Continuous Quality Improvement - ADvancing States€¦ · Continuous Quality Improvement in Georgia...
Transcript of Continuous Quality Improvement - ADvancing States€¦ · Continuous Quality Improvement in Georgia...
Continuous Quality Improvement
in Georgia
Arvine Brown, Sharise Thurman, and Deborah Price
Department of Human Services Division of Aging Services
What is Quality Assurance?
Quality assurance, or QA for short, refers
to a method for the systematic monitoring
and evaluation of the various aspects of a
project, service, or facility to ensure that
standards of quality are being met.
How Do You Do That?
DAS uses the never-ending
quest of Continuous
Quality Improvement (CQI)
for improving all aspects
of performance through small
incremental steps as
well as through targeted
breakthroughs.
DO
ACT
PLAN
CHECK
PDCA Cycle
Great, How Do You Do CQI?
• 4 Step Approach:
• Customer Focus– We must understand who they are, what they need and then satisfy their needs.
• Data Driven Decision Making– Focus on processes, data that measures the processes and performance, and then use that
information to make improvements.
• Use Teams to Solve Problems– Include everyone because all work is part of a process and teams must be empowered to
improve them.
• Integrate Planning– Learn from the past, work together to shape the future, identify and remove barriers to
success.
Why Do This in Government?
Meet or exceed customer expectations
Become more competitive
Use successes (and sometimes failures) as advocacy tools
Demonstrate ROI (Return on Investment) for decision makers
GEORGIA DCSS RECEIVES 2010 MOST
IMPROVED PROGRAM AWARD
Congratulations to the Division of Child Support Services (DCSS) for
being named as a recipient of the 2010 Most Improved Program Award.
This award is based on a 3-year review and given by the National Child
Support Enforcement Association (NCSEA). It recognizes any program
throughout the nation that has shown exceptional improvement in child
support performance. DCSS is leading the way in superior performance;
and we are pleased to call them one of our own. They will be honored
with this award at the NCSEA Annual Conference in Chicago this
August.
GEORGIA DFCS RANKED 7TH IN US – FOOD
STAMP ACCURACY
• The Department of Family and Children’s Services (DFCS) will receive a performance award of over $4 million from the Food and Nutrition Service (FNS). This award is in recognition of outstanding performance in the issuance of Food Stamp benefits. Last year, DFCS distributed nearly $2 billion in food stamp benefits, giving them a payment accuracy rate of 97%. This accuracy rate is now ranked 7th in the country.
Ranking of States by Rates of Food Insecurity among Senior
Americans 2001-2007 – Order from Highest to Lowest
State Rank Rate State Rank Rate
Mississippi 1 12.29 Kansas 27 5.03
South Carolina 2 9.83 New York 28 5.03
Arkansas 3 9.7 Oregon 29 5.01
Texas 4 8.9 Alaska 30 4.96
New Mexico 5 8.82 Washington 31 4.83
Georgia 6 8.58 Montana 32 4.79
Alabama 7 7.39 West Virginia 33 4.71
Louisiana 8 7.36 Utah 34 4.65
North Carolina 9 7.3 New Jersey 35 4.64
Oklahoma 10 7.12 Vermont 36 4.52
Arizona 11 6.41 Nevada 37 4.36
Indiana 12 6 Pennsylvania 38 4.31
Missouri 13 5.88 Massachusetts 39 4.29
Maryland 14 5.76 Colorado 40 4.15
Idaho 15 5.69 Iowa 41 3.95
Tennessee 16 5.62 South Dakota 42 3.9
Maine 17 5.46 Wyoming 43 3.9
California 18 5.44 Illinois 44 3.88
Rhode Island 19 5.41 Delaware 45 3.76
Kentucky 20 5.4 Connecticut 46 3.64
District of
Columbia 21 5.37 Wisconsin 47 3.6
Virginia 22 5.27 Nebraska 48 3.32
Hawaii 23 5.24 Minnesota 49 3.08
Florida 24 5.14 New Hampshire 50 3.01
Michigan 25 5.09 North Dakota 51 1.53
Ohio 26 5.06
Regional Benchmarking Work Group
• The purpose of this work group is to develop standardized performance indicators that can be used to demonstrate program benefits and outcomes. Creating a more consistent method of accountability and accessing meaningful evaluative data can better position State Units on Aging (SUAs) to advocate in their own states and at the federal level to continue or enhance funding for services that have proven benefit for consumers.
• Consists of Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina and Tennessee
• Looks beyond NAPIS data for comparisons
Regional Benchmarking Work
Group Comparative Measures
Fiscal Accountability - Percent of State/Federal Funds Expended by SUA
Ombudsman Responsiveness - Percent of complaints resolved to resident’s satisfaction
Home Delivered Meals - Percentage of Clients Improving High Nutritional Risk Scores
ADRC Consumer Safety and Protection - Crisis call follow up within 14 days
“Good is no longer good enough!”
