Guidebook For Performance Measurement (public Health)
t em eniPo anaggin Mr n nceuTo f rmasefoeri Persnain e s otcsF i r sourrent1Guidebook for PerformanceMeasurementPatricia LichielloBernard J. Turnock, ConsultantTurningPointCollaborating for a New Century in Public Health
AcknowledgementsThis guidebook benefited from the thoughtful and good-natured input of twokey people:Bernard J. Turnock, M.D., M.P.H.Guidebook ConsultantClinical Professor of Community Health SciencesUniversity of Illinois at Chicago – School of Public HealthJohn T. (Jack) Thompson, M.S.W.Peer ReviewerSenior LecturerUniversity of Washington, School of Public HealthSenior ConsultantUniversity of Washington Turning Point National Program OfficeInfrastructure support, including computer and communications technology,was provided by:University of Washington Health Policy Analysis ProgramSchool of Public Health and Community Medicinehttp://depts.washington.edu/hpapThose of us affiliated with the technical assistance program of the University ofWashington Turning Point National Program Office would like to express ourgratitude to the many Turning Point state and local partners that participated intechnical assistance workshops to help determine the contents of thisguidebook. Their input and good humor were invaluable. The author, inparticular, hopes that the guidebook does justice to their candor,thoughtfulness, and willingness to be perplexed.And she hopes they find it useful.The Turning Point Guidebook for Performance Measurement was researched and written by Patricia Lichiello,M.A., AICP, Senior Policy Analyst with the University of Washington Health Policy Analysis Program, undercontract to the Robert Wood Johnson Foundation/University of Washington Turning Point National Program Office.Contact: lichiell@u.washington.edu.Acknowledgements1
Table of ContentsIntroduction5Chapter 1What Do We Mean By “Performance Measurement?”What is a performance measure, exactly?Then what is a performance standard?How do other performance assessment activities relate toperformance measurement?Performance measurement is an aspect of performance managementPerformance measurement is an aspect of program evaluationPerformance measurement might be referred to as performancemonitoring or performance auditingPerformance measurement is not.911121315Chapter 2Performance Measurement In Public Health17Are we unique?Diverse services provided directly to diverse constituents with diversehealth concernsCore functions and essential public health servicesHealthy people 2000 and 201017171921Chapter 32Why Do Performance Measurement?25Seven good reasons to conduct performance measurementIs performance budgeting an eighth good reason?Reasons to hesitate before taking on performance measurement253436Guidebook for Performance Measurement
Chapter 4Key Components In Developing An Effective PerformanceMeasurement Process41Incorporate stakeholder inputPromote top leadership supportCreate a mission, long-term goals, and objectivesFormulate short-term goalsDevise a simple, manageable approachProvide technical assistance414750575767Chapter 5A Few Words About Reporting Results71Provide contextCreate clear, easy-to-read, understandable report designsDetermine reporting frequencyOffer staff training73747777Glossary81Table of Contents3
Introduction"Accountability for Results!".a rallying cry that has taken our country by storm. And it seems that those mosteager to be swept into the tempest are our government programs. Publicprograms of every stripe and size across the nation are shifting from seeingthemselves as accountable for creating and carrying out activities to beingaccountable for achieving results – meeting goals, effecting change, and improvingthe quality of their services.Such transformation can be exciting: changing the way you work, the way youassess your work, and the way you inform others of your progress. And it can bedifficult: redefining roles and responsibilities, creating new collaborations,overcoming resistance to change.But in public health, such struggling to understand a program's role and striving tofairly evaluate how well it's carrying out that role really isn't new.We've been at this for decades!Public health has been measuring itself in one way or another for over 80 years [1].We've been surveying and assessing and comparing the work of state and localpublic health organizations across this country since about 1914, always with theintent of gathering information to improve public health practice.To help us in these assessments, we've developed many ways of looking at thefundamental activities of public health: the basic six local public health services (1945)optimal responsibilities of local health departments (1950)the eight basic services of local public health (1963)model standards (1985)the three core functions (1988)332 national health objectives for the year 2000 (1990)ten organizational practices (1990)and now, the essential public health services (1994) [1]And this is just a few of these efforts – there are many others you might bethinking of right now (yes, like APEXPH)!Along the way, the emphasis of all these evaluations and assessment tools hasshifted back and forth between examining whether public health was doing thingsIntroduction5
