Ramaswamy, Rohit PhD, MPH, Grad Dip (Bios); Segal, Stephanie MPH; Harris, Joy MPH; Randolph, Greg D. MD, MPH; Cornett, Amanda MPH; Harrison, Lisa Macon MPH; Lea, C. Suzanne PhD, MPH
Nationwide, the movement to improve the accountability and quality of public health departments is gaining momentum. The push toward national accreditation of public health departments led by the Public Health Accreditation Board (PHAB) is well under way, with a national launch in 2011.1 Like many other states, Iowa is preparing for national accreditation and is working toward accreditation of the Iowa Department of Public Health and 1 local health department by early 2012.
By definition, accreditation requires performance standards that can be objectively verified by an independent auditing agency and quality improvement programs to achieve or exceed these standards. Beginning in 2004, the Iowa Department of Public Health, in partnership with local public health agencies, embarked on a modernization initiative to reduce the fragmentation of the public health system and to deliver “what every Iowan can reasonably expect from public health.”2 As part of this initiative, the Iowa Department of Public health has implemented several quality improvement (QI) activities. These include QI training, creation of a Public Health Quality Improvement Network, and participation in the Multi-State Learning Collaborative (MLC).
This article describes 1 quality improvement activity at the Iowa Department of Public Health: the development of standard processes for local environmental health. Standardized work has been described as the “baseline for continuous improvement” by the Lean Enterprise Institute.3 Many improvement projects focus on fixing what does not work or on solving specific problems. Documenting standard processes is a precursor to problem solving and facilitates understanding of work flow and measuring performance across multiple organizations, which is a typical situation for a state department of health when collaborating with multiple local health departments on improvement activities. This article describes the lessons learned from a pilot project to create standard environmental health (EH) processes collaboratively by a state health department and 3 local public health departments. The project began in July 2010 and is planned to continue until December 2011. The final output will include standard process maps for all core EH activities, output and process metrics, and preliminary identification of improvement opportunities needed for accreditation. In this article, we describe the first stage of this project, the creation of standard process maps.
It is important to emphasize that standardization by itself does not guarantee process efficiencies. Standardizing processes may achieve a few efficiencies by eliminating unnecessary activities. But the purpose of standardization is to develop a common representation of work done in different counties so that there is an agreed-upon basis for measurement of efficiency and a framework for designing and testing improvement interventions. Agreeing on common work processes and developing common documentation is an important first step in an organization's continuous improvement journey.
The population in Iowa is 3 007 856. Approximately 22% of Iowa's citizens reside in Greater Des Moines, with a population of 648 748.4 The remainder of Iowa consists of small towns and cities, as well as roughly 80 000 farms.5 There are 99 counties, some of which have fewer than 10 000 residents. Thus, the public health structure in Iowa must accommodate for the varying environmental, demographic, and resource differences throughout the state.
In Iowa, governmental public health is the responsibility of local boards of health, local public health agencies, the Iowa Department of Public Health (IDPH), and the State Board of Health. Iowa's governor appoints the State Board of Health, which is the policy-making group for the IDPH. The IDPH provides technical support, funding, and consultation for the county boards of health, 2 city boards and 1 district board. County boards of supervisors appoint members of the local boards, and these have jurisdiction over local public health matters. They can determine what services to provide and how to provide them for the area(s) that fall within their jurisdiction. As a result, the size and structure of public health agencies and the services available within a community can vary greatly throughout Iowa.6
The IDPH modernization initiative mentioned previously was initiated to attempt to address unnecessary variability in performance at the local level. The objective of this effort has been to “improve the quality and performance of Iowa's public health system and ensure a basic standard service delivery to all Iowans.”6 Modernization addresses the following components of public health in Iowa:
* Communication and information technology;
* Community assessment and planning;
* Prevent epidemics and the spread of disease;
* Protect against environmental hazards;
* Prevent injuries;
* Promote healthy behaviors; and
* Prepare for, respond to, and recover from public health emergencies.
Within each of these components are sets of standards, as well as local and state criteria to meet these standards. Supported by training from the University of Iowa and the Public Health Foundation, the local public health agencies are identifying areas that need to be addressed to prepare for accreditation.7 However, in a decentralized system, without standard work processes, it is difficult to determine where to focus and how to set improvement goals and priorities.
The pilot project was designed to create standard processes for the modernization component Protect against environmental hazards. This is because there has been little emphasis on quality improvement in environmental health services in Iowa. It was felt that focusing on this component of modernization would both address an immediate need and serve as a template for work standardization for the other modernization components in the future.
