BPHC Performance Improvement

FPSI/RLG 1

BPHCBPHCPerformance Performance Improvement Improvement

National Health Care for the HomelessConference and Policy Symposium

Philip L. LeeThe Results Leadership Group

and University of Maryland School of Public Policywww.resultsleadership.org

http://www.resultsleadership.org/

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Objectives Gain insight into BPHC’s

implementation of performance improvement measures and principles

Explore application of principles to HCH Programs and Partners

Explore opportunities to support BPHC’s vision of performance improvement

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Some Themes The uses (and misuses) of

performance measures

Using data to tie day-to-day decisions at all staff levels to achieving desired ends

Aligning program management, strategic planning, and budgeting

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Some Themes

Innovation, including how to surface and challenge outdated thinking

Managing decision-making processes that build trust, move quickly from talk to action, and get results

FPSI/RLG 5

Reframing:Reframing:

(1) Performance(1) Performance AccountabilityAccountability

andand

(2) Performance (2) Performance ImprovementImprovement

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““[I]n business it does not much [I]n business it does not much matter if you get it wrong 10 matter if you get it wrong 10

percent of the time as long as you percent of the time as long as you turn a profit at the end of the turn a profit at the end of the

year. In government, it does not year. In government, it does not much matter if you get it right 90 much matter if you get it right 90 percent of the time because the percent of the time because the

focus focus will be on the 10 percent of will be on the 10 percent of the time you got it wrong.”the time you got it wrong.”

Donald J. Savoie, “What is Wrong with the New Donald J. Savoie, “What is Wrong with the New Public Public Management?” Management?” Canadian Public Administration Canadian Public Administration (1995)(1995)

FPSI/RLG 7

““AccountabilityAccountability is seen as the is seen as the product of product of limits on bureaucratic limits on bureaucratic

discretiondiscretion

– – limits that flow from clear rules limits that flow from clear rules (commands), and the formal (commands), and the formal procedures, monitoring, and procedures, monitoring, and

enforcement enforcement

that make them stick (controls).”that make them stick (controls).”Paul C. Light, Paul C. Light, Monitoring Government: Inspectors General Monitoring Government: Inspectors General

and the Search for Accountability (Brookingand the Search for Accountability (Brookings, 1993)s, 1993)

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““Accountability” vs. Accountability” vs. Discretion: Discretion: A Tradeoff?A Tradeoff?

DiscretionDiscretionEntrepreneurs who Entrepreneurs who

actively exercise actively exercise and protect their and protect their discretion discretion and in and in

the process create the process create high-performance high-performance organizations that organizations that produce results. produce results.

AccountabilityAccountabilityManagers who Managers who

assiduously assiduously obeyobey all of the all of the rulesrules and and regulationsregulations

even if this even if this ensures that ensures that

they accomplish they accomplish little.little.

Rethinking Democratic Accountability, Robert D. Behn (Brookings, 1997)

versus

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Performance Accountability Performance Accountability Changing the Changing the FocusFocus? ?

Accountability for Accountability for Results Results (ends)(ends) requires requires

discretiondiscretion requires requires

trusttrust

Rethinking Democratic Accountability, Robert D. Behn (Brookings, 1997)

FPSI/RLG 10

Reframing the focus inperformance improvement:

Improvement used to be: “How do we get people to do

better today what they did yesterday?”

Now, improvement is: “What do we need to be doing

today?”From Doug Krug, Author, Leadership Made Simple and Enlightened Leadership

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Start With EndsStart With Ends Start With EndsStart With Ends

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To what end?To what end?

Ends vs. means?Ends vs. means?

FPSI/RLG 13

THE LANGUAGE TRAP

Benchmark

Target

Indicator Goal

Result

Objective

Outcome

Measure

Modifiers Measurable Core Urgent Qualitative Priority Programmatic Targeted Performance Incremental Strategic Systemic

Lewis Carroll Center for Language Disorders

Too many terms. Too few definitions. Too little discipline.

FPSI/RLG 14

Starting at the “End”Starting at the “End”

The well-being ofCLIENT POPULATIONS

The well-being ofWHOLE

POPULATIONS Communities – Cities – Counties – States - Nations

Programs – Agencies – and Service Systems

FPSI/RLG 15

DISTINCTIONSRESULT

INDICATOR

PERFORMANCE MEASURE

Children succeeding in school, Safe communities, Clean environment, Free from death and suffering due to cancer

Rate of high school graduation, Crime rate, Air quality index, Cancer mortality rate

1. How much did we do? 2. How well did we do it? 3. Is anyone better off?

A condition of well-being for children, adults, families or communities.