right, and examining whether the right things were being done. We havecounted visits and inspections and immunizations (Are we doing things right?)and we have conducted community health assessments (Are the right thingsbeing done?) Yet as time has marched on, we've been inching ever closeralong the "doing things right–doing theright things" continuum to the "rightAssessment of service delivery at thethings" end: toward measuring resultslocal level of government is not new,rather than only measuring resources andbut linking the measures, oractivities, toward measuring outcomesindicators,to program mission;rather than just counting inputs andsettingperformancetargets; andoutputs.regularly reporting on theachievement of target levels ofperformanceare new features in theSo as government programs across theperformancemeasurementmovementcountry jump into the stormy sea ofsweepingacrossthepublicand"Accountability for Results!", we in publicnonprofitsectorsintheUnitedStates.health should take pause – and a deep– Kathryn E. Newcomer [2]breath. Those big waves of performancemeasurement zeal we see sweeping thenation don't have to crash on top of us. We can use our history andexperience to ride them! Public health is on strong footing when itcomes to performance measurement – we have a history of trial anderror in assessing our work and assessing the needs of those weserve. When it comes to this most recent version of organizationalself assessment, we can take what we've learned and build on it.And for what we don't know, a little common sense and some goodinformation will help keep us upright in the water.Jargon Alert!But we do need to watch out for the jargon sharks.Jargon is one of the most perplexing things aboutperformance measurement, and can really.muddy.the waters. Asthe rest of this guidebook – and any person involved in performancemeasurement – will attest, this enterprise is not for the lexical faint of heart!About this guidebookThe Turning Point Guidebook for Performance Measurement offers thefundamentals of performance measurement in public health. It covers basicinformation about what we mean by performance measurement in general, andbackground information on performance measurement in public health, inparticular. It offers reasons for developing a performance measurementprocess and a description of the key components in developing such a process.It offers performance measurement strategies tried by public healthpractitioners across the country and by other public and private sectororganizations.6Guidebook for Performance Measurement
The guidebook provides an overview of the fundamental steps – the keycomponents – in developing a performance measurement process. Thesefundamentals are critical to developing a process that is accepted, successful,and respected. The guidebook does not offer a set of step-by-step instructions.The literature, the World Wide Web, and several public and private performancemeasurement consultants offer many such guidelines that walk you througheach step of the performance measurement process. Although no two ofthese step-by-step guidelines are completely alike, there is one thing aboutalmost all of them that is key: they have several particular, and clearlyfundamental, steps in common. It is these fundamental steps, or keycomponents, that are described in this guidebook.Chapter 1 of the guidebook offers an answer to the question, “What do wemean by performance measurement?” It then provides definitions for somekey terms, including performance measure, performance standard, andperformance management, and offers some insight into how the termsprogram evaluation and performance monitoring and auditing are used.Chapter 2 describes some of the unique attributes of public health thatinfluence the design and implementation of a performance measurementprocess in this field of work. Chapter 3 offers seven good reasons forconducting performance measurement, no matter what field you're in. Thischapter also offers a few reasons to hesitate before taking on performancemeasurement.Chapter 4 gets down to basics, describing the key components in developingan effective performance measurement process. These are the fundamentalsthat can be found in just about any set of performance measurementguidelines. Finally, Chapter 5 offers some general guidance for reportingperformance measurement results, both internally and out to constituents.Each of the five chapters offers information on both concept and practice. Thetext is full of references to resources where you can find additional or moredetailed information. In particular, note the boxes labeled KEY RESOURCES.The text also is packed with tips, insights, suggestions, illustrations, and GOODEXAMPLES gleaned from public health practice, other public and private sectorexperience with performance measurement, and from the literature. TheGOOD EXAMPLES are full-page worksheets designed to help you think throughsome key steps in developing a performance measurement process.Finally, the guidebook ends with a GLOSSARY. This comes last because thetext tries very hard to avoid using the jargon of the trade. This, of course, isjust not possible! Consequently, wherever specific performance measurementor public health terms are used, the definitions are provided right in the text.These are then collected in the GLOSSARY, to give you a single location to turnto when you experience a jargon alert!Introduction7