Good, better, best.
Never let it rest,
Till your good is better,
And your better is best!
St. Jerome
1
Leadership
2
Strategic
Planning
3
Customer and
Market Focus
6
Process
Management
5 Workforce
Focus
7
Business
Results
4
Measurement, Analysis and Knowledge Management
Organizational Profile:
Environment, Relationships, and Challenges
Criteria for Performance Excellence Framework: A Systems Perspective
ADLI•A = Approach – Refers to systematic methods used,
appropriateness, and effectiveness of these methods
– How do we do what we do?
•D = Deployment – Approach is deployed in depth and breadth
to appropriate work units
» Is everyone knowledgeable of our approach to a
process?
• L = Learning – Refers to new knowledge/skills acquired
through systematic research, evaluation/improvement cycles,
input from stakeholders, benchmarking
•“Integration” refers to the extent to which your measures,
information, and improvement systems are complementary across
processes and work units
DAS Plan Alignment
Area Plan DAS Hoshin DHSState PlanAOA
5. Management Effectiveness (HR, Financial,
Technology, Evaluation)
1. Access (Information, Program, Collaboration)
2. Wellness (Information, Program, Collaboration)
3. Caregiver Support (Information, Program,
Collaboration)
4. Elder Rights/ Protection (Information, Program,
Collaboration)
Increase
Healthy Pro-
social Behavior
Improve Use of
Technology
Employee
Engagement
Increase
Employment &
Self-
Sufficiency
Increase
HCBS
Employee
-Professional
Development
-Satisfaction
-Recruit/Retain
-Succession
Planning
Financial
-Resource
Development
-Accountability
Process
-Efficient/
Effective
-Optimize
Technology
-Internal
Communications
Customer/
Client
-Access
-Marketing
-Prevention
-Advocacy
Wildly
Important
Goal (WIG)
Prioritization Matrix -2010
Impact on all
Customers
Need to
Improve
Aligned
to
Vision TOTAL
O – Elder Justice Act 4 3 3 M
O – Healthcare Reform 4 4 4 M
T – Loss of DAS State Funding (Policy Waiver increases Risk) 5 5 4 100
O – Placement resources/processes for vulnerable adults (Housing) 4 5 4 80
W – Limited Resources 5 5 3 75
W – Internal IT funding and support (we don’t get Gaits) 5 5 3 75
W _ Partnership with AAAs is strained 4 4 4 64
W – Lack of bilingual staff (cultural competency) 4 4 4 64
O – Funding/ Grant Opportunities/ Develop Internal Process for Grant
Development 4 4 4 64
W/O – Transportation/ mobility (Innovative approaches) 4 4 4 64
T – Growth in APS target population 4 4 4 64
O – External collaborators (Law enforcement) 4 4 4 64
T – Loss of DAS Programs 4 4 4 64
T – Limited funding for Community-based programs (Institutional bias for
NF) 4 4 4 64
O – Streamline measures and action plans 4 5 3 60
W – Staff overworked (stress) 3 4 4 48
W – Aging not priority in DHS/ they don’t understand us 3 4 4 48
W – Knowledge transfer/ cross training/ succession planning 4 4 3 48
SCALE: 1= None 2=Low 3= Moderate 4=High 5=Extreme M=Mandate
O – Marketing of Division 4 4 3 48
O – HB 850 levels of care for Assisted Living 3 4 4 48
O – AIMS Redesign (Data mining) 4 4 3 48
O – Cooperative Community-based approach to Aging in Place 4 4 3 48
O – Website development 5 3 3 45
W – Partners now in other Departments 4 3 3 36
O – Timely Communications (External) 3 4 3 36
W – Inconsistent revision/ deployment/ implementation of policies/
standards/ processes 3 4 3 36
O – Foster internal partnerships 4 3 3 36
O – Timely Communications (Internal) 3 3 3 27
O – Project 2020 3 3 3 27
O – AAAs should be Gateway with ADRC 3 3 3 27
O – Coordination of training events 3 3 3 27
W – Training on QI Tools (JIT) 3 3 3 27
O – Leverage expertise in innovative ways 3 3 3 27
W – Limited External Training 3 3 2 18
SCALE: 1= None 2=Low 3= Moderate 4=High 5=Extreme M=Mandate
1717
Strategic Objectives – 2011 – 2015
DAS Strategic Objectives
Scorecard
Perspectiv
e Objective Champion Measure
Targets
2011 2015
1.0
Customer/
Client
1.1 Expand Community
Living Strategies Jamie Plan developed by 9/30/2010
1.2 Improve Marketing J
Marketing Plan by 6/30/2010
Measures related to DAS brand, Service Branding, Providing
Information
1.3 Improve Protection
of Vulnerable
Adults
Shirley/
Barbara
1.31 % APS cases timely investigated within 10 calendar days
1.32. % of APS cases investigation completed w/in 30 business days
1.33 Client Fall Rate (HCBS)
% APS clients going into long-term care
2.0
Financial
2.1 Develop/expand
Funding Streams
Blake/Jamie
/
Arvine/
Jeni
Develop Internal Process for Grant Development
2.11 Competitive Grant Funding Received ($)
2.12 Funding Leveraged through Partnerships ($)
2.13 % Budget from Non-traditional sources
2.2 Increase funding for
technology
development Blake 2.21 Infrastructure Budget Attained ($)
1818
Strategic Objectives – 2011 – 2015
DAS Strategic Objectives
Scorecard
Perspectiv
