Ask an Expert

Public health practitioners are increasingly using quality improvement (QI) methods and tools to improve agency performance and individual programs. Professionals already working in the field are learning how to apply these concepts through various professional development trainings and technical assistance offered by National Network of Public Health Institutes (NNPHI), the Association of State and Territorial Health Officials (ASTHO), the National Association of City and County Health Officials (NACCHO), the National Network of Public Health Institutes (NNPHI) and the Public Health Accredidation Board (PHAB) among others.  To improve the future public health workforce, exposure to public health practice–based QI should also be provided to students during their formal graduate public health education. QI is incorporated into the Association of Schools and Programs in Public Health MPH Core Competency Model and the Core Competencies for Public Health Professionals.

The Public Health Quality Improvement Exchange (PHQIX) is a useful tool for teaching students about the application of QI concepts. PHQIX is an online community designed to be a communication hub for public health professionals interested in learning and sharing information about QI in public health. The purpose of PHQIX is to disseminate information learned through QI initiatives and facilitate increased use of QI in public health practice. PHQIX includes an online database of QI efforts conducted by public health departments across the country. The search and query functions enable users to find projects and tools relevant to their needs. I have used PHQIX in teaching QI to MPH and DrPH students. It is an ideal online platform for “on-the-ground training” that significantly supplements course content.

PHQIX is a resource that helps teach the real-world application of public health QI. In my courses, I have incorporated PHQIX at various times during the semester. Once students have learned a particular theory or QI method, tool, or approach, they are then assigned to review its application in PHQIX. For example, students analyze aim statements of QI projects; assess how and when a QI project engages its customers and stakeholders; and evaluate stages of Plan, Do, Study, Act cycles. Furthermore, students compare and contrast how QI tools have been used in different projects to advance their understanding of the connection between QI and public health department accreditation. Ultimately, students gain an improved understanding of how to assess success for a QI project beyond the project reaching its intended aim. Equally important, they learn from the lessons learned by the project’s developers. Students are encouraged to engage with project authors via the PHQIX online community for additional questions and insights into the project. My students have commented that learning the history of public health QI and using the appropriate methods and tools combined with real-world application via PHQIX is an asset of the course. Students have also noted that they have referred their colleagues to PHQIX. Beyond a course specifically in public health QI, PHQIX could easily be incorporated into a variety of other graduate or undergraduate public health courses to demonstrate improvement processes conducted in the field of public health administration.

PHQIX, created by RTI International and funded by the Robert Wood Johnson Foundation, launched in September 2012. To date, there are 1674 registered users of PHQIX who are helping achieve the project goal of sustaining national QI efforts by providing public health practitioners with a means for obtaining knowledge about their colleagues’ experience. From my experience, public health students also greatly benefit from learning about first-hand QI experiences from those in the field.

Kusuma Madamala, PhD, MPH

Public Health Systems Consultant
Adjunct Assistant Professor/DrPH Faculty—University of Illinois at Chicago School of Public Health
Adjunct Assistant Professor—Medical College of Wisconsin

Tuesday, October 21, 2014 - How do you remove the waste in your work process? How do you provide your services in less time with greater quality? 

Written by PHQIX Expert Panel member Chris Bujak and his business partner Pam Vecellio, of Continual Impact LLC. Visit the Ask an Expert page for more advice from PHQIX Expert Panelists.

The COPPHI Kaizen Event Program recently completed foundational QI and kaizen training, coaching, and co-application of kaizen events at 10 health departments.  The program was funded by the Robert Wood Johnson Foundation (RWJF), and managed by National Network of Public Health Institutes (NNPHI); training and expertise was provided by Continual Impact LLC.  Kaizen utilizes methods and techniques to observe the current work process and analyze the value and waste in every step. This process provides the team the understanding to redesign the work process for improved efficiency while staying focused on the work process’s customers and objectives.

