Template: December 2023
Florida Department of Health in Broward County
Performance Management and
Quality Improvement Plan
Ron DeSantis
Governor
Joseph A. Ladapo, MD, PhD
State Surgeon General
Paula Thaqi, MD, MPH
Florida Department of Health in Broward County
Health Officer and Director
Published: March 2024
Last Update/Revision: March 29, 2024
March 2024 – February 2027
PERFORMANCE MANAGEMENT AND QUALITY IMPROVEMENT PLAN
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Revisions Page
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For questions about this plan, please contact:
Florida Department of Health in Broward County
Performance Excellence
Lakisha Thomas-DeVlugt, MPH
Lakisha.Thomas-DeVlugt@FLHealth.gov
954-467-4700
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Table of Contents
Section 1: Introduction 3
Section 2: Culture of Quality 5
Section 3: Performance Management and Quality Improvement Structure 7
Section 4: PMQI Training 10
Section 5: Planning QI Projects 11
Section 6: PMQI Plan Monitoring 13
Section 7: PMQI Communication 16
Section 8: PMQI Plan Annual Review and Update 17
Section 9: PMQI Plan Goals, Strategies and Objectives 18
Section 10: Current QI Projects Terms 21
Appendices
Appendix 1: Key PMQI Terms 23
Appendix 2: Data Sources 30
Appendix 3: PMQI Planning Participants 31
Appendix 4: 2021 DOH-Broward NACCHO SAT 2.0 Results 32
Appendix 5: DOH-Broward PM Council Charter 33
Appendix 6: DOH-Broward NACCHO Model Practice Recognitions 35
Appendix 7: DOH-Broward Table of Organization 36
Appendix 8: Southeast PMQI Consortium Team Charter 37
Appendix 9: PMQI Consortia Map 40
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Section 1 Introduction
Purpose
The Florida Department of Health in Broward County (DOH-Broward) is the county health
department located in Fort Lauderdale, Florida. It provides population/community-based
services to the county’s 1.9 million residents and over 10 million visitors annually. DOH-Broward
is the lead agency providing core public health functions and essential services in the county as
part of a complex public health system that includes hospitals, clinics, planning agencies,
community-based organizations, and others. Public health is a fundamental element of the
quality of life available to residents and visitors in Broward County and focuses on protecting
and promoting community health through organized state and community efforts and a
cooperative agreement with the county.
This Performance Management and Quality Improvement (PMQI) Plan summarizes DOH-
Broward’s comprehensive approach to improving outcomes through evidence-based decision-
making, continuous organizational learning, and performance improvement. The plan describes
how the county integrates quality improvement and performance management into its staff
training, leadership structure, planning and review processes and administrative and
programmatic services. The plan also describes how DOH-Broward shares best practices and
evaluates its success in achieving established priorities and public health objectives.
The goals of the DOH-Broward PMQI Plan are to ensure ongoing organizational improvement
and to attain and sustain a culture of quality that follows key indicators from an established
culture of quality tool such as the National Association of County and City Health Officials
(NACCHO) Roadmap to a Culture of Quality.
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I. Organization Statement of Commitment to Quality
DOH-Broward is committed to systematically evaluating and improving the quality of its
programs, processes, and services. This commitment is demonstrated by DOH-Broward’s
recognition as a 2018 recipient of the Florida Governor’s Sterling Award for Performance
Excellence and 16 NACCHO Model Practice program recognitions (Appendix 6). This
intentional focus on quality enables the Department to achieve high levels of efficiency,
effectiveness, and customer satisfaction.
The PMQI Plan covers a three-year period and is evaluated and updated annually. The PMQI
program described in the Plan supports the Department’s culture of quality by identifying
opportunities for improvement, implementing data-supported improvement initiatives, sharing
best practices, and evaluating measurable impacts on strategic priorities. DOH-Broward’s day-
to-day operation of work processes ensures that key process requirements are met through
supervision, continuous measurement of in-process metrics, quantity and quality of work
process outputs, and customer satisfaction. Leadership will ensure that practices are
implemented to create a workforce culture of action, continuous improvement, and performance
excellence.
1
See Appendix 1, Performance Management and Quality Improvement Plan Key Terms, for a summary of common
terminology and definitions used throughout this document.
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The Department’s focus on quality begins with its mission, “To protect, promote and improve the
health of all people in Florida through integrated state, county and community efforts”.
The Department’s values exemplify a culture of quality:
Innovation: We search for creative solutions and manage resources wisely.
Collaboration: We use teamwork to achieve common goals and solve problems.
Accountability: We perform with integrity and respect.
Responsiveness: We achieve our mission by serving our customers and engaging our
partners
Excellence: We promote quality outcomes through learning and continuous
performance improvement.
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Section 2 Culture of Quality
I. Current and Future State of Quality
The NACCHO Roadmap to a Culture of Quality Improvement (QI) defines organizational culture
as:
“The culture of an organization is the embodiment of the core values, guiding principles,
behaviors and attitudes that collectively contribute to its daily operations. During this process,
organizational culture is the very essence of how work is accomplished. It matures over several
years, during which norms are passed on from one ‘generation’ of staff to the next. Because
culture is ingrained in an organization, transforming culture to embrace QI when minimal
knowledge or experience with QI exists, a strong commitment and deliberate management of
change over time is required.”
In June of 2021, the DOH-Broward Performance Management (PM) Council engaged in a
formal department-wide culture of quality self-assessment. The assessment results (Appendix
4) were shared with the State Health Office and used to inform the Agency PMQI Plan. DOH-
Broward PM Council members reached a consensus assessment of the current culture of
quality as a 5.4 which is Phase 5: Formal Agency-Wide QI in the development of a culture of
quality. The following are the phases in the development of a culture of quality:
• Phase 1: No Knowledge of Quality Improvement (QI)
• Phase 2: Not Involved with QI Activities
• Phase 3: Informal or Ad Hoc QI
• Phase 4: Formal QI in Specific Areas of the Organization
• Phase 5: Formal Agency-Wide QI and
• Phase 6: Overall Organizational Culture of Quality
The self-assessment enabled DOH-Broward to identify opportunities for improvement and to
use the results to:
• Create the foundation for an effective quality monitoring system.
• Help select quality improvement projects.
• Identify PMQI training needs in collaboration with staff and the PMQI Champion.
• Incorporate self-assessment results into the County Health Department (CHD) PMQI Plan.
• Adopt transition strategies using a recognized tool, such as the NACCHO Roadmap, to
strengthen and standardize PMQI activities.
Based on the results of the culture of quality self-assessment, the DOH-Broward PM Council
identified opportunities for improvement and incorporated these findings into the development of
the Performance Management and Quality Improvement Plan’s goals, strategies, and
objectives. With the intent to institutionalize performance management and quality improvement
and to increase the unit’s overall culture of quality score, the PM Council selected the following
Roadmap foundational elements/sub-elements to work towards improving the plan goals:
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Goal 1: NACCHO SAT 2.0, Element 1: Employee Empowerment
• Sub-Element 1.2: Knowledge, Skills, and Abilities (KSA’s)
Goal 2: NACCHO SAT 2.0, Element 4: Customer Focus
• Sub-Element 4.2: Meeting and Exceeding Customer Expectations
Goal 3: NACCHO SAT 2.0, Element 5: QI Infrastructure
• Sub-Element 5.2: Performance Measurement and use of data
• Sub-Element 5.3: Quality Improvement Planning
Goal 4: NACCHO SAT 2.0, Element 6: Continuous Quality Improvement
• Sub-Element 6.1: Improving Standardized Work
• Sub-Element 6.2: Planning for QI Projects
The strategies to accomplish these goals will be adapted from the suggested transition
strategies available in the Roadmap
.
To support continued process improvement and development, DOH-Broward intends to conduct
another formal culture of quality self-assessment when a statewide assessment tool is available
for use.
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Section 3 PMQI Structure
I. Structure
The Florida Department of Health is an executive branch agency, established in Section 20.43,
Florida Statutes. The agency is led by the State Surgeon General and State Health Officer who
is appointed by the Governor and confirmed by the Senate. The Department’s Executive
Management Team includes the General Counsel, the Chief of Staff and four Deputy
Secretaries who oversee business and programmatic operations. The State Health Office
provides leadership to DOH-Broward through the Office of the Deputy Secretary for County
Health Systems. The DOH-Broward Health Officer reports to the Deputy Secretary for County
Health Systems. This officer sets expectations and monitors performance.