e Objective Champion Measure
Targets
2011 2015
3.0
Employee
3.1 Increase Employee
Engagement Becky/ Allan 3.11 % Employee Engagement (Gallup12)
3.2 Improve Internal
Knowledge
Sharing Arvine/ Jean 3.21 % Employees with access to SharePoint
4.0
Internal
Process
4.1 Improve Internal
Communication Barbara
4.11 % Employees Satisfied with Internal Communications
Project to get employees to understand various communications
channels
4.2 Improve AAA
Satisfaction with
DAS Services J 4.21 Customer Engagement Index (Gallup)
4.3 Improve/ Prioritize
Internal Processes S & S & D 4.31 % Key Processes Documented
4.4 Streamline/ Improve
Programmatic
Measures “ 4.41 Determine critical measures to report for management level
Prioritization of Internal & External FactorsW
O
T
Issue Impact on
Customer
Need to
Improve
Alignment to
Vision
Total Mandate
t
Budget Crisis- Morale issues due to furloughs, benefits cost increases and travel restrictions. Basic office supplies are depleted. Spending restrictions for equipment replacement and f2f training opportunities -impends work due to travel restrictions 0 M
oContinued growth in target populations
0 M
oDiversity of clients
0 M
o
Partnering with DHS & DCH; provide input into restructuring & influence
0 M
t
Personal economic impact on staff increasing stressors. (rising costs in personal expenditures/gas costs and no cost of living raises). 0 M
t
Uncertain political climate and structural reorganization. (program & staff job security) 0 M
t
Medicaid growth rates outpace the state and national economic growth; strain on Medicare resources (baby-boomers).
0 M
t
Lack of state dollars negatively impacts our ability to match federal/other grants
0 M
tLoss of TCM$
0 M
tRestructure of DHR and DCH
0 M
Prioritization of Internal & External FactorsW
O
T
Issue Impact on
Customer
Need to
Improve
Alignment to
Vision
Total Mandate
w Lack IT support that is readily available. 5 5 5 125
w Marketing/education to community /Web Site 5 5 5 125
w Data still exists in two systems 5 5 5 125
w
Waiting list for services; especially direct services (APS) and HCBS (marketing); response time to be able to meet the demand and need of customers
5 5 5 125
o
LTC demands are shifting away from facility based services to in-home services. 5 5 5 125
o
Consolidation of all programs into AIMS – comprehensive case management 5 5 5 125
w
Lack of communication w/ other sections, contractors, DHR; MG provides good leadership w/ UR2NO 5 4 5 100
w
Multiple responsibilities impedes ability to complete duties in a timely manner 4 5 5 100
o
Managing using data (workforce mgmt. including assignments/coverage). 5 4 5 100
o Efficiencies in service delivery. 5 4 5 100
o
AAAs find a market for private pay for certain services (case management) 4 5 5 100
t
Lack of strong home health provider capacity system including housing, transportation 5 4 5 100
w
Staffing levels (hiring) in some areas around the state are insufficient. Barriers to hiring 4 4 5 80
o External collaboration which leads to innovations 4 4 5 80
Aligning Objectives with SectionsDAS Strategic Objectives - Alignment Matrix - 2010
APS LTCO CCSP LC AtS FA PI DIR
1.1 Increase Access to Quality
Services (Jamie and Shirley) H H H H H H M M1.2 Improve Marketing (Maria &
Jeni) M H M L H M M M1.3 Expand Prevention
Initiatives (Shirley and Mary H L H L L L L H
1.4 Advocacy (Becky)L H M L M M L M
2.0 Financial 2.2 Accountability (Blake)M M M L M H M M
3.2 Satisfaction (Arvine)M M M M M M H M
3.3 Recruitment/ Retention
(Jean) M L M L L M L M3.4 Succession Planning (Mary
Martha) H L M L M M M M4.3 Improve Internal
Communications(Doris, Arvine) M L M M M M H M4.4 Enhance Technology -
Fiscal Accountability WIG M L H L M H H HAlignment H- High, M-Medium, L-Low
Rev. 2/10
4.0 Internal
Processes
1.0
Customer/Clie
nt
3.0 Workforce
Sections
Scorecard Division Objective
Strategic Challenges & Advantages
Category 1 - Leadership
1
Leadership
2
Strategic
Planning
3
Customer and
Market Focus
6
Process
Management
5 Workforce
Focus
7
Business
Results
4
Measurement, Analysis and Knowledge Management
Organizational Profile:
Environment, Relationships, and Challenges
Criteria for Performance Excellence Framework: A Systems Perspective
Mission Statement
DAS, together with the Aging Network and
other partners, assists older individuals,
at-risk adults, persons with disabilities,
their families and caregivers to achieve
safe, healthy, independent and self reliant
lives
Vision Statement
Living Longer, Living Safely, Living Well
2727
Review Mission, Vision, Values
• Lets Review & Discuss Our Values:
Value: Definition:
A Strong Customer Focus We are driven by customer, not organizational, need…
Accountability and Results Good stewards of the trust and resources …
Teamwork Teamwork is the way we do business...