Who is the guidebook for?Public health practice comes in many forms: work groups, service programs,agencies, departments, divisions, intra-agency and interagency committees,and public-private initiatives such as community coalitions andagency/community steering committees and task forces, among others. Any ofthese organized groups can measure the performance of its work. Thisguidebook is designed for any such group, no matter its size or fundingmechanism or participants or any other organizing principle. To acknowledgethis, the text uses the phrase work group, program, or organization as acatch-all for any group of public health practitioners that wants to measure itsperformance. It doesn't matter if you're an interagency committee or animmunization program, the phrase "work group, program, or organization"means you!81Bernard J. Turnock and Arden S. Handler. "From Measuring to Improving Public HealthPractice," Annual Reviews, Inc. (1997): 261-282.2Kathryn E. Newcomer. "Using Performance Measurement to Improve Programs,"New Directions for Evaluation 75 (Fall 1997): 5-13.Guidebook for Performance Measurement
Chapter 1: What Do We Mean By“Performance Measurement”?Performance measurement is a simple concept without a simple definition.Essentially, performance measurement analyzes the success of a work group,program, or organization's efforts by comparing data on what actually happenedto what was planned or intended [1]. Performance measurement asks “Isprogress being made toward desired goals? Are appropriate activities beingundertaken to promote achieving those goals? Are there problem areas thatneed attention? Successful efforts that can serve as a model for others?” [2]Any article, book or paper you read on performance measurement will provide agood working definition – and each of these will say essentially the same thing.They might use different words or look at performance measurement from adifferent angle, but the underlying concept will be the same. Here are twosuch definitions:Performance measurement is the selection and use of quantitativemeasures of capacities, processes, and outcomes to develop informationabout critical aspects of activities, including their effect on the public. [2]That's a pretty good definition. Here's an even simpler one:Performance measurement is the regular collection and reporting of datato track work produced and results achieved. [3]To understand the first definition, you need to know what is meant by capacity,process, and outcome. Capacity, process, and outcome are three keycomponents of public health practice:Capacity means the ability of a work group, program, or organization tocarry out the essential public health services, and in particular, to providespecific services; for example, disease surveillance, community education,or clinical screening. This ability is made possible by specific programresources as well as by maintenance of the basic infrastructure of thepublic health system [2]. Capacity means, for example, that you havesufficient staff, training, facilities, and finances, among other things.Process means the things that are done by defined individuals or groups –or to, for, or with individuals or groups – as part of the provision of publichealth services. Process means all the things we do in public healthpractice; for example, conducting educational classes, performing a test orprocedure, investigating a complaint, crunching data, or meeting withcommunity groups. [2]Chapter 1: What Do We Mean by “Performance Measurement?”9
Outcome means a change, or lack of change, in the health of a definedpopulation that is related to a public health intervention – such as the tests,investigations, or educational services you offered as part of your process,above. Outcomes can be of three types:Health Status Outcome. A change, or lack of change, in physicalor mental status.Social Functioning Outcome. A change, or lack of change, in theability of an individual to function in society.Consumer Satisfaction. The response of an individual to servicesreceived from a health provider or program. [2]KEY RESOURCESBuilding Results III: Measuring Outcomes for Oregon's Children, Youth, and Families.1998. Oregon State University Family Policy Program (C. C. Pratt, et al.). Oregon Commissionon Children & Families, 530 Center Street NE, Suite 300, Salem, OR 97310. Phone 503-3731283.Health Performance Measurement in the Public Sector: Principles and Policies forImplementing an Information Network. 