A measure which helps quantify the achievement of a result.

A measure of how well a program, agency or service system is working.

= Customer Results

PO

PU

LA

TIO

N

“EN

DS

”P

ER

FO

RM

AN

CE

“E

ND

S”

Three types:

FPSI/RLG 16

1. Free from death and suffering due to diabetes

2. Per capita cases of diabetes

3. Avg. A1C hemoglobin rate for clients of clinic

4. Healthy People

5. % people with blood pressure under 140/90

6. Babies born healthy

7. % of low birth weight babies in region

8. % clients entering prenatal care in 1st trimester

IS IT A RESULT, INDICATOR OR PERFORMANCE MEASURE?

RESULT

INDICATOR

PERF. MEASURE

RESULT

INDICATOR

RESULT

INDICATOR

PERF. MEASURE

FPSI/RLG 17

Why Distinguish Population Ends from Performance Ends?

ENDS

MEANS

RESULT&

INDICATORS A STRATEGY

& PERFORMANCE MEASURES

Customer result

Service delivery

A question

of

versus

Ends

Means

FPSI/RLG 18

Result and Indicator (baseline)

Community-Wide Strategy/Partners

Program Performance

Measures (baselines)

EN

DM

EA

NS

Customer Result END

? X

1.Right Strategy?1.Right Strategy?

2. RightImplementation?

2. RightImplementation?

Population Accountability

Performance Accountability

FPSI/RLG 19

Right Strategy: Tools?

FPSI/RLG 20

Right Strategy: Roles & Partnerships?

FPSI/RLG 21

Right Implementation?

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I sure am glad we don’t have that

problem!!

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However beautiful However beautiful the strategy, the strategy, you should you should

occasionally occasionally look at the look at the resultsresults..

Winston ChurchillWinston Churchill

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Selecting Selecting Performance Performance

MeasuresMeasures

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The alternative to using data to gauge whether you are achieving

your desired ends

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If you were selecting If you were selecting performance measures only performance measures only for yourself as a manager for yourself as a manager (and would not be sharing (and would not be sharing

them with anyone): them with anyone):

1.1.What information What information would you want to would you want to have? have?

2.2.How would you use How would you use the performance the performance measures?measures?

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Selecting Performance Selecting Performance MeasuresMeasures

1. Who are our customers and what services do we provide to them?

2. How well do we provide those services?

3. What is the desired impact of

those services for/on our customers

(a.k.a. “customer results”)?

FPSI/RLG 28

Use performan

ce measures to ask the

right question.

Start with EndsStart with Ends

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Results Results IndicatorsIndicatorsPerformance MeasuresPerformance Measures

How much did we do?How much did we do?How well did we do it? How well did we do it? Is anyone better off?Is anyone better off?

Contributionrelationship

Alignmentof measures

Appropriateresponsibility

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WORK BACKWARDS WORK BACKWARDS

TO MEANSTO MEANS

(Data-driven and transparent

decision making)

WORK BACKWARDS WORK BACKWARDS

TO MEANSTO MEANS

(Data-driven and transparent

decision making)

FPSI/RLG 31

Mental Models:

Deeply ingrained assumptions,

generalizations, or even pictures or images that

influence how we understand the world

and how we take action.

Peter Senge, The Fifth Discipline

FPSI/RLG 32

"All the significant breakthroughs

were 'break-withs'

old ways of thinking.”

Thomas Kuhn

FPSI/RLG 33

"The significant problems we face

cannot be solved at the same level of thinking

we were at when we created them.“

Albert Einstein

FPSI/RLG 34

Noteworthy Mental Noteworthy Mental ModelsModels

FPSI/RLG 35

Other Noteworthy Mental Other Noteworthy Mental ModelsModels

"I think there is a world market for "I think there is a world market for maybe five computers."maybe five computers."

Thomas Watson, chairman of IBM, 1943

"Who the hell wants to hear actors "Who the hell wants to hear actors talk?"talk?"

H.M. Warner, Warner Brothers, 1927. "This 'telephone' has too many "This 'telephone' has too many

shortcomings to be seriously considered shortcomings to be seriously considered as a means of communication. The as a means of communication. The device is inherently of no value to us." device is inherently of no value to us."

Western Union internal memo, 1876.Western Union internal memo, 1876.

"We don't like their sound, and guitar "We don't like their sound, and guitar music is on the way out."music is on the way out."