Partnership Value partners and actively pursue new partnerships…
Open Communication Communication is the lifeblood of organizations…
A Proactive Approach Anticipate the needs of our customers and advocate …
Dignity and Respect We respect the rights and self worth of all people...
Our Workforce Workforce, including volunteers, are our best assets…
Trust Honest with one another and with our customers…
Diversity Value diverse workforce, it broadens perspective…
Empowerment We believe in self-determination for our customers…
Positive Work Environment Division maintains a learning environment with
opportunities to increase professional growth…
Category 2 – Strategic Planning
1
Leadership
2
Strategic
Planning
3
Customer and
Market Focus
6
Process
Management
5 Workforce
Focus
7
Business
Results
4
Measurement, Analysis and Knowledge Management
Organizational Profile:
Environment, Relationships, and Challenges
Criteria for Performance Excellence Framework: A Systems Perspective
Hoshin HistoryFirst HOSHIN Planning Session January 1998
GOAL: Manage the Organization Using Data
Sub-Objectives:
1. Data are available (Resulted in AIMS Database)
2. Data are used (Key success factors,
measurements have been adopted)
Lesson Learned: Since plans are dynamic an
audit/review process must be used
Second Hoshin - 2006
Second HOSHIN Planning Session January 2006
Developed Second Hoshin Statement: By the year
2011, Georgia will have the highest performing aging
network in the US that champions consumers living
safer, healthier, more self reliant lives.
Strategic Focus Areas: Via Balanced Scorecard
Format
1. Customer/Client
2. Financial
3. Employee
4. Internal Process
Lesson Learned: How will we know it when we see
it?
Strategic Planning Process (Hoshin Planning)
Staff StakeholdersSenior Leaders
NEED PLAN
1. Review Mission,
Vision, Values
2. Review Existing
Plans, Reviews, Audits
3. Review/Understand Customer/Partner Requirements
4. Perform Internal and External SWOT
5. Determine Strategic Objectives/Targets/
Timelines
Assign Champions
6. Align Objectives with Sections
7. Develop Section Objectives and Action
Plans
8. Align with Budgets
9. Review Plans and Progress
10. Evaluate and Improve Process
Plan
Developed
DAS SPP
HOSHIN – every 4 years
State Plan – every 4 years
Annual Baldrige assessment
Annual review of MVV
SWOT/Environmental Scan – every 1 to 2 years
Dashboard/Balanced Scorecard – update quarterly; review and revise
semiannually
Section Action Plans – update and review quarterly
PDCA system
MAP measures – Update & review quarterly; LT reviews quarterly and
annually to review trends
Customer Requirements – Annual Area Plan Cycle
LT reviews monitoring and evaluation reports as they are conducted;
review of Public Hearings comments; C3 process;
Key Processes – Review and update annually as of SFY09
Focus
AreaStrategic Objectives Measure
Current Year
Goals/Measures
2008-09
3 Year Projection
(2011)Selected Current Year Action Plans
1.0
Custo
mer/
Client
1.1 Increase the #/%
of high risk customers
in HCBS and CCSP
1.11 DON-R impairment level of 15 and 1
unmet need (HCBS)
75% 80% each year
(2010 & 2011)
1.11 Increase the #/% of high risk customers
(non Medicaid eligible) in Home and Community Based
Services (HCBS)
1.12 DON-R impairment level of 15 and 1
unmet need; plus composite score of 23
or higher(CCSP)
New Measure
SFY09
TBD based on initial
result
1.12 Increase the #/% of high risk customers
(Medicaid eligible) in Community Care Services Program
(CCSP)
1.2 Improve
Marketing
1.21. # ADRC information & assistance
served;
1.22. ADRC web visits
1.23. LTCO web visits
1.24. DAS web visits
1.25. DAS 1-800# calls received
1.26. Live Well Age Well web visits
1.21 - 55,516
1.22 – New
Measure
1.23 – 60,042
1.24 - 7116
1.25 - 2,254
1.26 – 41,803
1.21 – Increase 5%
annually
1.22 – New Measure
1.23 – 64,000
(2010 & 2011)
1.24 – Increase 3%
per year
1.25 - New
Measure
1.26 – Increase
5,000 visits per year
1.21. Increase # of customers accessing Aging and Disability
Resource Connection (ADRC) for information and assistance
1.22. Increase ADRC web visits
1.23. Increase LTCO web visits
1.24. Increase DAS web visits
1.25. Increase DAS 1-800# calls received
1.26. Increase Live Well Age Well web visits
1.3 Expand
Prevention Initiatives
(WIG measures)
1.31 % APS cases timely investigated
within 10 calendar days
1.32. % of APS cases investigation
completed w/in 30 business days
1.31. 93.6%
1.32. 80.7%
1.31 95% each year
1.32 85% each year
1.31 & 1.32 Reduce APS investigations not completed timely
within guidelines as defined by policy by June 30, 2009.
