DOMAIN 9

Evaluate and continuously improve health department processes, programs, and interventions
Standard 9.1: Use a performance management system to monitor achievement of organizational objectives

PHAB Measures

HAI/AR Specific Programs or Activities

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

PHAB Measures

Measure 9.1.1:

(All) Staff at all organizational levels engaged in establishing and/or updating a performance management system

HAI/AR Specific Programs or Activities

HAI/AR Programs are expected to develop metrics and processes for ongoing performance improvement. HAI/AR Program staff should be aware of how program specific performance improvement strategies may contribute to an overall performance management system

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: HDs must document engagement of staff at all levels in determining the nature of a performance management system (PMS) for the dept./program/division.

Opportunity: This supports the need for the inclusion of HAI coordinators, HAI program staff, and HAI program activities in these efforts. HAI staff may have an opportunity to participate on such committees or teams.

PHAB Measures

Measure 9.1.2:

(All) Performance management policy/system

HAI/AR Specific Programs or Activities

n/a

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

n/a

PHAB Measures

Measure 9.1.3:

(All) Implemented Performance Management System

HAI/AR Specific Programs or Activities

HAI/AR Programs may develop their own goals, objectives and targets for demonstrating performance improvement that may include but not be limited to the addition of National measures and benchmarks for HAI/AR infections and antibiotic stewardship programs. HAI/AR Program staff should be aware of how program-specific performance improvement strategies may contribute to an overall performance management system.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: HDs must provide documentation of HD team, committee, etc. that is responsible for implementation of a PMS. HDs must provide 2 examples of the implementation of the PMS in monitoring and evaluating achievement of goals and objectives. HDs must also demonstrate that performance monitoring is accomplished for the objectives identified, using any of a variety of means of measuring progress (e.g. run charts, etc.). Results must be analyzed and be able to show that performance improvement occurred.

Opportunity: HAI/AR Programs may be one programmatic area to provide such documentation with the strong emphasis on performance across all activities and sub-activities.

PHAB Measures

Measure 9.1.4:

(All) Implemented systematic process for assessing customer satisfaction with HD services

HAI/AR Specific Programs or Activities

n/a

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

n/a

PHAB Measures

Measure 9.1.5:

(All) Opportunities provided to staff for involvement in the department’s performance management

HAI/AR Specific Programs or Activities

HAI/AR Programs are expected to develop metrics and processes for ongoing performance improvement. HAI/AR Program staff should be aware of how program-specific performance improvement strategies may contribute to an overall performance management system and can be engaged in the planning and process through interactions with key HD staff or leaders.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: HDs should include staff from across the agency in performance management efforts, particularly those who will be working on performance measure monitoring and analysis. .

Opportunity: HAI/AR staff should be involved in, or at least aware of, HD-wide performance management activities.

PHAB Measures

Measure 9.1.6:

(All) Technical assistance and / or training provided on performance management to Tribal and local HDs

HAI/AR Specific Programs or Activities

n/a

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

n/a

Standard 9.2: Develop and implement quality improvement processes integrated into organizational practice, processes, and interventions

PHAB Measures

HAI/AR Specific Programs or Activities

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

PHAB Measures

Measure 9.2.1:

(All) Established quality improvement program based on organizational policies and direction

HAI/AR Specific Programs or Activities

Jurisdictions conduct a variety of performance improvement and program improvement activities including but not limited to coordination with internal HD programs. HAI/AR Programs and public health laboratories are expected to develop process and impact evaluations and work towards ongoing quality improvement efforts.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: HDs must establish an agency Quality Improvement (QI) Plan.

Opportunity: While the agency-wide plan will likely be produced from QI staff, HAI/AR staff should be aware of or involved in the quality improvement efforts occurring across the HD.

PHAB Measures

Measure 9.2.2:

(All) Implemented quality improvement (QI) activities

HAI/AR Specific Programs or Activities

CDC values and supports quality improvements activities in all funded programs. HAI/AR Programs are expected to develop and implement quality improvement initiatives that align with overall HD efforts.

Opportunities / Considerations For Connections Between HAI/AR and Accreditation

Context: HDs must provide 2 examples of QI activities being implemented, including how staff were involved in implementing QI.

Opportunity: HAI/AR Programs may have examples of QI, although the HD should be careful to use examples that represent their public health HAI/AR activities rather than clinical setting QI work. With that noted, the HAI/AR area has been a focus of QI in health care settings and there may be expertise to draw from when learning about QI and implementing new QI efforts within the HD.