Decca Recording Co. rejecting the Beatles, 1962.

FPSI/RLG 36

"Everything that can be invented has "Everything that can be invented has been invented." been invented."

Charles H. Duell, Commissioner, U.S. Office of Patents, 1899.

"Louis Pasteur's theory of germs is "Louis Pasteur's theory of germs is ridiculous fiction."ridiculous fiction."

Pierre Pachet, Professor of Physiology at Toulouse, 1872

"The abdomen, the chest, and the brain "The abdomen, the chest, and the brain will forever be shut from the intrusion of will forever be shut from the intrusion of the wise and humane surgeon."the wise and humane surgeon."

Sir John Eric Ericksen, Surgeon-Extraordinary to Queen Victoria, 1873.

"There is no reason anyone would want a "There is no reason anyone would want a computer in their home." computer in their home."

Ken Olson, president, chairman and founder of Digital Equipment Corp., 1977

FPSI/RLG 37

Mental Models that ConstrainMental Models that Constrain

How toHow to

(1) identify (1) identify and and

(2) “break with”?(2) “break with”?

FPSI/RLG 38

The discipline of working with mental models starts

with turning the mirror inward, learning to unearth our internal

pictures of the world, to bring them to the surface, and hold them to rigorous

scrutiny.

Peter Senge

FPSI/RLG 39

Reflection: Becoming aware of your own thinking and reasoning.

Advocacy: Making your own thinking and reasoning more visible to others.

Inquiry: Inquiring into the thinking and reasoning of others.

FPSI/RLG 40

Collaborative Decision Making: The Ladder of Inference

Advocacy

Advocacy

InquiryInquiry

Data

Select Data

Reasoning

Conclusion

Belief System

Action

FPSI/RLG 41

Those of us who focus

on issues of fairness too often

effect

agreement by giving in

instead of first using our

powers of persuasion to

affect

a fair outcome that will

fully satisfy all of our

legitimate interests.

FPSI/RLG 42

Those of us who focus

on issues of fairness too often

effect

agreement by giving in

instead of first using our

powers of persuasion to

affect

a fair outcome that will

fully satisfy all of our

legitimate interests.

FPSI/RLG 43

FPSI/RLG 44

FPSI/RLG 45

(a.k.a., building a “Learning (a.k.a., building a “Learning Organization”)Organization”)

Institutionalizing Institutionalizing the disciplines of:the disciplines of:

1. Starting with the ends, 1. Starting with the ends, andand

2. 2. Surfacing and challenging assumptions,

including “data”

FPSI/RLG 46

Some Criteria for Any Accountability Framework

SIMPLE

COMMON SENSE

PLAIN LANGUAGE

MINIMUM PAPER

USEFUL

Some Criteria for Any Accountability Framework

SIMPLE

COMMON SENSE

PLAIN LANGUAGE

MINIMUM PAPER

USEFUL

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How are we doing?

Why?

Start at the End

Work Backwards

to MeansWhat do we propose to do?

What are our options?

Data

Data

Data

Ends-to-Means, Data-Driven, and Transparent

Advocacy & Inquiry

Who can help?

Answer these Questions

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Agency/Division/Branch/Program

PerformanceMeasure

Story Behind the Baseline --------------------------- ---------------------------

Action Plan (including partners)

------------------------------------------------------

Performance Turn-the-Curve Report

Make this

Report

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Story behind the baseline

Partners (with a role to play in turning the curve)

What Works

Action Plan (w/ Budget)


Performance MeasureBaseline

How are we doing?

Why?

Help?

Options?

Results-Based Decision Making: Talk to Action

Propose to do?

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The Matter of Baselines

Baselines have two parts: history and forecast

H

M

L

History Forecast

Turning the Curve

OK?

Forecast

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What Works




Why?


How are we doing?

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The Story Behind the Baseline

The Story Behind the Baseline

Key Factors/Causes? Root Causes (Ask “Why?”

5 times) Prioritize – which are the

most important to address to “turn the curve” of the trend line?

Research agenda?

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Force Field Analysis

Factors Contributing?

Factors Restricting?

FPSI/RLG 54

Alternative to Traditional Evaluation Methods:DEMONSTRATING a CONTRIBUTION

to complex change efforts… requires 3 elements:

A Curve to Turn

1 We tried a bunch of stuff that had a credible

chance of making a difference …

2 …and it had a timely relationship to….