The Division of Public Health Statistics and Performance Management (Division of PHSPM)
develops and maintains the Department’s performance management system. Key Division
functions and responsibilities include:
• Managing and developing the Agency PMQI Plan,
• Coordinating continued accreditation and reaccreditation efforts through the Public
Health Accreditation Board for the State Health Office and the 67 CHDs,
• Providing technical assistance, tools, and resources to build capacity for performance
improvement,
• Coordinating health improvement and strategic planning processes for the State Health
Office and the CHDs,
• Providing accessible health data including health profiles, individual indicators, maps
and query systems, and
• Leveraging local, state, and federal resources to improve primary care access and
health professional workforce availability in medically underserved communities
throughout Florida.
To ensure a statewide focus on performance management and quality improvement, the
Division of PHSPM established eight PMQI Consortia teams comprised of PMQI Champions
from each CHD. These PMQI Consortia teams are fostering a strong culture of quality by
supporting local performance management activities, promoting capacity building, and providing
technical assistance, training, and communications support for statewide and local performance
management and quality improvement initiatives. DOH-Broward is an active participant in its
PMQI Consortia Team. PMQI champions are appointed to the PMQI Consortia by their Health
Officer / Administrator.
The DOH-Broward infrastructure for supporting a culture of quality and implementation of
improvement initiatives throughout the Department consists of four organizational structures.
A. The DOH-Broward leadership team (Health Officer, Deputy Director, Performance
Excellence Director, PMQI Champion, Business Analytics Manager, Workforce
Development Manager, and Talent Management Director) is accountable for building
and sustaining a culture of quality in the Department by:
1) Removing barriers associated with completing strategic goals as outlined in either
the Strategic Plan, the PMQI Plan or the Community Health Improvement Plan within
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this document all three plans are referred to as “Plans”) and continuous performance
improvement.
2) Engaging various stakeholder groups to promote involvement and obtaining support
for department strategic goals.
B. The PMQI Champion is appointed by leadership and possesses core competencies
identified by the State Health Office. The champion is responsible for:
1) Leading the development of the PMQI Plan and self-assessment.
2) Coordinating training identified in the PMQI Plan.
3) Serving as the point of contact between the Performance Management Council and
the PMQI Consortia team.
4) Serving as the point of contact in the organization for reporting progress through
lessons learned and sharing results of improvement initiatives and learned practices
that result in improved performance.
5) Serving as a quality steward, maintaining responsibility for promoting PMQI within
the CHD.
C. The PM Council is chaired by the health officer and comprised of the DOH-Broward
leadership team, DOH-Broward Program Managers, PMQI Champion and CHA, CHIP,
Strategic Plan, PMQI Plan and Workforce Development Plan leads. It will operate in
accordance with the team charter and is responsible for:
1) Selecting priority strategies for QI projects.
2) Assessing progress toward a sustainable culture of quality within the CHD using an
established culture of quality self-assessment tool.
3) Developing and implementing a three-to-five-year PMQI Plan.
4) Developing, approving, monitoring, and evaluating plans and QI projects.
5) Conducting a quarterly review of progress toward completion of a PMQI Plan,
including QI projects.
D. All DOH-Broward staff have a role in fostering a culture of quality by:
1) Developing an understanding of basic PMQI processes and tools and applying PMQI
into daily work.
2) Identifying and recommending to the PM Council (or via other established processes
such as an anonymous suggestion box) opportunities for improvement that may
become QI projects.
3) Participating in QI project teams as appropriate.
The DOH-Broward PM Council meets monthly, for no less than ten times per year. The DOH-
Broward leadership team and PM Council memberships are reviewed at the end of each
calendar year for succession and rotation. PMQI Champions are rotated at the discretion of the
Health Officer.
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Section 4 PMQI Training
I. Training Plan
The Department recognizes that ongoing training in PMQI methods and tools is critical for
creating a sustainable performance management and quality improvement program. These
training opportunities are available through providers including Department subject matter
experts, TRAIN Florida, the National Network of Public Health Institutes’ Public Health Learning
Network, the American Society for Quality and other organizations. The Department’s PMQI
Training Plan requires that, at a minimum:
A. CHD PM Councils complete the Department’s problem-solving methodology training
series in TRAIN Florida at least once.
B. QI project team members complete the Department’s problem-solving methodology
training series in TRAIN Florida at least once and complete the PMQI projects identified
in this plan.
These minimum training requirements are included in the local CHD PMQI Plans for alignment
and are monitored and reported annually (via the Agency PMQI Plan Annual Progress Report).
In addition, the Division of PHSPM provides regular training to Department staff on PMQI
principles, tools, and techniques to support the ongoing development of the Department’s
quality-focused culture. DOH-Broward PMQI Champions also provide trainings to county health
department staff on Customer Focus, Leadership and Workforce Development.
Training in PMQI methodology and QI tools are critical in creating a sustainable culture of
quality. PMQI training opportunities are available and offered by DOH-Broward personnel,
TRAIN Florida, the Public Health Learning Network, and the American Society for Quality
(ASQ).
The following DOH-Broward PMQI training plan is verified by TRAIN completion reports and/or
certificates of completion (maintained by DOH-Broward Workforce Development) and includes:
PMQI Training Plan
Name of Training
Staff Identified for Each Training
Time
FDOH Problem Solving Methodology
Training Series, TRAIN# 1058483
45 - PMC members 3 hours
FDOH Customer Focus Training Fiscal Year
2023-2024, TRAIN# 1111288
All DOH-Broward staff 1 hour
Organizational Culture of Quality Self-
Assessment Tool Training, DPHSPM
1 - PMQI Champion N/A
DOH-Broward Customer Focus – New
Employee Orientation, 2024
All DOH-Broward new hires within 30
days
1 hour
Malcolm Baldrige/Sterling Criteria Training
20 - PMC members and Leadership
staff
3-day training
Six Sigma Green Belt Training 4 – PMC members 40 hours
Public Health Improvement Training (PHIT),
National Network of Public Health Institutes
2 – PMQI Champions 2-day training
Korn Ferry Executive Leadership Workshop
to drive performance
70 – DOH-Broward Leadership staff 3-day training
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Section 5 Planning QI Projects
I. Processes to Identify Opportunities for Improvement, Areas of
Excellence and Best or Promising Practices
Customer Feedback and Key Performance Indicators for Continuous Improvement
The DOH-Broward PM Council establishes processes to identify opportunities for improvement,
areas of excellence, and best or promising practices, which includes a process to solicit
customer feedback and administer the culture of quality assessment.
The PM Council reviews key performance indicators utilizing the Active Strategy Performance
Management system to identify potential quality improvement projects. Key performance
indicators include customer feedback data, culture of quality assessment results, quarterly
performance data and annual progress reports for the CHD’s strategic plan and Community
Health Improvement Plan (CHIP). Key performance data may indicate opportunities for
improvement to be discussed with the DOH-Broward leadership team for prioritization and
implementation as potential QI projects.
Target attainment for performance indicators is monitored monthly, quarterly, and annually
through the use of scorecards and dashboards. Underperforming metrics are assigned variance
reports and corresponding action plans. DOH-Broward utilizes a multi-level business review
process to ensure data and progress toward achieving goals and objectives are shared
throughout the organization. During Program and Divisional Level meetings, staff have a venue
to share thoughts to generate potential improvement projects.
DOH-Broward also uses customer focused performance measures to drive continuous
performance improvement and ensure excellence. For this reason, DOH-Broward gathers,
analyzes, and reports customer feedback data in several ways like conducting customer
satisfaction surveys and community meeting surveys.
2
Customer feedback data are used to
improve policies, programs and/or interventions as outlined in Section 6 of this document.
Where appropriate, customer focused data may result in the selection of a QI project by the PM
Council.
QI Project Identification, Alignment, and Implementation Processes
QI projects are selected and prioritized based on their alignment with the priorities and goals in
the CHD’s PMQI plan, strategic plan, CHIP, workforce development plan or other
emerging/priority areas. In addition, QI projects may also be prioritized based on their alignment
with state level plans.