1999. E. B. Perrin, J. S. Durch, and S. M. Skillman,eds. National Research Council. National Academy Press. Available from the National AcademyPress, Box 285, 2101 Constitution Avenue, N.W., Washington, DC 20055. Phone 888-6248373. Also available at tmlVirginia's Handbook on Planning & Performance. 1998. (See Section 3: PerformanceMeasurement.) Virginia Department of Planning and Budget, Planning and Evaluation Section,200 North Ninth Street, Room 418, Richmond, VA 23219. Phone 804-786-5132. Also availableat tmServing the American Public: Best Practices in Performance Measurement.Benchmarking Study Report. 1997. The National Performance Review (now the NationalPartnership for Reinventing Government). Available through the Government Printing Office.Phone 202-512-1800; Fax 202-512-2250. Also available ok.html10Guidebook for Performance Measurement
What is a performance measure, exactly?Unfortunately, there is no "exactly" when it comes to our collective use of theterm "performance measure." Different people have very clear anddifferent definitions for what constitutes the "measure" part. Thegood news is that although there are many different ideas about what a"measure" is, there is one commonality among them:Jargon Alert!A performance measure measures something.usually progress toward anobjective or goal.So it doesn't matter if we call it a performance measure or a performanceindicator or, in some cases, a performance standard. What matters is theconcept:A performance measure measures something.Here's a good, straightforward definition of a performance measure:A Performance Measure is the specific quantitative representation of acapacity, process, or outcome deemed relevant to the assessment ofperformance. [2]Key Attributes of a Performance MeasureValidity. a valid measure is one that captures the essence of what it professes tomeasure.Reliability. a reliable measure has a high likelihood of yielding the same results inrepeated trials, so there are low levels of random error in measurement.Responsiveness . a responsive measure should be able to detect change.Functionality. a functional measure is directly related to objectives.Credibility. a credible measure is supported by stakeholders.Understandability. an understandable measure is easily understood by all, withminimal explanation.Availability. an available measure is readily available through the means on hand.Abuse-Proof . an abuse-proof measure is unlikely to be used against that which is, orthose who are, measured.Chapter 1: What Do We Mean by “Performance Measurement?”11
Sample Performance MeasuresProposed or Used by Public Health and Social Service Agencies Across the Nation Percentage of children with age-appropriate immunization levels at age two.Percentage of patients maintaining adequate blood glucose.Percentage of persons age 18-65 with disabilities who are in the work force.Length of time between a request for services and an actual meetingwith a service provider.Proportion of assessed rivers, lakes, and estuaries that support beneficialuses (e.g., fishing and swimming approved).Percentage of constituents reporting "satisfactory" ratings.Whether the local health jurisdiction has access to people technically skilled incarrying out prevention programs.Percentage of target audiences that recall content of public serviceannouncements, brochures, posters, or presentations.Number of residents on community meeting sign-up sheets.Proportion of adults satisfied with the health care system in the community.Availability of effective patient and family support programs.Percentage of individuals without a usual source of care.Increase to 65% the proportion of healthcare facility and servicesinspections completed within established timelines.Then what is a performance standard?A Performance Standard is a generally accepted, objective standard ofmeasurement such as a rule or guideline against which an organization'slevel of performance can be compared. [5]A performance standard establishes the level of performance expected.Standards can be descriptive or numerical. A descriptive standardcharacterizes certain infrastructure components or certain activities – that is,certain capacities or processes – that are expected to be in place. Here aresome sample descriptive performance standards:12 A system for communicable disease surveillance and controlshall be maintained. The local public health system is actively involved in thedevelopment and review of public health policies. The information systems in use enable the collection,
things" end: toward measuring results rather than only measuring resources and activities, toward measuring outcomes rather than just counting inputs and outputs. . practitioners across the country and by other public and private sector organizations. 6 Guidebook for Perf
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