3 …. a turn in the curve.

c FPSI

FPSI/RLG 55

Reduction in Crime in NYC Under Giuliani

A Curve to Turn

1 We tried a bunch of stuff that had a credible

chance of making a difference …

2 …and it had a timely relationship to….

3 …. a turn in the curve.

c FPSI

?

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What Works




Why?

Help?


How are we doing?

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PartnersPartners

Who are partners who may have a role to play in turning the curve?

Does the story behind the curve suggest any new partners?

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What Works




Why?

Help?

Options?


How are we doing?

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What WorksWhat Works

Options for actions to “turn the curve”?

Research-based?

Low-cost/no-cost?

Off-the-wall ideas?

Research agenda?

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What Works




Why?

Help?

Options?


Propose to do?

How are we doing?

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Action PlanAction Plan

Leverage: will turn the curve of the baseline?

Feasible? Specific: who, what, when,

where, how? Consistent with values?

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LeverageHigh Low

Lo

w

Hig

h

Feas

ibili

ty

X?

FPSI/RLG 63

“Program”: ___________________

Story behind the baseline --------------------------- --------------------------- Partners --------------------------- ---------------------------

Action Plan ---------------------------------------------------------------------------------

Performance Turn-the-Curve Report

PerformanceMeasure

FPSI/RLG 64

The Use (and Misuse) of Performance Measures

1. To manage/improve performance

• Collaboratively (transparent, best thinking, data)

2. Comparisons

• To own performance

• To the performance of others – “apples & oranges”

Getting from Thinking to Action

Always tell the story behind the curve



3. Standards

• What is known?

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Advanced Baseline Display

Your Baseline

Comparison Baseline

Goal (line)Target or Standard

Instead:Count anything better than baseline as progress.

Avoid publicly declaringtargets by year if possible.

●

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Management, Budgeting & Management, Budgeting & Strategic PlanningStrategic Planning

ManagemeManagementnt

Monthly or Monthly or quarterly quarterly

performance performance assessment and assessment and action planning action planning

using the using the framework./steps.framework./steps.

At all agency At all agency levels of levels of

implementation of implementation of the agency the agency

annual/strategic annual/strategic plan.plan.

BudgetingBudgeting

Use the Use the Performance Performance

Report format Report format for budget for budget

hearings and hearings and budget budget

submissions to submissions to present current present current

performance performance and what will be and what will be done next year done next year

to improve.to improve.

Budget Budget priorities priorities

informed by the informed by the strategic planstrategic plan

Strategic Strategic PlanningPlanning

Population LevelPopulation Level Results & Results & Indicators, Indicators,

comprehensive comprehensive strategy among strategy among

the agency and all the agency and all other stakeholdersother stakeholders

Agency LevelAgency Level

Agency’s role in Agency’s role in comprehensive comprehensive

strategy. strategy.

Agency’s multi-Agency’s multi-year priorities.year priorities.

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Leadership MeetingSAMPLE AGENDA

1. New data

2. New story behind the curves

3. New partners

4. New information on what works.

5. New information on financing

6. Changes to action plan and budget

7. Adjourn

1. New data

2. New story behind the curves

3. New partners

4. New information on what works.

5. New information on financing

6. Changes to action plan and budget

7. Adjourn

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The Cost of Bad Results

Invest in prevention to reduce or avoid out-year costs.

The costs of remediating problems after they occur

InvestmentTrackCost

Revenue

Convergenceof Cost & Revenue

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Criteria for Choosing

Key Performance Measures

Communication Power

Proxy Power

Data Power

Does the performance measure communicate to a broad range of audiences?

Does the performance measure say something of central importance about the result?

Does the performance measure bring along the data HERD?

Quality data available on a timely basis.

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Acknowledgement

Portions of these materials draw upon the work of:

1. Mark Friedman, Founder of the Fiscal Policy Studies Institute and author of: Trying Hard Is Not Good Enough (Trafford, 2005)

www.resultsaccountability.com; www.raguide.org

2. Peter Senge, The Fifth Discipline: The Art and Practice of the Learning Organization (Doubleday 1990); Fifth Discipline Fieldbook (Doubleday)

3. Doug Krug and Ed Oakley, Leadership Made Simple (Enlightened Leadership Publications, ) and Enlightened Leadership: Getting to the

Heart of Change (Simon and Schuster Canada, 1994)

4. Roger Fisher and William Ury, Getting to Yes (Penguin, 1981, 1991; Random House Business Books, 2003)

http://www.resultsaccountability.com/

http://www.raguide.org/