PHIG-Funded Local Health Agencies Model Strong Performance Management Systems

January 20, 2025 | Anna Bradley, Melissa Touma

""Performance management (PM) systems are essential in modern public health, driving efficient service delivery, resource optimization, and transparency. By measuring and improving performance, public health agencies can enable data-driven decision making and communication, and support public health accreditation.

With support from Big Cities Health Coalition, ASTHO conducted key informant interviews with performance management leaders from three accredited local health jurisdictions with Public Health Infrastructure Grant (PHIG) funding. These interviews highlight work by Columbus Public Health, Philadelphia Department of Public Health, and San Antonio Metropolitan Health District to build PM programs, create a culture of performance and quality improvement (QI), and ultimately enhance performance. In addition, they provide important insights to other health agencies.

Visible Leadership

Successful PM systems begin with strong leadership support. Visible leadership includes promoting a customer focus, transparency, strategic alignment, and a culture of quality within the organization. In each of the three health departments, PM programs sat directly under the health commissioner or an assistant director, ensuring the visibility and involvement necessary to drive PM efforts across the organization. Leadership involvement proved particularly important during periods of rapid growth and change, such as during the COVID-19 pandemic. All three jurisdictions experienced an increase in staff, programs, and funding, and leadership played a crucial role in championing the integral operational and administrative functions PM teams provided. For example:

  • San Antonio prioritized growing the PM team as the agency grew to support agency operations as the “engine of the department.” Interviewees recalled that direct access to an assistant director was essential for team growth. As a result, the team expanded from three to seven people serving a department of 700 staff, for a ratio of 1:10.
  • Columbus and Philadelphia also invested in expanding their PM programs. Funding for PM programs in these departments came largely from general funds, Medicaid waivers, and previous grants. However, PHIG funding went towards partial and full staff salaries as well as operational and programmatic dollars. One key informant reflected on the importance of this support, noting that prior to PHIG, the team felt shorthanded.

Examples of the influence leadership had on a strong PM system included obtaining participation in QI councils, setting expectations for regular PM reviews, prioritizing PM among other projects, and advocating for increased resources.

Performance Standards, Measures, and Reviews

The importance of investing in a simple, manageable PM system and corresponding software tools cannot be overstated. When it comes to reporting on performance, the three jurisdictions favor methods that can provide progress snapshots, such as Balanced Score Cards. In Philadelphia, there is not a maximum or minimum required number of indicators per division, but there tends to only be six to 15 each. Keeping the number of metrics manageable and the format simple makes regular reviews between the PM staff and other agency teams easier to maintain. Columbus described a system with a similar focus on simplicity: Only one to two users per division have accounts within the performance management software for updating data. Conversations about performance management can focus less on learning how to use the software and more about how to decide on, analyze, and act on the resulting data.

The three jurisdictions described ongoing discussions and training with programs around how many and what types of measures to collect. Relevant standards, indicators, goals, and targets naturally vary by jurisdiction:

  • Philadelphia division directors review the Strategic Plan and the Community Health Improvement Plan and consider current needs of Philadelphians. Data are collected quarterly via Excel spreadsheets, which the Performance Management Unit maintains and distributes for use in quarterly reviews with the health commissioner.
  • Columbus and San Antonio gather data quarterly using Insight Vision (Columbus) and VMSG (San Antonio) and condense it into Quarterly Data Reports for leadership review.

Quality Improvement

The three jurisdictions prioritize fostering a culture of QI over compliance by emphasizing one-on-one connections and coaching. The adoption of hybrid work environments and virtual communication platforms has opened more informal communication channels between PM/QI staff and other agency members. This allows staff to ask questions more frequently and identify “little QI” projects instead of only looking for larger, agency-wide, “big QI” projects. Hybrid environments also make it easier for staff from multiple locations to join in virtual trainings, meetings, and celebrations, ensuring broader engagement.

These agencies also model QI by allowing their PM systems to adapt. They shared examples of how their QI Councils have periodically taken breaks to reassess scope and update group charter documents, membership, and participation requirements, ensuring the systems remain flexible and effective:

  • Columbus recently changed their schedule from quarterly to monthly, with two months of one-on-one meetings between the QI team and members, and a group gathering in the third month. Membership includes the PM team, the Safety Officer, an epidemiologist, the Workforce Development Manager, a union representative, QA staff, and at least one representative from each division.
  • Philadelphia is considering a matrix-style approach to their structure, in which the PM team would communicate with both QI Council members and individual division leadership to improve awareness of internal improvement opportunities and progress. Membership includes the PM team and representation from each division.
  • San Antonio is planning to restructure the QI Council to be project-focused, potentially meeting every other month with less than 15 members representing each division, which is a reduction from 38 total staff. Membership includes upper leadership, frontline staff, and mid-level management from throughout the agency.

PM teams can be champions and subject matter experts in change management. Getting ahead of change by communicating clearly, consistently, and with transparency is an important part of every strong workplace culture. Frameworks, such as NACCHO’s Roadmap to a Culture of Quality Improvement, can make change easier.

Staff recognition and development are vital for embedding a QI culture. The three jurisdictions shared stories about celebrating and promoting QI by providing QI awards, staff symposiums, and partnering with academic institutions to display QI storyboards, in addition to leadership development programs that include QI projects and participation in the PM system or QI Council that empower staff and future leaders to confidently propose and discuss improvements with leadership.

Key Recommendations for a Strong System

  • Keep in mind that PM and QI are related and interdependent but not the same. Review the best practices available through PHAB standards and measures to fully develop and monitor the PM system, with QI as a critical component that uses PM data to prioritize agency-wide QI projects.
  • Formalize processes, consider developing process flow maps to create consistency and clarity, and commit to transparent process improvement.
  • Enhance training programs by making clear plans for training of different levels of staff. For example, differentiate the requirements for members of the QI Council, leadership, program managers, and agency wide opportunities. Also, include foundational elements of QI, the agency-specific PM system, the interaction of PM and QI, and how QI culture manifests.
  • Engage staff of all levels through participation in the QI Council, training opportunities, and development and implementation of the PM system.
  • Check out ASTHO’s online courses on QI and process improvement to refresh your memory on the basics and share them with peers.
  • Schedule regular PM reviews with the highest levels of leadership, and use easy-to-adopt and at-a-glance tools to understand and report on performance.
  • Get ahead of change management by using an established framework and developing a transparent internal communication plan.
  • Operationalize health equity, including in PM systems.
  • Connect with peers through online communities to share ideas, solicit feedback, and find inspiration.
  • Managing public health organizations to improve quality and performance can be overwhelming—submit a PHIG TA request through the PHIVE system for support.

Looking Ahead

As health departments continue to evolve their PM systems, a focus on leadership participation, staff engagement, and change management is critical for driving improvements. By fostering a culture of continuous quality improvement and investing in infrastructure, public health agencies can ensure their PM systems not only meet accreditation standards but also contribute to better health outcomes for the communities they serve.