DOH-Broward completes and submits at least one formal QI project annually to the Division of
PHSPM through Florida Health Performs. Projects undertaken collaboratively with other CHDs
can apply toward this requirement. Projects may be a combination of the following project types:
• Administrative – Projects that improve organizational processes, including activities that
impact multiple sections/programs (e.g., contract management, vital records, human
resources, staff professional development, workforce development and financial
management).
2
Florida Customer Standards Act (s. 23.30, Florida Statutes) and DOHP 180-1 Customer Focus
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• Population-based – Projects that feature interventions aimed at disease prevention and
health promotion that effect an entire population and extend beyond medical treatment by
targeting underlying risks (e.g., tobacco, drug and alcohol use, diet and sedentary lifestyles,
and environmental factors).
• Programmatic – Projects that have a direct impact within one specific program (even if
administrative in nature) and include the functions, services and/or activities carried out
through the daily work of public health department programs.
Project teams develop team charters and project scopes to identify the PMQI tools and
methodology that will be utilized to structure the project. Teams develop action plans to
establish accountability for project monitoring and evaluation expectations. Projects align with
PMQI plan goals, strategies, and objectives to support activities contributing to the
accomplishment of the plan.
Project teams document the completion of QI projects in a storyboard or narrative that covers
the minimum project components outlined by the Division of PHSPM:
• List the type of QI project: administrative, programmatic or population based
• Describe how the opportunity for improvement was identified including how data were used
in this process.
• Include a SMART
(Specific, Measurable, Achievable, Relevant, Time-Oriented) aim
statement
• Describe the type of PMQI method used such as Plan Do Check Act (PDCA), Define,
Measure Analyze, Improve, Control (DMAIC), Kaizen, lean, rapid cycle improvement or
other recognized PMQI method(s).
• Describe the use of PMQI tools
to better understand or make decisions about 1) the current
process, 2) root causes, 3) possible solutions and 4) prioritization and selection of solutions
for implementation.
• Describe the QI project outcomes including progress toward the aim statement. The
description must include data used to determine whether the project’s objective(s) was met
and identify next steps resulting from the project.
• Indicate if a best practice was identified through the QI project process.
The documentation (storyboard or narrative) is included in the PMQI Plan Annual Progress
Report. Progress on QI projects is documented in the DOH-Broward PM Council quarterly
meeting summaries or minutes.
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Section 6 PMQI Plan Monitoring
I. Measures and Monitoring Performance
DOH-Broward members of the PM Council are responsible for measuring, monitoring, and
reporting progress achieved on the goals, strategies and objectives of the CHIP, Strategic Plan,
Workforce Development Plan and PMQI Plan. To ensure the PMQI plan is routinely monitored,
the DOH-Broward PM Council meets at least quarterly to monitor progress. The status of the
PMQI Plan is reported in the meeting summary and submitted to the Division of PHSPM within
ten business days after the summary has been approved by the DOH-Broward PM Council.
Based on the quarterly progress monitoring, the PM Council will update plan objectives as
needed.
The Division of PHSPM collects the following key performance indicator data from all CHDs and
includes this data in the Annual Agency PMQI Progress Report:
• Percentage of identified individuals completing PMQI trainings>
o <Number of PMC Members / Number who have completed training>
o <Number of staff working on QI Projects / Number who have completed training>
• Percentage of PMQI Plan objectives resulting in improved results
o <Number of PMQI Plan Objectives / Number resulting in improved results>
Annually, DOH-Broward submits a PMQI Plan Annual Progress Report assessing progress
toward reaching goals, strategies, objectives, and achievements for the year. From these
annual reports, the Division of PHSPM provides an annual statewide progress report to the
Agency Performance Management Council. The CHD PM Council oversees the development of
all PMQI Plans, annual progress reports and revision of these plans.
3
DOH-Broward monitors progress in achieving objectives through our performance management
system Active Strategy, and business reviews which are conducted at PM Council meetings.
Business reviews are held regularly with staff at different levels of the organization and establish
accountability for performance reporting. Variance reports are created for underperforming
metrics to track cycles of improvement in support of our Mission, Vision, and Values. Employee
engagement and accountability is achieved by linking metrics to each employees’ performance
evaluation. In addition, employees and programs that achieve outstanding performance are
recognized at the annual DOH-Broward Employee Conference.
II. Customer Focus
The Department is dedicated to meeting key customer requirements and protecting, promoting
and improving the health of all people in Florida through integrated state, county and community
efforts. The Department is accountable for ensuring that it uses effective methods to engage its
key public health customers. Furthermore, the Department seeks to be fully responsive to
changing and emerging customer requirements; and it pays close attention to and responds to
customer feedback.
Florida Statutes requires each state department under the executive branch to comply with the
Florida Customer Standards Act (s. 23.30, Florida Statutes). This act requires agencies to
establish a process which can measure, monitor, and address issues related to customer
satisfaction and complaints.
3
Section IX, PMQI Plan Goals, Strategies, and Objectives contains a list of the Year 2024–2027 DOH-Broward PMQI
Plan goals, strategies and objectives
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The Department has developed and implemented a Customer Focus Policy, DOHP 180-1 to
establish expectations and provide guidance regarding collecting, monitoring, and addressing
customer feedback. Employees are expected to always meet and often exceed customer
expectations for quality, timeliness and effective personal interaction when providing health
products, services, and information to the public. The Department uses customer satisfaction
data to identify unmet needs and continuously improve the quality of services offered. All
employees are required to complete an online Customer Focus training each year.
The Department gathers, analyzes, and reports customer feedback data in several ways,
including conducting customer satisfaction surveys and community meeting surveys. County
health departments annually report data on their customer satisfaction processes, results and
timeframes for acknowledging complaints in the CHD Snapshot.
DOH-Broward uses customer feedback data to improve policies, programs and/or interventions.
Methods used to collect customer feedback include the following methods:
• Conducting customer satisfaction surveys (via paper, website link, telephone, and
touchscreen kiosks)
• Direct feedback provided face-to-face, by phone or by email to specific staff member
• Customers email the Office of the Governor and DOH Central Office with feedback,
questions, and comments, which are transmitted to DOH-Broward for follow up
• Contracted providers are required to administer customer surveys and DOH-Broward
reviews this data during the contract monitoring process
• Managers interact directly with customers, resolving complaints in real time at the lowest
organizational level possible
• For internal customers, DOH-Broward provides a continuous Customer Survey for support
services such as Talent Management, IT and General Services
Customer feedback is analyzed, shared with staff at all levels of the agency, and used to inform
decisions. Survey data is aggregated and segmented by program/site and disseminated to
program managers who analyze the data and initiate improvement cycles as necessary.
Customer satisfaction metrics and variance reports are also tracked at monthly PM Council
meetings. Customer satisfaction metrics are also included in staff annual performance
evaluations.
DOH-Broward also has a process by which customer complaints are submitted, investigated,
and followed up on with corrective actions as necessary. Complaints may be received in
electronic and paper form, or over the telephone. Complaints are logged in DOH-Broward’s
complaint reporting system and resolutions documented.
Customer feedback data is also included in the annual PMQI Plan progress reports. Customer
satisfaction data may indicate opportunities for improvement, opportunities and projected
implementation plans to be discussed with the DOH-Broward leadership team.
Voice of the Customer Indicators
Indicator Name
Customer Group External/Internal
Overall Customer Satisfaction Rate – Top Box Only External
Overall Customer Satisfaction Rate External
Customer Satisfaction Rate by Program External
Customer Satisfaction Rate by Program Service Time External
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Percent of Documented Customer Service Complaints
Acknowledged by the End of the Next Business Day
External
Overall Employee Satisfaction Rate Internal
First Contact Resolution Help Desk Score Internal
Customer Satisfaction Score – IT, General Services Internal
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Section 7 PMQI Communication
I. Communication
Ongoing communication is critical to the continuous PMQI process and the institutionalization of
the Department’s quality improvement culture. The success of the Department’s PMQI process
and its ongoing progress towards becoming a learning organization is promoted by systematic
information-sharing, networking collecting, and reporting on knowledge gained.
The DOH-Broward PM Council, chaired by the Health Officer, meets at least quarterly but may
meet more frequently. Meetings are documented using an agenda, sign-in sheet, and meeting
summary. Key performance indicators are reviewed during the meeting and progress is
communicated to CHD staff, the Board of County Commissioners, other governing entities, and
community partners as appropriate.
