Chad Brown, Licking County Health Department

1. Chad Brown, Licking County Health Department Jan Shepard and Becky Webb, Madison County Health Department Susan Ramsey, Washington Department of Health Applying qi to cost effectiveness and hospital inspections: initial stories from the nnphi qi award Program

2. Licking County Health Department Medical Supply QI Project Chad Brown, RS, MPH NNPHI Open Forum June 20,2012

3. LCHD Background • Licking County, Ohio is located in central Ohio just east of Franklin County and the state capital Columbus. • 166,492 population as of 2010 census. • We have 62 total employees, 58 are FTEs • We submitted our application to PHAB in December 2011, and we plan to submit our documentation in September 2012.

4. LCHD QI Experience • LCHD began incorporating QI into its operation in January 2010. • LCHD secured grant funding to have 5 staff members receive QI training and implement a project. • As a result of the project LCHD developed the Influenza Reporting Improvement System (IRIS) • IRIS was recognized by NACCHO as a Promising Practice in 2011.

5. LCHD QI Experience • LCHD secured additional grant funding in 2010 allowing all of its management staff to receive QI training. • This resulted in the creating of our QI Council, which meets monthly. • The meetings allow for discussion of ongoing projects and potential future projects.

6. LCHD QI Experience • QI discussions have also been incorporated into our monthly divisional staff meetings. • As has the status of our accreditation efforts. • Our department has completed a total of 4 QI projects since 2010, and we have 4 ongoing projects. • Each project has been a learning experience, and most importantly a success (each in their own way!)

7. Medical Supply Project • Our QI Council chose to address our department’s ordering and storage of medical supplies as part of the NNPHI grant program. • The project was chosen due to the lack of a uniform ordering process. • Additionally, our department lacks an adequate inventory tracking system.

8. Aim Statement Original Aim Statement: • By November 30, 2012, the amount of money spent on medical supplies will be 10% less than the amount spent during the same timeframe in 2011. • Our original intent was to focus on the financial implications of the fractured process. • However, as the team worked on the project the aim statement was revised.

9. Revised Aim Statement Revised Aim Statement: • By December 31, 2012, decrease medical supply orders to 1 order/60 days, as compared to the current average of 9.5 orders/60 days. • Reducing the number of orders will demonstrate a quality inventory tracking system is in place. • It will also eliminate multiple staff members placing multiple orders for the same item. • Of which we may have on hand, but the staff member placing the order was not aware.

10. Work Completed • Thus far, our team has conducted several brainstorming sessions to discuss the process in its current state. • Team members developed an affinity diagram during the sessions. • The team also developed a flow chart to examine the current process.

11. Work Completed • Team members have been collecting and analyzing baseline data in order to properly evaluate their intervention. • This evaluation will occur during the check portion of the PDCA process. • The team has also begun the discussion of potential solutions to implement as part of a pilot project.

12. QI Tools QI Tools Used: • Affinity Diagram • Flow Chart Potential Tools: • Run Chart • Check Sheet • Pareto Chart

14. Challenges • Limited QI experience on team. • However this was done intentionally to have additional staff trained. • “This is how we have always done it” thinking. • Large amount staff turnover due to retirements and resulting reassignment of job duties.

15. Key Lesson Learned • Involve front line staff in projects • They are the experts • They know what parts of the process are broken • The often know how to fix the process as well

16. Expected Results • As a result of this project we expect to see a reduction in the number of medical supply orders. • We also expect to develop an accurate on-hand inventory system making the ordering process easier. • Ultimately we expect the cost of medical supplies to decrease with the implementation of a standardized ordering process.

17. Contact Information Chad Brown, RS, MPH Director of Community Health Licking County Health Department 675 Price Road Newark, Ohio 740-349-6535 cbrown@lickingcohealth.org www.lickingcohealth.org

18. Madison County, NC Health Department QI Process for 2012

19. We knew we had a problem when… We checked in with our billing department of one and saw this.

20. And several weeks later we saw this…

21. We looked at our balance sheet and saw that revenues were not meeting projections in the Medicaid and private insurance lines, and fees.

22. Why did we want to do a QI project? • We had convinced the Board of Health and the County Commissioners that we needed additional staff in our billing department • We promised increased revenue to support the position • We could see from our Medicaid and private insurance revenue that we were behind in our revenue projections • We knew we had issues with a new billing system mandated by our State to use for Medicaid billing • We wanted to improve staff morale related to billing • Our health department had never engaged in a formal QI process

23. Why did we pick this process? • Fairly new process: had never billed for health services until 3 years ago • Did not use any formal planning or QI process as the billing process began • Urgent need to improve the process of capturing revenue • This was one process that included almost all departments (and staff) working together toward the same goal • Not all staff recognized their role in capturing revenue and did not see what they did or did not do mattered down the line

24. What is our AIM statement? We started with this: “By July 1, 2013 denied insurance billing claims will be reduced to 5% of overall billing claims increasing revenue from fees by 40% over FY2011.” We realized that billing is ultimately a patient process and that it included more than just billing, so we revised our statement to this: “Develop an enhanced, efficient patient process that will maximize revenue by November 2012.”