Current state of environmental health processes in Iowa
Depending on the county, EH services in Iowa are administered by different offices, not all of which are part of the local public health department. The EH reporting structure also differs by county. Some directors oversee a single county, while others have accountability for multiple counties. Some EH offices report directly to the local board of health, while others report to the public health office that reports to the local or county board of health.
These differences in organization and resources across counties are not aspects of Iowa's public health delivery system that can be addressed in the short term. However, all citizens of Iowa have a right to expect a consistent standard of services irrespective of their county of residence, and differences in organization and services offered should not be barriers to meeting this need. The IDPH felt focusing on work processes rather than on organizational structure should be the way to achieve the modernization goal of “standard service delivery.” By helping counties understand that some differences in activities at the local level may be unnecessary and wasteful, the process-mapping exercise would guide them to develop a common core set of EH activities that are needed to fulfill the needs of Iowa residents.
The project team and the IDPH leaders also strongly felt that those who do the work must be involved in the process standardization effort. This is in keeping with the continuous quality improvement (CQI) philosophy of W. Edwards Deming that “Workers work in the system, which management created or allowed to continue. Management must work on the system to improve the process. With instruction, workers can be enlisted in this improvement.”8 Therefore, the methodology adopted for this project was a facilitated participatory reflective process during which the selected staff in the county EH departments could review, discuss, and document their everyday work in conjunction with the researchers.
Three counties were chosen for participation in the standardization project based on their prior exposure to public health modernization in Iowa, their willingness to participate in quality improvement, and their varying demographics. The first county is an urban county located near Des Moines and has a 2010 population of approximately 62 000.9 The 2 other counties are rural and roughly 120 miles from Des Moines with populations of approximately 20 000 each. Because rural and urban communities vary greatly from an environmental and cultural perspective, it was important to have representation from both types of counties to provide a standard that could be more easily replicated throughout the state. Three Environmental Health (EH) staff members, 1 from each of the 3 county offices, were selected to participate in the project. These members were selected because they expressed interest in the modernization program and had already done some initial work to document some of their processes.
Stakeholder selection and communications planning
The authors worked with leaders at the Iowa Department of Public Health to develop a project plan, communications plan, and a list of stakeholders. Along with the 3 county participants, the project team identified the Director of Environmental Health and the Bureau Chief of EH Services at the state level as important stakeholders. Their support is critical for scale-up to the state level after the pilot project is complete. A communication plan was developed to ensure that all stakeholders were regularly informed about the progress of the project. The plan requires all participating counties to receive project status updates once every other month. Updates to the modernization leader at the IDPH and internal communication meetings with the state-level stakeholders are held monthly.
Developing initial process maps
The first step was an open-ended exploratory meeting with the selected staff members to discuss the intent of the project and to develop the overall plan. These meetings were not formal data collection efforts but were intended to begin the process of getting EH staff members to think about their work and to gain their support for the project. These meetings were also used to generate ideas about how best to involve the selected staff members in the project without taking a significant amount of their time. During these meetings, all 3 participants agreed that the initial process-mapping effort should be led by the urban county because of its close proximity to resources in Des Moines, and then reviewed and modified by the other counties.
Following these meetings, the process mapping exercise began with a visit to the urban county's EH department to collect written documented procedures. (The Appendix shows an example of an existing procedure for dealing with a possible rabies cases.) The first step was to identify the core body of work performed by the department to provide services to the community. This was accomplished by obtaining all relevant documents pertaining to the county's services and reviewing them with the county's selected staff member. This review resulted in the following activities being identified:
* Responding to mold complaints
* Responding to disease outbreak
* Responding to possible rabies cases
* Obtaining a septic permit
* Conducting a septic inspection
* Conducting a pool or spa inspection
* Conducting a tanning or tattoo facility inspection
* Addressing a complaint
Other activities were more ad hoc or office management related and did not involve core EH services. These 8 activities were therefore used as the starting point for creating the initial high-level process maps. These maps were created by the researchers.
Revising and improving the process maps
Once the first draft of each process map was complete, a follow-up meeting with the selected staff member for the urban county was scheduled to fill in any unknown steps and clarify any steps that were vague. To do this, a series of “what happens when ...” questions were used. These questions helped to identify situations that were not covered by the current procedures and resulted in a more comprehensive map that addressed more scenarios than the initial one based on existing procedures.
Validating the process maps with other counties
The process maps developed with the EH staff member of the urban county were presented to staff in the 2 rural counties. There were several steps to this activity. The first step was to determine whether the 8 process maps represented the totality of EH work performed by the rural counties, or whether these counties had additional responsibilities that had not been covered. Not surprisingly, although many of the processes were common, there were some important differences. Table details the EH processes performed by each county.