1.33 % Safety protocols developed
1.34 Recidivism Rate
1.33 – See Safety
Team Report
1.34 – 5.67%
1.33 – TBD
1.34 < 1%
1.33 Increase APS safety protocols that prevent serious injury
or unexpected death of APS staff.
1.34 Reduce APS Recidivism Rate
1.35 % of CCSP clients contacted timely
1.36 Decrease rate of falls resulting in
fractures
1.35 100%
1.36 12 counts of
fall incidents
1.35 100%
1.36 Reduce by
20% (2010 & 2011)
1.35 Achieve 100% of CCSP clients contacted in a timely
manner by Case Management.
1.36 Decrease falls resulting in fractures by 20% in 2009
1.4 Improve
Advocacy
1.41 % of desired Legislation
Amended/ Passed
1.41 3.5% SFY08 1.41 3% increase in
legislation passed
per year
1.41 Increase % of legislation amended / passed at the state &
federal level
2.0
Financi
al
2.1 Reduce Lapse 2.11 DAS100% expended each fiscal
year; AAA 95% expended within 5% + / -
of program guidelines
2.11 -DAS 99.79%
AAA’s – Available
onsite
2.11 DAS -99%
expenditure per
year; AAA – 95%
with a goal of 100%
expenditure
2.11Reduce Budget Lapse by AAAs & DAS
Focus AreaStrategic
ObjectivesMeasure
Current Year
Goals/M
easures
2008-09
3 Year
Projectio
n (2011)
Selected Current Year Action Plans
3.0 Employee
3.1 Increase
Employee
Satisfaction
3.11 % satisfied with job and overall
atmosphere
3.11 - 85% 3.11 2010/11-90% 3.11 Increase employee satisfaction with job and overall
atmosphere with DAS
3.2 Increase
Employee
Satisfaction
with
Compensati
on
3.21 % satisfied with benefits and
compensation
3.21 – 50% 3.21 2010/11-
60%
3.21 Increase employee satisfaction with benefits and
compensation received
3.3 Reduce Hiring
Cycle Time
3.31 # of days to hire employee from
posting of position
3.31 - 62 days 3.31 - 45 days
2010/11
3.31 Decrease number of days to hire an employee from posting
of position
3.4 Reduce
Turnover
Rate
3.41 # of vacated positions/ # of filled
positions x 100
3.41 - < 10% 3.41 - < 20%
2010-11
3.41 Achieve under 20% annually for DAS turnover rate
3.5 Reduce
Turnover
Rate for
First Year
Employees
3.51 # of vacated positions/ # of
budgeted positions x 100
3.51- < 1% 3.51 - < 3%
2010-11
3.51 Maintain the DAS turnover rate for first year employees
under 3%
3.6 Deploy
Succession
Planning
Process
3.61 # of candidates successfully
completing succession
planning program
3.61 Baseline of
4
candidat
es
3.61 –
2010 – 5
2011 - 6
3.61 Achieve the number of succession planning candidates
annually who complete the program every 12 months
4.0 Internal
Process
4.1 Improve
Internal
Communica
tion
4.11 % Employees Satisfied with
Internal Communications
4.11 - 84% 4.11 –
2010 – 90%
2011 – 95%
4.11 Increase DAS employee satisfaction with internal
communication processes
4.2 Improve
Technology
– Fiscal
Accountabil
ity (WIG)
4.21 New Measure being developed 4.21 Baseline for
SFY09
4.21 - TBD 4.12 Integrate CHAT into AIMS database
Section Name:
CCSP
Section Objective: 2.2
Maintain and increase
financial accountability
for CCSP
Action Plan for:
Accountability
Resources Needed: Staff
Hours Each
Track On-
going
Referral
Time
To be Completed by: $: Labor
Hours:
Document Source: J:\CQI\Hoshin
Success to be
Measured by:
100% of CC
funds
are
expend
ed.