25. What have we done so far? • Established a multi-disciplinary QI Process Team • Identified the leader and facilitator • Identified the overarching reason for our QI project We want to improve the revenue system for Madison County Health Department to provide the programs and services to our communities with the least burden to the tax payer. • We begin each meeting making this statement and repeating the AIM statement to remind everyone why we are here.

26. Other steps taken • Had phone conference with our coach at least 4 times • Developed a flow chart representing our current patient process – this took 5 meetings to work through • Have begun to work on metrics and change strategies • We are going to incorporate some “LEAN” principles as we move toward change strategies LEAN: **Remove waste, empower employees to take action, and create mobility.

27. Model For Improvement What are we trying to accomplish? AIM How will we know if changes will be improvements? MEASURES What change can we make that will result in improvement? CHANGES

28. Start with small cycles of PDSA and continue with scope and time as you move along through the change strategies.

29. Did we have any problems? • We realized that we had no solid baseline data to create a starting point, even though we knew there was a real problem. • Our systems have faulty reporting mechanisms. We wonder how we’re going to evaluate progress. This has not been fixed.

30. What has happened so far? • We have noticed a heightened awareness and appreciation of the whole team approach as it relates to our patient process • We are noticing good team work and real interest in the process • We have staff THINKING OUTSIDE THE BOX and really considering what is essential, what is non-essential, and what is truly customer motivated

31. What will we realize? Even though we are a small health department and staff juggle many tasks, we will increase efficiency and improve revenue!

32. Questions?

33. HOSPITAL INSPECTION/LICENSING PROCESS Washington StateJune 2012 Presented by: Susan Ramsey, Director Office of Performance and Accountability Washington State Department of Health 360-236-4013 – susan.ramsey@doh.wa.gov 33

34. Why Did We Choose This Project? Background: • DOH required to conduct inspections of hospital facilities on an average of every 18 month • DOH role: Protect patient safety and well being • Audit reviewed DOH compliance with Medicaid grant requirements to conduct hospital inspections • Hospital inspections were not being done in a timely fashion

35. Why Did We Choose This Project? Background cont. • Baseline: Fiscal year 2011, 55% of surveys were not done within the 18 month timeline • 96 active hospitals in three categories: acute care/general hospitals, chemical dependency hospitals and psychiatric hospitals • Scope: Acute Care Hospitals

36. Quality Improvement Project Steps • Assess • Assess organizational goals and current performance • Determine most important problems/biggest opportunities • Define • Define problem/opportunity • Define process(es)/service to be addressed • Define measure(s) of success • Define stakeholders, customers and team • Analyze • Analyze process(es) and data • Determine potential causes • Determine “root” causes • Change • Consider solution options • Determine “best” solution(s) • Test Solutions • Manage Change • Social • Technical • “Hand-off” to operations – including Evaluation plan • Evaluate • Monitor performance against measures • Maintain solution(s) (if working) • Re-enter Improvement Cycle Based on adaptation of Public Health model Plan Do Study Act

37. Quality Improvement Project Steps Using PDSA model Determine Area Needing Improvement Define problem (AIM statement) Gather/review baseline measures Analyze problem/process ACT PLAN Determine causes Take corrective action Develop possible solution Test solutions STUDY DO Monitor/evaluate performance Implement solutions system wide Manage change

38. Plan Phase Assess Define Analyze Change

39. Assess: Most important/biggest opportunity Aim Statement : Increase the percentage of acute care hospital inspections within 18 month timeline from 52% to 75% by December 2012 and to 100% by December 2013. Assess and Define PhasePlan

40. Define PhasePlan Stakeholders, Customers and Team: Excerpt from Charter document. Challenge was defining customer. SPIT • Reviewers • Office of Performance and Accountability

41. AnalyzePlan Value Stream Mapping Event – June 2012 Current State Map Future State Map Implementation Plan

42. Current State Map

43. Future State Map

44. Key Lessons Learned • Time to pre-plan the Value Stream Mapping Event • Agreement from everyone on who is the customer • Data, data, data - establish baselines to demonstrate accomplishments throughout the process

45. What Are Our Expected Results? • Decrease in the overall time to conduct a hospital inspection • Develop a standardize process to conduct an inspection • Maximize and Optimize resources and existing staff • Inspect all 96 hospitals within the 18 month timeline

46. Contact Information Susan Ramsey, Director Office of Performance and Accountability Washington State Department of Health 360-236-4013 – susan.ramsey@doh.wa.gov