizations may be undertaking quality improvement projects that are neither organizational priorities nor critical to the mission of the organization and community.^32,33 Projects that may be easy to implement can help the organization build momentum for future efforts, such as preparing for accreditation. Moreover, they enable staff to gain quality improvement expertise. However, public health agencies should be making deliberate choices about program implementation in the greater context of organizational priorities. Performance management with leadership oversight and buy-in ensures that this alignment occurs through proactive engagement.

The need for PM systems applied to public health daily operations could not be more critical with the significant challenges and changes in today’s environment. Challenges facing health departments are exacerbated by shrinking funding for public health, shifting population demographics, health care workforce shortages, and integration of public health into health care.³⁴ A greater emphasis continues to be placed on accountability for outcomes and return on investment of public resources, even as budgets and staff are reduced.^35–37 The ability of public health to continuously improve quality and performance of agencies and public health systems is strongly tied to the ability to understand and confront challenges as they arise.³⁸

The Turning Point Framework refresh was intended to be a first step toward elevating the current issues and considerations for successful PM application. Additional resources and tools developed through PHF’s refresh efforts and new examples collected from health departments will be made available via the online PHF PM toolkit as they occur.

Practitioners and researchers could take a number of directions in the next decade to better understand the challenges and opportunities in PM. There may be value in forming a Performance Management Learning Community for public health that allows for peer learning and information exchange, including the sharing of PM frameworks and approaches among different geographic areas, similar to the exchange of public health data. Such an exchange could provide an opportunity for health departments to gain greater familiarity with a number of PM approaches—in addition to Turning Point—including Baldrige, LEAN, and Balanced Scorecard, among others. Both the NPHII PIM Network and Robert Wood Johnson Foundation’s Community of Practice for Public Health Improvement facilitate the exchange of best practices and build capacity among the nation’s public health departments to become accredited and conduct quality improvement. PHF’s Academic Health Department Learning Community,³⁹ an initiative of the Council on Linkages Between Academia and Public Health Practice supported by the Health Resources and Services Administration and the CDC, is a model that enhances public health education, training, and research between academic health institutions and state or local health departments. These communities could serve as models or could be leveraged or expanded to address more deeply the complex topics related to PM: how can information technology infrastructure best support a PM system, how should strategic planning be aligned with a PM system, and what opportunities exist to teach principles of PM in academic settings before professionals enter the workforce?

For public health PM to be successfully implemented, national stakeholders and state and local public health agencies must be aligned in taking a leadership role in innovating and sustaining PM systems, ensuring that PM systems are accountable for producing improved outcomes, leveraging technology advances, and incorporating best practices. Much remains to be learned from health departments currently operating PM systems that are achieving more efficient and effective practices. Attainment of full implementation is within our reach if collectively all disciplines and public health organizations are dedicated to learning together on this journey.