PM Councils leverage the advantage of Florida’s integrated local public health system by
sharing resources and information with peers. On a regular basis, QI project leads are
responsible for informing the PMQI Champion on project results and progress. The PMQI
Champion and PM Council communicates PMQI activities to staff at all levels, including QI
projects, best practices, results of improvement initiatives and lessons learned using:
1) PM Council meetings and meeting summaries
2) Staff meetings that include staff at all levels
3) PMQI Consortia Team Meetings
4) Sharing/submitting information with the Division of PHSPM, County Health Systems and
other appropriate state office programs
5) Statewide/community meetings or events
6) Appropriate internal and external award nominations
7) Storyboards or narratives addressing key topics
8) Newsletters or similar publications
9) Florida Health Performs – the Department’s web-based platform for the performance
management system
The Department’s State Surgeon General meets regularly with the Executive Office of the
Governor to brief them on the Department’s activities, programs, and public health impact. This
briefing includes information on the Department’s performance management system functions,
data, and activities as appropriate. Key updates from Agency Performance Management
Council meetings, which include County Health Department health officer representation, may
also be included as appropriate.
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Section 8 PMQI Plan Annual Review and Update
I. Review and Update the PMQI Plan
Annually, the DOH-Broward PM Council reviews the PMQI Plan during PM Council meetings to
identify strengths, opportunities for improvement and lessons learned by reviewing the status of
PMQI projects and achievement of objectives. Program managers meet with stakeholders and
report project progress at the monthly PM Council business reviews. DOH-Broward program
managers and leaders participate in community meetings and share business results. Regular
monthly multi-level business reviews at different levels of the organization provide a way to
share business results and for staff to contribute ideas regarding revisions to QI projects or
suggest new QI projects. This information is reported and evaluated at the annual PM Council
meeting by the PM Council. Staff who contributed toward QI projects are invited to share results
and best practices during the business review section of the PM Council monthly and annual
meetings. During this review process, DOH-Broward also reviews PMQI training and resources
for relevance and usefulness to staff and makes revisions as necessary. Data is compiled
through Active Strategy and this information is reported to the Division of Public Health Statistics
and Performance Management through an Annual Progress Report.
The focus of this review includes examining:
• Culture of Quality Self-Assessment
• Progress towards designated performance measures
• Progress on QI projects
• Developing a stronger training plan
• Reviewing and enhancing employee training content
• Expanding upon the QI project process
• The focus of the council’s roles and responsibilities
• Reviewing budget and staffing appointments
• Linkages with Departmental priorities
This evaluation process informs planning for each subsequent year and supports a culture of
continuous improvement and excellence. During PM Council meetings, a review of the years
progress in achieving the Plans SMART objectives is conducted through review of PMQI
indicators. DOH-Broward monitors progress in achieving strategic objectives through review of
metric data in Active Strategy. Variance Reports are created for underperforming metrics to
track cycles of improvement in support of our Mission, Vision, and Values. Based on a metrics
performance, it may be revised based on data analysis.
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Section 9 Priorities, Goals and Objectives
Priority 1: Customer Focus
Goal 1.1: Promote a Culture of Customer Service Excellence
Objective 1.1A: By December 31, 2024, create an internal operating
procedure (IOP) for Health Management System (HMS) downtime to ensure
continuity of services and clients are minimally impacted during a potential
system disruption, from 0 in 2023 to 1.
Data Source: Completion of an HMS Downtime IOP
Lead Individual and Title
or Organizational Unit
Status Alignment
HMS Users Committee
On Track
Agency Plans:
APMQI - 1.1.2
ASP - 4.1.1A
AWFD - 4.1
CHD Plans:
SP - 4.1.5
Objective 1.1A: By December 31, 2026, improve signage at DOH-Broward
clinic sites to help clients navigate to our programs and services from 0 sites
in 2023 to 7 sites.
Data Source: Signage implemented at DOH-Broward clinic sites
Roland Martinez,
Deputy Director
On Track
Agency Plans:
APMQI - 1.1.2
ASP - 4.1.1A
AWFD - 4.1
CHD Plans:
SP - 4.1.5
Priority 2: Quality Improvement Training
Goal 2.1: Foster a Culture of Quality through Quality Improvement Training and Employee Empowerment
Objective 2.1A:
By December 31, 2026, increase the number of DOH-Broward PM Council
members who have completed the FDOH Problem Solving Methodology
course from 0% in 2023 to 100%.
Data Source:
TRAIN Learning Management System
Training participant logs
Lead Individual and Title
or Organizational Unit
Status Alignment
Workforce Development
Not Started
Agency Plans:
APMQI - 3.2.2
ASP - 4.1.1A
AWFD - 4.1
CHD Plans:
SP- 4.1
WFD - 5.1
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Objective 2.1B:
By December 31, 2026, increase the number of DOH-Broward PM Council
Members who have completed Six Sigma Green Belt Training from 0 in 2023
to 4.
Data Source:
Six Sigma Green Belt Certification
Training participant logs
Performance Excellence
Not Started
Agency Plans:
APMQI - 3.2.2
ASP - 4.1.1A
AWFD - 4.1
CHD Plans:
SP - 4.1
WFD - 5.1
Objective 2.1C:
By December 31, 2024, increase the number of DOH-Broward PM Council
members who have completed Malcolm Baldridge/Sterling Criteria Training
from 9 in 2023 to 20.
Data Source:
Malcolm Baldridge/Sterling Criteria Certification
Training participant logs
Roland Martinez,
Deputy Director
On Track
Agency Plans:
APMQI - 3.2.2
ASP - 4.1.1A
AWFD - 4.1
CHD Plans:
SP - 4.1
WFD - 5.1
Objective 2.1D:
By December 31, 2026, increase the number of DOH-Broward leadership
staff who have completed the 3-day Korn Ferry Executive Leadership
Workshop to drive performance from 0 in 2023 to 70.
Data Source:
Training participant logs
Roland Martinez,
Deputy Director
On Track
Agency Plans:
APMQI - 3.2.2
ASP - 4.1.1A
AWFD - 4.1
CHD Plans:
SP- 4.1
WFD - 5.1
Objective 2.1E:
By February 28, 2027, increase the number of PMQI related training
opportunities conducted by the DOH-Broward PMQI Champion or PMQI
consortium from 2 in 2023 to 6.
Data Source:
Training participant logs
Performance Excellence
On Track
Agency Plans:
APMQI - 3.2.2
ASP - 4.1.1A
AWFD - 4.1
CHD Plans:
SP - 4.1
WFD- 5.1
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Priority 3: Continuous Quality Improvement
Goal 3.1 Improve DOH-Broward programs and services through innovation and QI projects
Objective 3.1A:
By December 31, 2026, increase the percentage of initiated and completed
QI projects from 0% (January 2024) to 75%.
Data Source:
Division of Public Health Statistics and Performance Management, Bureau of
Performance Assessment, and Improvement
Lead Individual and Title
or Organizational Unit
Status Alignment
Performance Excellence
On Track
Agency Plans:
APMQI – 2.1
ASP – 4.1
CHD Plans:
SP-4.1.6
Objective 3.1B:
By December 31, 2026, increase the number of DOH-Broward public health
practices/program initiatives submitted to NACCHO for Model practice
recognition from 7 in 2023 to 12.
Data Source:
Active Strategy Performance Management System
NACCHO Model Practices
https://www.naccho.org/membership/awards/model-practices
Performance Excellence
On Track
Agency Plans:
APMQI – 5.1.1
ASP - 4.1
CHD Plans:
SP - 4.1.3
Objective 3.1C:
By February 28, 2027, increase the number of new technology-based
innovations implemented at DOH-Broward to maximize organizational
efficiency from 0 in 2023 to 3.
Data Source:
Active Strategy Performance Management System
Business Analytics
Not Started
Agency Plans:
APMQI - 2.1
ASP- 4.1
CHD Plans:
SP – 4.1.6
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Section 10 Current QI Projects
QI Project 1: Increase Immunization Rates among Kindergarten Children in Broward County
Aim Statement: Increase the percent of Broward
County children in kindergarten who are fully
immunized from 91.9% in 2023 to 95.0% by
December 31, 2026.
How was the opportunity for improvement
identified? A decrease in immunization rates
among this population and a vaccine-preventable
disease outbreak in a local elementary school.