Specific Actions By Whom When How Accomplished Update
1. Care
Coordination
review of
expenditures
JS, CC
Speciali
sts;
SPM &
DAS
Admin
Qtrly
Ongoing
Initiate qtrly review of AAA CC
dollars expended;
formalize process that
contact or notification
from the Specialist
and/or Section Manager
speaks with the AAA if $
are being lapsed in the
2nd qtr (variance of 5%).
Annual review of
allocation during each
new budget process.
9-21-06 - Current monitoring process
- State CC specialists speaks
with AAA if 25% of $ has not
been expended in Q1. Process
Improvement - Section Mgr
provides a call and letter in Q2 if
expenditures have not met the
50% threshold.
-6-07 Review and approval of
budget variance MAP. SFY
2008 run bew MAP. DONE
Action Plans Continued
2. Monthly
monitoring of
fiscal budget
(4.2 on DAS
Scorecard)
SPM; JR Qtrly
Ongoing
Review MID reports for benefit
expenditure; Compare the
different billing numbers in
terms of what CCSP
spent vs. what OFS
indicates as being spent;
analyze spikes; Work with
Judy Hagebak within
DCH. Compare services
authorized files versus
paid files deauthorized.
Review service authorization and
payment form in AIMS.
Note: providers have a 6
month window to bill which
creates a claim lag in actual
expenditures.
-7/07 Quarterly memo sent
to OFS Jim Sanregret.
Invoice and AIMS reports
closer. Ongoing monthly
review.
Category 3 – Customer & Market
Focus
1
Leadership
2
Strategic
Planning
3
Customer and
Market Focus
6
Process
Management
5 Workforce
Focus
7
Business
Results
4
Measurement, Analysis and Knowledge Management
Organizational Profile:
Environment, Relationships, and Challenges
Criteria for Performance Excellence Framework: A Systems Perspective
DAS’ Customers
The OAA, other federal laws,
and Georgia state law define
DAS’ customers, clients,
customer groups, and market
segments.
• Our end customers, as defined by these
laws, include senior citizens, other adults
with disabilities and their families,
caregivers, and advocates.
Voice of the Customer
How do we listen to our clients?
• Monitoring and evaluation of partners and suppliers, including during site visits
• Consumer satisfaction surveys for various services
• Focus groups
• Public hearings
• Client data assessment tools such as the Determination of Need-Revised (DON-R)
• Client consent for protective services interventions
• Program wait list data
• Advisory councils and
• Complaint data
Figure 3.1-1 DAS Customer and Market Groups and Voice of the Customer
DAS
SectionsCustomer and Market Products and Services Key VOC Listening Approaches
APS
Elders 65 years of age or older
Disabled persons over the age of 18 years of age
Persons above who are not residents of long
term care facilities (O.C.G.A. 30-5-1)
Investigation
Case Management
Community Education
Training
DHR Guardianship of Wards
Program Management/ Development
Emergency Relocation
Personal Care Home (PCH) Relocation
Consumer Fraud Prevention Program
Case Management
Central Intake 1-800#
Surveys
Future Providers and Partners Survey
C3 Process
DON-R
Advisory Groups
Area Plan Feedback
Customer Complaints
AtS
Elderly Legal Assistance Program (ELAP) - Persons 60
years of age and older needing legal
representation, information, and education in civil
legal matters.
Aging Disability Resource Connection (ADRC) - Older
adults, individuals with disabilities and their
families to a coordinated system of partnering
organizations dedicated to providing accurate
information about publicly and privately financed
long-term supports and services and offering a
consumer-oriented approach to learning about
the availability of services in the home and
community.
GeorgiaCares - Helps Medicare beneficiaries and
others understand their rights, benefits and
services offered under Medicare and Medicaid,
and other health insurance options offered
through public-private partnerships.
Group Community Education
Benefits/Resources Counseling for Medicare
Beneficiaries
Legal Services
Training and Technical Assistance
Senior Medicare Patrol (SMP) Fraud Reporting
Information& Referral to Resources for the elderly
and disabled
Case Consultation
Outreach to the general public
Focus Groups, Public Hearings
ADRC Advisory Group
GeorgiaCares Advisory Group
Area Plan Feedback
Customer Complaints
Professional Affiliations
Surveys
C3 Process
Category 4 – Measurement, Analysis &
Knowledge Management
1
Leadership
2
Strategic
Planning
3
Customer and
Market Focus
6
Process
Management
5 Workforce
Focus
7
Business
Results
4
Measurement, Analysis and Knowledge Management
Organizational Profile:
Environment, Relationships, and Challenges
Criteria for Performance Excellence Framework: A Systems Perspective
DAS
DASHBOARD
LTCOP ACTION PLAN /
OBJECTIVE
MAP TITLE AND BASELINE RESULT
S FY 09
TARGE
T
FY 09
BY QUARTER
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
Customer
Organizational
Effectiveness
Response Time within Standard –
Abuse Complaints: Resident at
Risk. Baseline: 100 percent (FY
05)
97 % 98 % 100 % 100 % 100 % 89 %
Response Time within Standard –
Abuse Complaints: Resident Not
at Risk. Baseline: 99 percent (FY
05)
97 % 98 % 100 % 100 % 97 % 89 %
Response Time within Standard –
Other Complaints. Baseline: 98
percent (FY 03)99 % 98 % 99 % 99 % 99 % 97 %
Customer
1.1 – Increase access to quality
services: Increase LTC residents’
access to quality LTCO services
Complaint Resolutions – Positive
Outcomes. Baseline: 94 percent
(FY 03)93 % 97 % 96 % 94 % 97 % 93 %
Customer
1.1 – Increase access to quality
services: Increase LTC residents’
access to quality LTCO services
Routine Visits – Nursing Homes.