TABLE Processes Per...Image Tools
The next step was to develop maps for the services offered only by the rural counties. This was done at a single meeting with the staff from both counties working together. At this meeting, the process maps for the common processes were also reviewed to identify where standardization was appropriate and where there was good reason to adopt a customized local practice. To do this, participants from the rural counties generated a variety of operational scenarios that were tested against the process maps developed with the urban county. The process documentation was modified or enhanced to address scenarios that were not adequately covered in the maps. The last step was to create the final set of maps, which incorporated the combined perspectives of the 3 pilot counties for the common processes. For the services that were not common, county-specific process maps were created.
An example of process maps generated through these efforts is shown in Figures 1 to 3 for the Respond to possible rabies cases process. Figure 1 is the initial process map developed from the written procedures for the urban county.
As described previously, this map was used as the starting point for asking the “what-if” questions to test whether it adequately covered all possible scenarios associated with a response to a potential rabies case. This resulted in the revised version shown in Figure 2. It should be apparent that this version is more detailed than the map in Figure 1.
This revised map was then reviewed with the EH staff from the 2 rural counties. As indicated in Table, the EH departments in the rural counties only deal with potential rabies cases involving bats. By ordinance, bites from other animals in these counties are addressed by the sheriff's department. A county-level process map shown in Figure 3 was created to highlight this difference.
Although formal performance measures are still under development, some insights were immediately apparent. One of the advantages of process maps is that they visually illuminate what may be hidden in written procedures. Wasteful activities, unnecessary rework loops, and convoluted steps are some examples of process inefficiencies that are made visible through process mapping. We now describe some of the insights gained from the IDPH process maps and some recommendations for successful process mapping in public health settings.
Insights from process maps
(1) Process documentation reduces interpretations and assumptions about work activities: The map in Figure 1 was derived from current documented procedures. The difference between the maps in Figures 1 and 2 shows that without the level of detail in Figure 2, employees can interpret the procedures in many different ways. For example, in Figure 1, there is no process path that describes what to do when the animal owner is not identified. This path, along with paths for several other decision points, is built into the map in Figure 2.
(2) Process documentation identifies areas of potential risk: Figure 4 shows a small segment of the rabies process from Figure 2. This segment illustrates that if the county has no funding for testing and euthanizing, the victim is financially responsible. The county EH officers saw this as a potential community health risk, since the victim may choose not to euthanize the animal or may not get vaccinated. An immediate improvement opportunity might make this step the county's responsibility, and a project could be launched to identify funding sources for testing and euthanasia.
Another example of the use of process documentation to identify risk can be seen in the Performing lead poisoning inspection process. Figure 5 shows a small segment of this process. This segment shows that there is no end to the follow-up process when a building with a known safety risk is not repaired (the process map guidance is to follow up “indefinitely”). An immediate improvement opportunity might be to launch a QI project to ensure that violations are dealt with in a timely manner.
(3) Process documentation brings nonstandard practices to light: While mapping the process Conduct septic tank inspections (the map for this process is not shown in this article), there was a discussion about a checklist to ensure that the inspector followed all the steps. The urban county had a checklist, but was unaware that a recent process improvement activity led by EH staff from the rural counties had created and tested a new and more robust tool that was available to all counties. The discussion using the process maps allowed the identification of this and other nonstandard activities.
(4) Process documentation facilitates the development of metrics: At the moment, there are no identified process measures, and very few required output measures for environmental health processes. There are no metrics regarding process times, errors, productivity, cost, or customer satisfaction, although some of these may be needed for accreditation. The development of metrics is often a time-consuming activity. Process maps allow a team to visually identify potential measurement points, and this makes metrics development easier. For example, in the rabies process, it would be important to regularly track volumes, compliance, and funding available for animal control. Trigger points for data collection can be identified on the maps so that counties can develop standardized metrics for each process.
(5) Process documentation allows the identification of knowledge sharing opportunities: Many counties are resource constrained. During process documentation sessions, EH staff often mentioned how difficult it was to manage their numerous processes given their resource constraints. The maps allowed staff from different counties to identify processes that they felt comfortable with and processes that they needed to manage better. In the future, this can be the basis for formal knowledge-sharing activities to improve the level of EH expertise across the state.
Overall, we found that participants found great value in the process-mapping activities and considered it to be an important initial step in the process of standardization. After the process mapping was complete, one EH director said, “after this effort, our county has had to revise some of our policies and make new policies because no policies were in place.”
Recommendations for successful process mapping
In addition to the insights from the process maps, our work with the pilot counties provided us with operational insights about conducting process mapping session in local public health settings. Some important lessons are as follows.