Project Method: Rapid cycle improvement
Data source: FL Health CHARTS
Project Type Team Lead Project Start
Date
Project End Date Status
Population-based
Renee Podolsky,
Community Health
Director
February 15,
2024
December 31,
2026
On Track
QI Project 2: Increase Newly Diagnosed HIV Cases Referred to Test and Treat
Aim Statement: Increase the percent of all
newly diagnosed HIV positive cases in Broward
County referred to the Test and Treat Program
from 47.6% in 2022 to 75% by December 31,
2026.
How was the opportunity for improvement
identified? A negative trend in the percentage of
HIV positive cases referred to the Test and Treat
program from 2021 (68.8%) to 2022 (47.6%).
Project Method: PDCA
Data Source: Active Strategy Performance
Management System
Project Type Team Lead Project Start
Date
Project End Date Status
Programmatic
Patrick Jenkins,
Communicable
Disease Director
November 29,
2023
December 31,
2026
On Track
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QI Project 3: Decrease Congenital Syphilis Cases in Broward County
Aim Statement: Decrease the number of
congenital syphilis cases reported in Broward
County from 31 in 2022 to 10 or less by
December 31, 2026.
How was the opportunity for improvement
identified? A negative trend in the number of
congenital syphilis cases in Broward County was
identified from 2021 (13) to 2022 (31).
Project Method:
Rapid cycle improvement
Data Source: FL Health CHARTS
Project Type Team Lead Project Start
Date
Project End Date Status
Population-based
Yvette Gonzalez,
Perinatal Director
January 8, 2024
December 31,
2026
On Track
PERFORMANCE MANAGEMENT AND QUALITY IMPROVEMENT PLAN
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Appendix 1 Key PMQI Terms
TERM
DEFINITION
Accountability
Accountability is establishing a systematic method to assure stakeholders
(policymakers and the public) that the organizational entities are producing desired
results. Accountability includes establishing common elements that are applied to
all participants. These should include clear goals, progress indicators, measures,
analysis of data, reporting procedures, help for participants not meeting goals and
consequences and sanctions.
(Source: American Society for Quality)
Administrative
Project
An administrative project is a quality improvement project that improves
organizational processes. Administrative areas are activities that relate to
management of a company, school or other organization. For PHAB purposes,
administrative areas are distinguished from program areas which provide public
health programs or interventions.
Examples of administrative areas include contract management (e.g., looking at
the contract approval process or how contracts are tracked for compliance), vital
records (e.g., processing birth and death certificates or evaluating their accuracy),
human resources functions (e.g., the performance appraisal system), staff
professional development (e.g., effectiveness of the professional development
process), workforce development (e.g., appropriateness of employee wellness
program), or financial management system (e.g., the financial data development,
analysis, and communication process).
Alignment
Alignment is the consistency of plans, processes, information, resource decisions,
actions, results and analysis to support key organization-wide goals. (Source:
Baldrige National Quality Program, 2005).
Analyze
To analyze is to study or determine the nature and relationship of the parts of a
situation by analysis.
(Source: Merriam-Webster Online Dictionary)
Barriers
Barriers are existing or potential challenges that hinder the achievement of one or
more objectives.
(Source: The Executive Guide to Facilitating Strategy: Featuring the Drivers Model. Michael
Wilkinson. 1
st
Ed.)
Benchmarking
Benchmarks are points of reference or a standard against which measurements
can be compared. In the context of indicators and public health, a benchmark is an
accurate data point. The data point is used as a reference for future comparisons
(like a baseline). This is also referred to as “best practices” in a field. Communities
compare themselves against these standards. Many groups use benchmark as a
synonym for an indicator or target.
(Source: Norris T, Atkinson A, et al. The Community Indicators Handbook: Measuring
Progress toward Healthy and Sustainable Communities. San Francisco, CA: Redefining
Progress; 1997)
Best Practice(s)
These are the current best-known way to do something. Best practices are a)
recognized as consistently producing results superior to those achieved with other
means; b) can be standardized and adopted/replicated by others; and c) will
produce consistent and measurable results. Best practices can be replicated in
different processes, work units, or organizations such that the results of the original
application can be reliably reproduced. Best practices will evolve to become better
as improvements are discovered.
(Source: NACCHO QI SAT v2.0)
Change
Management
Change Management is a structured approach to transitioning an organization
from a current state to a future desired state.
(Source: NACCHO Roadmap to a Culture
of QI)
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TERM
DEFINITION
Continuous
Improvement
Continuous improvement includes the actions taken throughout an organization to
increase the effectiveness and efficiency of activities and processes to provide
added benefits to the customer and organization.
(Source: Certified Manager of Quality/Organizational Excellence Handbook. Russell T
Westcott, editor. 3
rd
Ed.)
Core
Competencies
Core public health competencies are a set of skills desirable for the broad practice
of public health, reflecting the characteristics that staff of public health
organizations may want to possess as they work to protect and promote health in
the community (i.e., deliver the Essential Public Health Services).
(Source: Council
on Linkages between Academia and Public Health Practice. Core Competencies for Public
Health Professionals [online]. 2010 [cited 2012 Nov 6].
http://www.phf.org/resourcestools/pages/core_public_health_competencies.aspx)
Culture of
Quality
Improvement
Culture of quality improvement exists when QI is fully embedded into the way the
agency does business across all levels, departments and programs. Leadership
and staff fully committed to quality and results of QI efforts are communicated
internally and externally. Even if leadership changes, the basics of QI are so
ingrained in staff that they seek out the root cause of problems. Staff do not
assume that an intervention will be effective, but rather they establish and quantify
progress toward measurable objectives.
(Source: Roadmap to a Culture of Quality
Improvement, Phase 6, NACCHO)
Customer
Focus
Customer focus encompasses the way an organization listens to the voice of its
customers, builds customer relationships, determines their satisfaction and uses
customer information to identify opportunities for improvement.
(Source: NACCHO QI
SAT v2.0)
Customer/Client
Satisfaction
Customer or client satisfaction is the degree of satisfaction provided by a person or
group receiving a service, as defined by that person or group.
(Source:
www.businessdictionary.com/definition/customer-satisfaction.html)
Data
Data is quantitative or qualitative facts presented in descriptive, numeric or graphic
form.
(Source: Certified Manager of Quality/Organizational Excellence Handbook. Russell T
Westcott, editor. 3
rd
Ed.)
Evaluate
To evaluate is to systematically investigate the merit, worth or significance of an object,
hence assigning “value” to a program’s efforts means addressing those three inter-
related domains: Merit (or quality); Worth (or value, i.e., cost-effectiveness); and
Significance (or importance).
(Source: CDC – A Framework for Program Evaluation)
Evidence-based
Practice
Evidenced-based practice involves making decisions based on the best available
scientific evidence using data and information systems systematically, applying
program-planning frameworks, engaging the community in decision making,
conducting sound evaluation and disseminating what is learned.
(Source: Brownson, Fielding and Maylahn. Evidence-based Public Health: A Fundamental
Concept for Public Health Practice. Annual Review of Public Health)
Formative
Evaluation
Formulative Evaluation means performing an evaluation to gain insight into the
nature of the problem so that you can “formulate” a program or intervention to
address it. During formative evaluation you might gain feedback from stakeholders
that will inform the development of the intervention—what the needs are in the
community, what factors they would like to see in a new program, etc. It could even
include testing different communications materials, for example. Whereas a QI
project will focus on a program or process that is already in existence and explore
how it can be made more efficient or effective.
Governing
Entity
A governing entity is the individual, board, council, commission or other body with
legal authority over the public health functions of a jurisdiction of local government;
PERFORMANCE MANAGEMENT AND QUALITY IMPROVEMENT PLAN
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TERM
DEFINITION
or region, or district or reservation as established by state, territorial, or tribal
constitution or statute, or by local charter, bylaw, or ordinance as authorized by
state, territorial, tribal, constitution or statute.
(Source: National Public Health
Performance Standards Program, Acronyms, Glossary, and Reference Terms, CDC, 2007.
www.cdc.gov/nphpsp/PDF/Glossary.pdf).
Implement
To implement is to put into action; to give practical effect to and ensure of actual
fulfillment by concrete measures.
(Source: Adapted from Merriam-Webster.com)
Key Processes
Key Processes are processes that focus on what the organization does as a
business and how it goes about doing it. A business has functional processes
(generating output within a single department) and cross-functional processes
(generating output across several functions or departments).