Baseline: 65 percent (FY 07)84 % 91 % 93 % 95 % 90 % 96 %
Routine Visits – ICF/MR.
Baseline: 64 percent (FY 07)100 % 91 % 100 % 100 % 100 % 100 %
Routine Visits – Personal Care
Homes. Baseline: 52 percent (FY
07)67 % 80 % 85 % 83 % 83 % 81 %
Routine Visits – Community
Living Arrangements. Baseline:
43 percent (FY 07)78 % 91 %
n/a –
based on
six
months
n/a –
based on
six
months
n/a –
based on
six
months
n/a –
based on
six
months
Customer
1.1a – Increase access to quality
services: Evaluate customer
satisfaction with ombudsman
complaint processing
Customer Satisfaction – Would
Use Again / Recommend.
Baseline: 94 percent (FY 06)
survey to
be
completed
in 2010
96 %survey to be completed and results made
available in 2010
Customer
1.2 – Improve marketing: Increase
the number of people served by
LTCOP
Website Sessions. Baseline:
35,554 sessions (FY 06)[1]
73,941
sessions1
64,000
sessions1
15,952
sessions1
17,826
sessions1
19,676
sessions1
20,487
sessions1
Visits to Website. Baseline:
43,114 visits (FY 06)[2]
unavailabl
e
64,000
visits
16,520
visits
18,703
visits
unavailable –host
changed stats package
SMART Measures
• Specific – Well defined measures that define, Quality, Timeliness, Cost (or Revenue), Safety, Environment
• Measurable – Must be quantifiable and focused on a specific outcome
• Achievable – Moon or Mountain Scenario
• Reportable – Measures item you desire to see impacted
• Time bound – Results should be collected and tracked at regular and frequent intervals.
Category 5 – Workforce Focus
1
Leadership
2
Strategic
Planning
3
Customer and
Market Focus
6
Process
Management
5 Workforce
Focus
7
Business
Results
4
Measurement, Analysis and Knowledge Management
Organizational Profile:
Environment, Relationships, and Challenges
Criteria for Performance Excellence Framework: A Systems Perspective
80%
10
0%
80%
83
%
78%1
00
%
100%
91
%
64%9
2%
79%
86
%
58%
10
0%
83%
80
%
46%
86
%
93%9
2%
33%
10
0%
67%
0%
30%
69
%
86%
50
%
35
%
80%
68
%
75%
78
%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
LTCO PI LC CCSP AtS COA DIR APS FA
2004 2005 2007 2008
Overall Response Rates
Positive About DAS
69%
65%
56%
68%
64%
69%
77%
53%
47%
59%
55%
64%
67%
72%
69%70%71%
77%75%
71%
80%
74%74%76%
81%
70%70%
71%
75%
78%
45%
55%
65%
75%
85%
Work
Environment
Organization Communication Personal
Satisfaction
Training Leadership
2002 2004 2005 2007 2008
Category 6 – Process Management
1
Leadership
2
Strategic
Planning
3
Customer and
Market Focus
6
Process
Management
5 Workforce
Focus
7
Business
Results
4
Measurement, Analysis and Knowledge Management
Organizational Profile:
Environment, Relationships, and Challenges
Criteria for Performance Excellence Framework: A Systems Perspective
Core Competencies
• 1. Depth/Breadth of experience in gerontology, social sciences and elder law/justice;
• 2. Engaged in developing and implementing evidence-based models and research;
• 3. Knowledge of national and state long-term care policies, trends and stakeholders;
• 4. Expertise in statewide program planning, development, administration, and evaluation;
• 5. Ability to establish and maintain key partnering relationships to build a statewide advocacy network; and
• 6. Systems design, development and management through the usage of accurate, timely and complete data.