(1) Do not rely solely on existing documentation: As the rabies example illustrated, existing documentation does not always provide a thorough and accurate picture of the way processes are actually executed. Although existing documentation can be a good starting point, procedures should be created from process maps, not the other way around.
(2) Use an external facilitator: It is strongly recommended that an external facilitator who is not familiar with the process lead the mapping sessions. A nonexpert facilitator can ask questions or challenge assumptions that might otherwise be taken for granted.
(3) Allow organizational concerns to be voiced and openly discussed: Even though process mapping is an analytical activity, there are likely to be personal and organizational concerns about the effect that “standardization” might have on personal autonomy and local level decision making. Providing some time for these concerns to be aired and discussed before mapping actually begins will make the mapping activity more participatory and effective.
(4) Ensure that processes are documented at the appropriate level of detail: Since process maps serve as the source for detailed operational procedures, each map should provide a realistic description of the most common work situations faced by staff in the process at the right level of detail. It is easy to document processes at a superficial level or to get bogged down in trying to capture every process nuance. A good guideline is to document a process to a level of detail such that a new staff member who is unfamiliar with the process can approach most common work situations by referring to the process map.
(5) Make sure that there are clear principles to decide when customized maps are appropriate: There will always be some intended and needed variation for local practice that deviates from standardized procedures. For example, local ordinances and requirements may vary. However, much of the variation in public health practice is likely unintended and unnecessary and often arises because of the habits of personnel and traditions accumulated over the years. It is important to establish clear principles in advance about how to decide whether county-specific variation is appropriate. In our work in this pilot project, the need to provide a consistent standard of EH services to all Iowa residents was used as a guiding principle. The understanding reached among the three counties was that the standard process would always be the default, unless there were some specific county-level requirements that would limit the quality of service that could be delivered by the standard process. The metrics needed to assure that the standard process is capable of delivering the required level of quality still need to be developed and are not presented in this article.
Two sets of activities will continue through late 2011. First, definitions of metrics, analysis of existing data, creation of baseline measurements, and identification of improvement activities will take place. These activities will continue to focus on the communities currently involved in the pilot, but improvement efforts will be identified and prioritized at the local level. The methods for driving improvement in a way that maintains local relevance but still allows best practices to be shared across the state will be tested. Second, the process maps will be spread across the state. Environmental health forums organized at the state level will be used for feedback and dissemination.
As states prepare for accreditation, there is still much work that needs to be done to apply QI tools and methods to areas that need the greatest improvement. Since time and resources are limited, careful prioritization of improvement opportunities and sharing of best practices to prevent duplication are important. Before collaborative efforts between states and local health departments for improvement begin, it is important for all participants to have an understanding of common work activities and where improvement resources can make the greatest impact. This article demonstrates how a QI tool, process mapping, can effectively achieve this foundation for improvement.
In 2009, Iowa passed the “Public Health Modernization Act”2 to “ensure that a minimal level of public health services are available in every corner of the state, and that public health agencies have the technology and tools they need to meet the challenges of the 21st century.” Small pilots such as these, with commitment and engagement at the local level, are a good way to begin taking first steps toward ensuring that the goals of this act are achieved, and that public health professionals in Iowa have the capacity to deliver basic services to every Iowan at a consistent and acceptable level of quality.
The desire for consistent high-quality service in public health is one that all states share. Process mapping is one tool that will likely be critical in all states as they collaborate with local agencies to protect and improve their populations' health.
APPENDIX Urban County—Rabies Procedure
The County Environmental Health receives numerous reports of dog and cat bites. These reports may be generated from the various law enforcement agencies within the County or may be reported from the physician's office treating the victim. The County staff will take the following information during the report:
1. Name of the victim (person bitten)
2. Age of the victim (if minor)
3. Location of the bite on the victim
4. Name, address, and phone number of the victim
5. Description of dog or cat and name, if available
6. Name, address, and phone number of dog or cat owner
If all of the above information is not available at the time of the report, the County staff will contact the victim or parent to obtain as much information as possible. The victim is advised to consult a physician, if they have not already done so.
The County staff will then contact the dog or cat owner to determine if the animal has a current vaccination record for rabies. If not, the animal is to be quarantined with a licensed veterinarian for a period of 10 days after the bite. If the owner refuses to quarantine the animal, the County staff will notify the first County Sheriff's department to remove the animal and place in quarantine at the owner's expense. This policy is known as the County Environmental Health Rabies Policy. Cited Here...
continuous improvement; county; efficiency; environmental health administration; gaps; Iowa Department of Public Health; local; metrics; public health administration; process map; rural; standard work; standardization; work flow
© 2012 Lippincott Williams & Wilkins, Inc.