(Source: Certified Manager of Quality/Organizational Excellence Handbook. Russell T
Westcott, editor. 3
rd
Ed.)
Key Customer
Requirements
Key customer requirements are performance standards associated with specific
and measurable customer needs; the “it” in “do it right the first time”
(Source: The Quality Improvement Handbook, John Bauer, Grace Duffy, and Russell
Westcott, editors)
Objective
An objective is a specific, quantifiable, realistic target that measures the
accomplishment of a goal over a specified period.
(Source: The Executive Guide to
Facilitating Strategy: Featuring the Drivers Model. Michael Wilkinson. 1
st
Ed.)
Objectives need to be Specific, Measurable, Achievable, Relevant and include a
T
imeframe (SMART).
Opportunity for
Improvement
Opportunities for improvement are the agents, factors or forces in an
organization's external and internal environments that can directly or indirectly
affect is chances of success or failure.
(Source: Adapted from BusinessDictionary.com)
Outcomes
Outcomes are long-term end goals that are influenced by the project, but that
usually have other influences affecting them as well. Outcomes reflect the actual
results achieved, as well as the impact or benefit of a program.
Performance
Excellence
Performance excellence is an integrated approach to organizational performance
management that results in 1) delivery of ever-improving value to customers and
stakeholders contributing to organizational sustainability; 2) improvement of overall
organization effectiveness and capabilities; and 3) organizational and personal
learning.
(Source: 2013 Sterling Criteria for Organizational Performance Excellence)
Performance
Gap
A performance gap is the gap between an organization’s existing state and its
desired state as expressed by its long-term plans.
Performance
Improvement
Performance improvement is an ongoing effort to improve the efficiency,
effectiveness, quality or performance of services, processes, capacities and
outcomes.
Performance
Indicators
Performance indicators are measurements that relate to performance but are not a
direct measure of such performance (e.g., the # of complaints is an indicator of
dissatisfaction but not a direct measure of it), and when the measurement is a
predictor (leading indicator) of some more significant performance (e.g., increased
customer satisfaction might be a leading indicator of market share gain.)
(Source:
2013 Sterling Criteria for Performance Excellence)
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TERM
DEFINITION
Performance
Management
Performance management is a continuous cycle of inquiry that encompasses the collection
and processing of data, the analysis of the data and the utilization of the analysis to adjust
actions and behaviors. The analysis of data is carried out through the act of rendering
comparisons over time, across units and against internal targets and external benchmarks.
The analysis of data should lead to decisions regarding strategy, program delivery, service
delivery, day-to-day operations, resource allocation, goals and objectives, performance
targets, standards and indicators. Processes needed to link data evaluation, decision-
making, and action as centering on the role of formal and informal “interactive dialogue”
about performance data. (Source: Public Performance & Management Review, Vol. 34, No.
4, June 2011, pp. 520-548)
Performance
Management
Council (PM
Council)
The PM Council is a cross-sectional group of leaders and key staff responsible for
overseeing the implementation of the performance management system and QI
efforts.
(Source: NACCHO Roadmap to a Culture of Quality)
Performance
Management
System
The Performance Management System is a fully integrated system for managing
performance at all levels of an organization which includes: 1) setting
organizational objectives across all levels of the department; 2) identifying
indicators and metrics to measure progress toward achieving objectives on a
regular basis; 3) identifying responsibility for monitoring progress and reporting;
and 4) identifying areas where achieving objectives requires focused QI processes.
(Source: NACCHO QI SAT v2.0)
Performance
Measures or
Metrics
Performance Measures or Metrics is a quantitative expression of how much, how
well and at what level programs and services are provided to customers within a
given time-period. The measures quantify the processes and outcomes of a work
unit providing insight into whether goals are being achieved; where improvements
are necessary; and if customers are satisfied.
(Source: NACCHO QI SAT v2.0)
Plan-Do-Check-
Act (PDCA)
A Plan-Do-Check-Act is also called: PDCA, Plan–Do–Study–Act (PDSA) cycle,
Deming Cycle, Shewhart Cycle. The Plan–Do–Check–Act cycle is a four–step
model for carrying out change. Just as a circle has no end, the PDCA cycle should
be repeated in an appropriate time period for continuous improvement.
(Source: ASQ.org)
PMQI Chairs
A PMQI Chair supports the PMQI Team by working with the Division of Public
Health Statistics and Performance Management to plan, organize and
communicate PMQI Team activities and efforts. This position is nominated by
PMQI Champions, confirmed by Health Officers and rotates annually. The chair
assists the Division of PHSPM in:
• Identifying significant gaps and strengths and participating in planning and
improvement activities.
• Supporting and assisting development and guidance of professional
development, training resources and expertise in quality improvement and
performance management practices.
• Supporting and assisting guidance and leadership while acting as point of
contact for members of the consortium.
• Participating in meeting preparation and agenda planning and facilitating
material at quarterly team meetings.
• Maintaining and updating the SharePoint site for the consortium.
A co-chair may also be named at the desire of the consortium. This individual
performs support functions to assist the chair.
PMQI Champion
A PMQI Champion is a staff member that possess enthusiasm for and has
expertise in QI; serves as a QI mentor to staff; and regularly advocates for the use
of QI in the agency.
(Source: NACCHO Roadmap to a Culture of Quality)
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TERM
DEFINITION
PMQI Consortia
A PMQI Consortia is a region-based grouping of CHDs that collaborates on PMQI
topics specific to their area. (Reference: the overview series for leaders slide,
September 2018 and CHS)
Policy
Policy is the general principles by which a government entity is guided in its
management of public affairs. For a health department, this may encompass
external or community-facing policies (e.g., clean air or school physical education
guidelines), as well as internal policies affecting staff (e.g., family leave or hiring
practices).
(Adapted from: Garner, B.A. editor. Black's Law Dictionary. 8th ed. West Group;
2004)
Population-
based Health
Population-based health are interventions aimed at disease prevention and health
promotion that effect an entire population and extend beyond medical treatment by
targeting underlying risks such as tobacco, drug and alcohol use, diet and
sedentary lifestyles and environmental factors.
(Source: Turnock BJH. Public Health: What It Is and How It Works. Gaithersburg, MD:
Aspen Publishers, Inc.; 1997)
Programmatic
Project
A Programmatic Project is a quality improvement project that has a direct impact
within a specific program. If the project applies to only one program, it is
considered programmatic even if the improvement is administrative in nature. For
example, issuing permits in EH may involve administrative work. However, this is a
program example because it is specific to the operation of a specific program, EH.
Programs, processes and interventions are the terms used to describe functions,
services or activities carried out through the daily work of public health
departments.
Promising
Practice
A Promising Practice describes a way to do something that shows some evidence
or potential for developing into a best practice.
(Source: NACCHO QI SAT v2.0)
Public Health
Public health is the mission to fulfill society’s desire to create conditions that enable
people to be healthy. Public health includes the activities that society undertakes to
assure conditions in which people can be healthy. These include organized
community efforts to prevent, identify and counter threats to the health of the
public. Public health is:
• The science and the art of preventing disease; the prolonging of life; and the
promoting of physical health, mental health and efficiency, through organized
community efforts toward a sanitary environment.
• The control of community infections through the education of the individual in
principles of personal hygiene.
• The organization of medical and nursing services for the early diagnosis and
treatment of disease.
• The development of the social machinery to ensure to every individual in the
community a standard of living adequate for the maintenance of health.
The Public Health Accreditation Board’s (PHAB) public health department
accreditation standards address the array of public health functions set forth in the
ten Essential Public Health Services. Public health department accreditation
standards address a range of core public health programs and activities including,
for example, environmental public health, health education, health promotion,
community health, chronic disease prevention and control, communicable disease,
injury prevention, maternal and child health, public health emergency
preparedness, access to clinical services, public health laboratory services,
management/administration and governance. While some public health
departments provide mental health, substance abuse, primary care, human and
social services (including domestic violence), these activities are not considered
core public health services under the ten Essential Public Health Services
framework used for accreditation purposes. The PHABʼs scope of accreditation
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TERM
DEFINITION
authority does not extend to these areas. PHAB’s scope of authority policy can be
found at https://phaboard.org/wp-content/uploads/Scope-of-Authority-
Policy_Mar2021.pdf
(Turnock. Public Health: What It Is and How It Works (4th Ed). Jones and Bartlett. MA.