Macro Processes
• Policy and Standards
• Fiscal and Contract Administration
• Public Education and Outreach
• Program Management
• Strategic Planning
Sec
-tion
Products/
Services
Key
Processes
Require-
ments
Mea-
sures
PI State & AAA contract deliverables
State Plan
State Reporting Tool to AoA
Provider performance, consumer
sat, measurement of svc quality &
programmatic standards; review
guides; surveys; monitoring rpts
AIMS – tool for data capture & rpt
Policy, recommendations for best
practice, reporting ed, knowledge
more geared towards safety
DAS annual report (JtF)
Meet goals, target objectives for
Div via Operational/Strategic Plan
Emergency/BC Plan
Area Plan
State Plan
NAPIS
Monitoring and Evaluation
Serious Incidence Review
Team (SIRT)
AIMS Development
Forensic Training
(Outreach targeted to
mandated reporters and 1st
responders)
Regulatory Reports (Just the
Facts (JtF))
Strategic Planning
Account Management Team
(AMT)
Consider RC processes –
1.Project Plan Completion
Information
Program Knowledge
Good Customer Service
Cultural Competence
Reliable/Accurate Data &
Systems
Successful
organizational
improvement initiatives
# of Area Plans
submitted on time
# of State Plans
submitted on time
NAPIS timely
submission
M&E – Timeliness
(date due vs. date
completed)
AIMS reliability - %
system up &
available
Forensic Training -
# of training
conducted police &
coroners
# of JTF completed
on time
SP - # of measures
Meeting &
exceeding targets
1.Work Plan
Effectiveness Measure
2.Success Rate of
project completion
Plan- Do- Check- Act
Plan – Determine what we are trying to accomplish
Determine process requirements, measures, and
evaluation methods.
Where are we now?
Where do we want to be?
What do we need to do to get there?
How do we monitor our progress?
Do – Execute plans.
Check – Assess progress; determine what is working
and what is not working; what process improvements
can be made; what organizational and personal learning
is occurring?
Act – Revise plans based on assessment findings,
learning, new requirements, and opportunities for
innovation.
Category 7 Results
1
Leadership
2
Strategic
Planning
3
Customer and
Market Focus
6
Process
Management
5 Workforce
Focus
7
Business
Results
4
Measurement, Analysis and Knowledge Management
Organizational Profile:
Environment, Relationships, and Challenges
Criteria for Performance Excellence Framework: A Systems Perspective
LeTCLiG
Performance Levels (Le)
• Are key results missing? What levels are provided? Is the measurement scale meaningful?
Trends (T)
• Are trends provided? Are the results favorable or unfavorable or flat? What is the rate of change in the trend?
Comparisons (C)
• Are comparisons provided? Are the comparisons relevant? Are the comparisons industry averages or best-in-class?
Linkage (Li)
• Do the results link to Key Factors or Process Items that are important to the applicant? Are the results segmented?
Gaps (G)
• Are there important results not reported or addressed?
0%
20%
40%
60%
80%
100%
2005 2006 2007
Customer Satisfaction
DAS
Coral Springs (Baldrige)
HCTC (Sterling)
ACSI Federal Govt.
AIMS
Aging Information Management System
Designed for Georgia’s Aging Network
AIMS
• Standardized statewide database
• Web-based
• One centralized system instead of
multiple stand alone systems
• Flexible programming
AIMS
• “Team Georgia”- based system: developed,
maintained and updated with user input
• Self-service application: users enter data
and run reports
• Required for data collection and reporting
DAS, AAAs and Providers/subcontractors
AIMS
• Provides high degree of accountability by linking programmatic and financial data
• Produces verifiable data on a uniform statewide basis
• Facilitates consistent implementation of aging programs statewide
AIMS
• Is a readily available tool that measures
efficiency, distribution of services and
compliance measures
• Plays a major role assuring access to vital
information and analysis
• Generates many versatile programmatic and
administrative reports that are used to manage
and evaluate programs
AIMS
• Provides all data needed for federal/state
reporting - no data entry into separate
tracking system needed
• Provides information to track trends and
client outcomes
• Has been recognized as a "best practice"
system model nationally
AIMS Users by Program
3,656 Total AIMS Users
1,061
558
519
329
266
212
189
121
39
255
107
0 200 400 600 800 1,000 1,200
Number of AIMS
Users by Program
ADRC/Gateway
(New)CCSP Care
Managers (New)SCSEP
Elder Abuse
PreventionLTCO
ELAP
Adult Protective
ServicesArea Plan/Financial
CCSP
GeorgiaCares
HCBS
AIMS Current Reports by
Program348 Total Reports
0 20 40 60 80 100 120
EAP
ELAP
All
NAPIS
Finance
Area Plan
GeorgiaCares
LTCO
APS
HCBS
CCSP
• Continue to strive to manage using data by having timely and accurate data
• Need for development of new reports as users and programs need them
• Modify AIMS to meet changing programs and priorities of aging network
• New development in process now for release in calendar year 2011
AIMS is a work in progress due to
constant changes in the aging network
Questions
Contact information:
Arvine Brown – [email protected]
(404)657-5278
Sharise Thurman – [email protected]
(404)657-5281
Deborah Price – [email protected]
(404)657-5265
Thank You!