2009; Winslow. Man and Epidemics. Princeton Press. NJ. 1952. Institute of Medicine. The
Future of Public Health. National Academies Press. Washington, DC. 1988; Public Health
Accreditation Board. Standards and Measures Version 1.5. Alexandria, VA, May 2011)
Quality
Improvement
Quality improvement in public health is the use of a deliberate and defined
improvement process, such as a Plan-Do-Check-Act, which is focused on activities
that are responsive to community needs and improving population health. It refers
to a continuous and ongoing effort to achieve measurable improvements in the
efficiency, effectiveness, performance, accountability, outcomes and other
indicators of quality in the services or processes which achieve equity and improve
the health of the community.
(Source: Riley, Moran, Corso, Beitsch, Bialek, and Cofsky. “Defining Quality Improvement in
Public Health”. Journal of Public Health Management and Practice. January/February 2010)
Performance
Management
and Quality
Improvement
(PMQI) Plan
A PMQI plan describes what an agency is planning to accomplish and reflects
what is currently happening with QI processes and systems in that agency. It is a
guidance document that informs everyone in the organization as to the direction,
timeline, activities and importance of quality and quality improvement in the
organization. The PMQI plan is also a living document and should be revised and
updated regularly as progress is made and priorities change. The PMQI plan
provides written credibility to the entire QI process and is a visible sign of
management support and its commitment to quality throughout the health
department.
(Source: Davis MV, Mahanna E, Joly B, Zelek M, Riley W, Verma P, Solomon Fisher J.
“Creating Quality Improvement Culture in Public Health Agencies.” American Journal of
Public Health. 2014. 104(1): e98-104)
The Public Health Accreditation Board requires a PMQI plan as documentation for
measure 9.1.2 A of the PHAB 2022 Standards and Measures.
Resources
Resources include personnel, equipment, facilities and funds available to address
organizational needs and to accomplish a goal.
Storyboard
A storyboard is a display created and maintained by a project or process
improvement team that tells the story of a project or initiative. The storyboard
should be permanently displayed from the inception to the completion of the
project in a location where it is likely to be seen by many associates and
stakeholders impacted by the project.
(ASQ)
Sustainability
Sustainability gauges the likelihood that improvements can be maintained over
time. It involves how well processes are defined and documented with the goal of
being repeated; how outputs and outcomes of the processes are measured and
monitored; whether ongoing training of those processes and standards for
implementation is provided; and whether the standards for the processes are
reviewed periodically as a part of continuous quality improvement.
System
A system is a network of connecting processes and people that together perform a
common mission.
(Source: The Quality Improvement Handbook, John Bauer, Grace Duffy, and Russell
Westcott, editors. 2
nd
Ed.
)
Targets
Targets are desired or promised levels of performance based on performance
indicators.
They may specify a minimum level of performance or define aspirations for
improvement over a specified time frame.
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TERM
DEFINITION
Technical
Assistance
Technical assistance is tailored guidance to meet the specific needs of a site, or
sites, through collaborative communication with a specialist and the site(s).
Assistance considers site-specific circumstances and culture; and it can be
provided through phone, email, mail, internet or in-person.
(http://www.cdc.gov/dash/program_mgt/docs/pdfs/dash_definitions.pdf)
Training
Training for the public health workforce includes the provision of information
through a variety of formal regularly planned means for the purpose of supporting
the public health workforce in maintaining the skills, competencies and knowledge
needed to successfully perform their duties.
(Institute of Medicine. Who Will Keep the
Public Healthy? National Academies Press. Washington, DC, 2003).
Validate
To validate is to confirm by examination of objective evidence that specific
requirements and/or specified intended uses are met.
(Source: Florida Sterling The Quality Improvement Handbook, John Bauer, Grace Duffy,
and Russell Westcott, editors. 2
nd
Ed.
)
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Appendix 2 Data Sources
1. DOH-Broward Strategic Plan, 2021-2026
2. DOH-Broward Community Health Improvement Plan, 2021-2026
3. DOH-Broward Workforce Development Plan, 2023-2027
4. DOH-Broward Strategic Plan Annual Progress Report, 2022-2023
5. DOH-Broward Community Health Improvement Plan Annual Progress Report, 2023
6. DOH-Broward customer feedback data collected via customer satisfaction surveys
(paper, website link, telephone, and touchscreen kiosks), 2023
7. DOH-Broward NACCHO Culture of Quality Self-Assessment, 2021
8. DOH-Broward Performance Management System, Active Strategy
9. Florida Community Health Assessment Resource Tool Set (CHARTS)
10. Time Affiliate Integrated Network (TRAIN) Online Learning Management System
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Appendix 3 PMQI Planning Participants
2024
Paula Thaqi, MD, MPH
Health Officer
Barbara Bateman
Executive Nursing Director
Jeffrey Mason
Chief Financial Officer
Juan Morejon
Business Analytics Manager
Lakisha Thomas-DeVlugt
Performance Excellence Analyst
Lisa Winchester
Workforce Development Manager
Melisa Gray
Talent/Risk Management Director
Patrick Jenkins
Communicable Disease Director
Renee Podolsky
Community Health Director
Roland Martinez
Deputy Director
Samantha Elberg
Staff Assistant
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Appendix 4 2021 DOH-Broward NACCHO SAT 2.0 Results
5.48
5.34
5.39
5.44
5.46
4.38
5.39
5.61
5.82
4.73
5.83
4.42
0.00
1.00
2.00
3.00
4.00
5.00
6.00
Element One:
Employee
Empowerment
Element Two:
Teamwork and
Collaboration
Element Three:
Leadership
Element Four:
Customer Focus
Element Five:
Quality
Improvement
Infrastructure
Element Six:
Continual Process
Improvement
NACCHO SAT 2.0 Responses
Elements One through Six
2020 Element Scores 2017 Element Scores
0.00
1.00
2.00
3.00
4.00
5.00
6.00
S1.1
S1.2
S2.1
S2.2
S3.1
S3.2
S4.1
S4.2
S5.1
S5.2
S5.3
S6.1
S6.2
S6.3
NACCHO SAT 2.0 Response
Staff Leaders 2017 Sub Element Scores
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Appendix 5 DOH-Broward PM Council Charter
Florida Department of Health in Broward County
Performance Management Council (PMC) Charter
Purpose: Each County Health Department (CHD) will assemble the Performance Management (PM)
Council as described in the Agency Quality Improvement Program and the County Health Department
Quality Improvement Plan. This charter delineates the mission, functions, organization, and procedures
of the PM Council whose overall objective is to support a culture of quality and the implementation of
improvement initiatives throughout the Department.
Primary Functions:
1) Selects priority strategies for QI projects.
2) Assesses progress towards a sustainable culture of quality within the CHD.
3) Conducts a monthly review of progress toward completion of the Community Health Improvement
Plan (CHIP), Strategic Plan, QI Plan, and Workforce Development (WFD) Plans.
Scope of Work: A monthly meeting is held by the Performance Management Council, chaired by the
Health Officer, which will be documented using an agenda, meeting minutes, and progress reports. A
quorum of two-thirds of members is required for meeting, and the following will be reviewed during the
meetings:
1) Progress toward completion of plans
2) Status of projects and objectives
3) Practices that result in improved performance
4) Quality of community engagement
Interdependencies:
1) Quality Improvement Program
2) Workforce Development Plan
3) Community Health Improvement Plan
4) Strategic Plan
Membership/Roles:
1) The Performance Management Council is comprised of the Health Officer, Senior Leaders,
Program Managers, Performance Excellence, and staff responsible for projects and objectives in
the QI Plan, CHIP, WFD, and Strategic Plans. The Performance Management Council is
accountable for building and sustaining a culture of quality in the department, and functions to:
a) Set strategic direction and infrastructure for quality improvement.
b) Authorize strategic plan and QI projects.
c) Monitor completion of strategic plan, CHIP, WFD and QI projects.
d) Remove barriers to performance improvement.
2) Performance Excellence Director:
a) Selected by leadership and possesses the core competencies identified by the state health
office.
b) Serves as the point of contact between the Performance Management Council and Office of
Performance and Quality Improvement (OPQI).
c) Leads the development of the annual QI plan.
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d) Coordinates training identified in QI Plan.
e) Serves as the point of contact for sharing results of improvement initiatives, lessons learned
and practices that result in improved performance.
f) Responsible for accreditation activities within the Department.
Meeting Schedule and Process:
1) Monthly meetings will be held to monitor
implementation of CHIP, Strategic Plan, WFD, and
QI Plans/Projects.
2) Perform annual evaluation to inform planning for
subsequent year.
3) Activities outside monthly PM Council meetings will
include ongoing email and/or phone communication
to review and monitor plan/project status.
Measures of Success:
1) % objectives met (Includes CHIP,
strategic plan, WFD, & QI Projects)
2) % objectives/projects that resulted in
improved results
3) % objectives/projects sustainable in
terms of structures, processes, and
policies
4) % objectives/projects with favorable
results that are adopted by peers
Deliverables:
Performance Management Council will develop documents including monthly meeting minutes,
scorecard for reporting on status and results of plans/projects, and annual evaluation which will be
uploaded to FL Health Performs.
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Appendix 6 NACCHO Model Practice Recognitions
https://barnstable.ma.networkofcare.org/ph/model-practices.aspx
DOH-Broward NACCHO Model Practice Recognitions
Year
Awarded
Program/Practice
2013
Connecting the dots between Public Health Preparedness and Prevention during a
Pandemic
2013 Paramedics as Partners: Back to School Immunizations
2015
Identifying Children Eligible for Low-Cost Health Insurance through Free/Reduced
Lunch Applications
2015
Managing Organizational Performance by Aligning SMART Expectations through a
System of Shared Accountability
2015 Utilizing Incident Command to Address Congenital Syphilis in Broward County
2016 “Beach Blitz”: A High Impact Prevention Strategy to Reduce New HIV Infections
2016 HIV Prevention, Care, and Treatment in Broward County
2016 Using Tracking Technology in a Point of Dispensing (POD) Vaccination Operation
2016
Performance Management Through Use of Cascading Scorecards in A Centralized
Performance Management System
2017 Getting to Zero
2017 HPV Vaccinations as a Part of Routine Vaccinations
2018 Developing a Pediatric Special Needs Shelter Registration
2019 Broward Dental Seals: Sealing & Educating Little Smiles
2020 Tobacco Free Broward Comprehensive Approach
2020 Students Preventing Unintentional Drowning (SPUD)
2023 In-School COVID-19 Vaccinations
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Appendix 7 DOH-Broward Table of Organization
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Appendix 8 Southeast PMQI Consortium Team Charter
Purpose:
The Southeast PMQI Consortia (Consortia) are an essential component of the Florida
Department of Health’s (Department) Performance Management System which allows the
Department to systematically track progress toward strategic goals and objectives and
provides a structured, data-driven approach to identifying and prioritizing opportunities for
improvement. The Consortia are a venue for continuous improvement activities, planning,
technical assistance, training and statewide communication. To achieve this purpose, the
Department has established eight regional PMQI Consortia among the 67 county health
departments (CHDs).
Each consortium meets at least quarterly to carry out activities. This charter delineates
the primary functions, roles, expectations and responsibilities for operating a consortium
that contributes to establishing and sustaining an agency-wide culture of quality.
Primary Functions:
• Supporting CHDs in maintaining accreditation standards and measures outlined by
the Public Health Accreditation Board (PHAB).
• Developing, sharing and maintaining comprehensive PMQI best and
promising practices, resources and trainings.
• Identifying and sharing opportunities for improvement that may become formal
QI projects or initiatives.
• Identifying and resolving barriers to developing a culture of quality.
• Utilizing systematic PMQI planning methodologies and tools that promote
organizational alignment with strategic priorities in the local foundational plans
(strategic plan, PMQI plan, workforce development plan and the community health
improvement plan).
• Establishing open and collaborative communication with state and other local
representatives regarding PMQI activities, practices, resources, tools and
opportunities for improvement.
Primary Roles:
Division of Public Health Statistics and Performance Management (PHSPM)
Activities of the PMQI consortia are coordinated with the Division of (PHSPM). The goal of the
Division of PHSPM is to ensure each consortium meets the purpose and intent stated in the
charter by:
Florida Department of Health
South East Region Performance Management and Quality
Improvement (PMQI) Consortium
Charter
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• Ensuring consortia receive one funded PMQI training opportunity per calendar year.
• Facilitating monthly meetings with PMQI Chairs and Co-Chairs to prepare for
consortia meetings and share information that co-chairs will disseminate to their
CHD’s PMQI champions and health officers/administrators.
• Collaborating with PMQI Chairs to develop and guide PMQI professional development,
training resources and tools.
• Providing guidance and leadership to consortium members to achieve a culture
of quality.
Consortium Chair
At the end of the calendar year, the Consortium Co-Chair will assume the role of Consortium
Chair. The Chair will lead the consortium by:
• Coordinating consortium activities with the Division of PHSPM.
• Communicating consortium activities and efforts to the Division of PHSPM,
consortium members and respective CHD health officers/administrators, as needed.
• Planning and facilitating at least one consortium meeting per quarter which includes
preparing agendas in advance, ensuring all Consortium members are notified at
least one week in advance of the meeting date and serving as the consortium’s
point of contact.
• Actively participating in the Monthly Chairs/Co-Chairs Meetings organized by the
Division of PHSPM. This includes recommending agenda items and providing
updates on their consortium.
• Analyzing opportunities for improvement and issues identified by the consortium to
determine which is most appropriate to complete a QI project. By December 31 of
each year, the consortium may choose to complete one of the following: 1) a regional
QI project or 2) a multi county QI project.
• Ensuring (on an annual basis) that each CHD within the Consortium shares at least
one QI project storyboard at a quarterly Consortium meeting. The QI project
storyboard may be part of a regional or multi-county QI project. Presentations and
storyboards are documented in meeting materials and uploaded onto the team
SharePoint or Teams site.
• Supporting, assisting and developing PMQI professional development activities,
training and resources.
Consortium Co-Chair
The Consortium Co-Chair serves a one-year calendar term after nomination by PMQI
Champions and confirmation by their health officer. At the end of the calendar year, the
Consortium Co-Chair will assume the role of Consortium Chair. The Co-Chair will support
the Chair by:
• Assisting in all duties of the Consortium Chair, as needed. This includes assisting
with meeting planning and preparation.
•
Designating or serving as scribe during consortium meetings.
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• Maintaining and updating the Consortium’s SharePoint or Teams site.
• Identifying and sharing opportunities for improvement that may be achieved as formal
QI projects or initiatives.
PMQI
Champion
One lead PMQI Champion per CHD is designated by the CHD health officer. Additional staff
within the CHD may be designated by the health officer, if needed, to serve as back-up
PMQI champions. The duties and responsibilities of the lead PMQI Champion include:
• Leading the process to develop the CHD PMQI Plan.
• Coordinating local trainings identified in their CHD’s PMQI Plan.
• Participating in PHAB Reaccreditation activities.
• Participating in quarterly consortium meetings by actively contributing to PMQI
activities.
• Serving as a liaison between their CHD and consortium for communication of
PMQI activities.
• Acting as quality stewards, maintaining responsibility for promoting PMQI in their CHD.
• Determining current organizational barriers to developing a culture of quality.
• Communicating and sharing best practices, issues, deliverables and other updates
between the CHD and consortium. This includes sharing (on an annual basis) at
least one QI project storyboard from their CHD at a quarterly consortium meeting.
The QI project storyboard may be part of a regional or multi-county QI project.
Presentations and storyboards are documented in meeting materials and uploaded
onto the team SharePoint site.
• Facilitating and/or coordinating their CHD’s Performance Management Council
(PMC) meetings by recommending agenda items, documenting meeting summaries
and acting as the point of contact for the PMC assessment led by the Division of
PHSPM.
• Uploading PMC meeting summaries to Florida Health Performs no later than two
weeks after the PMC meeting.
• Actively participating in at least one (per calendar year) advanced PMQI training
offered by the Division of PHSPM.
Meeting Schedule and Team Review:
The Consortium will hold meetings, conference calls and webinars, at least quarterly. Meeting
summaries are posted on the Consortium’s SharePoint site and distributed to Consortium
members and respective health officers within two weeks after each meeting. Required action
items from meetings/calls are captured and included attendance, summary of key topics,
decisions made and action items. The team charter is reviewed annually. Updates and
amendments are addressed as needed.
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Appendix 9 PMQI Consortia Map