Kaizen simply means “change for the better.”  A kaizen event is a team-based approach that enables improvement to be made by stepping through all phases of the improvement cycle effectively and rapidly. Before the event, a kaizen-appropriate problem is identified along with goals in areas such as customer satisfaction, cycle time and labor reduction, and error elimination. The team is then mobilized and a kaizen event begins. A typical event uses a systematic process to identify waste in the targeted work process, enable the team to understand and analyze the root causes, identify and test solutions, learn, install improvements, and create a system for ongoing improvement. As the event progresses, numerous QI and change management methods and techniques are applied. The event enables the team to accomplish all this work quickly, typically in 5 days with full benefits achieved within 1-3 months!      

Participants commented:

Several of the kaizen program sites targeted improvements in the efficiency of their processes. Take a look to see the amount of positive change made in a brief time by finding the waste and implementing solutions!

DOH-Seminole County realized savings of $7764 for goods and services from price negotiations during the first quarter following a Kaizen event – almost double the goal set by the QI team. Other improvements in the requisition process included a 38% decrease in process time, in addition to increases in the approval rate for submitted requisitions and the rate of correctly completed forms. The overall result is a much more efficient process that procures goods and services at significantly reduced costs.

Johnson County Department of Health and Environment used a kaizen event to improve the supply ordering process cycle time and increased the order placement and delivery accuracy for all programs in the department. The results included decrease in cycle time – total ordering process time per order from 93 to 16.5 minutes,( 82% ) time and improving the order and delivery accuracy to 100%. This means staff can focus on more value added activities and get the needed resources faster. During the 5 day kaizen event the team worked to understand the problem, identify and root cause the issues, develop, test, and begin installing the solutions. The process was re-sequenced and redesigned to eliminate unnecessary steps, recycle loops, wait time and other wastes. Key process aids were developed such as creating a standard vendor list (by category), creating a list of items than cannot be ordered, training members and distributing P-cards to heavy orderers, shredding non-preferred vendor catalogs, providing budget visibility and codes, creating 1 standard order form, creating a share point site to access the order form and store all ordering documents, creating delivery location rules, granting orderers access to vendor web sites, 5S’ing the one storage room, establishing a Kanban ordering system to decrease inventory and standardize ordering, and lastly moving the ordering process from as needed to monthly.

By streamlining their internal computer drive, creating an internal framework for its use/upkeep, and training staff on the efficient and effective use of the computer drive, the Three Rivers District Health Department has increased staff productivity.

Monday, September 29, 2014 - The heart, mind, soul, and muscle of your health department: your people! 

Written by PHQIX Expert Panel member Chris Bujak and his business partner Pam Vecellio, of Continual Impact LLC. Visit the Ask an Expert page for more advice from PHQIX Expert Panelists.

The COPPHI Kaizen Event Program recently completed foundational QI and Kaizen training, coaching, and co-application of kaizen events at 10 health departments. The program was funded by the Robert Wood Johnson Foundation (RWJF), and managed by National Network of Public Health Institutes (NNPHI), with the training and expertise provided by Continual Impact LLC.  Keys to successful Kaizen events and to creating a culture of high performance are the involvement, knowledge, actions and ownership of the individuals performing the work process.  A Kaizen event helps to unlock the capacity of the people in your organization!

Kaizen simply means “change for the better”.  A kaizen event is a team-based approach that enables improvement to be made by stepping through all phases of the improvement cycle in an effective and rapid fashion.  Before the event, a kaizen-appropriate problem is identified along with goals in areas such as customer satisfaction, cycle time and labor reduction, and error elimination. The team is then mobilized and a kaizen event begins. A typical event uses a systematic process to identify waste in the targeted work process, enable the team to understand and analyze the root causes, identify and test solutions, learn, install improvements, and create a system for ongoing improvement. As the event progresses, numerous QI and change management methods and techniques are applied. The event enables the team to accomplish all this work quickly, typically in 5 days with full benefits achieved within 1-3 months! 

DeKalb County Board of Health’s kaizen event improved the labor time and accuracy of filing death certificate registrations. The team looked critically at the waste in their work process and the root causes, and then identified solutions  such as: redesigning and mistake-proofing information request forms, creating standardized work for the funeral directors, defining and standardizing the acceptance criteria, defining team roles, eliminating redundant tasks, moving office space and equipment to facilitate the process flow, implementing scanning hardware/software, and redesigning the phone messaging prompts and the phone routing/rollover system. As a result, cycle time and labor content were reduced by more than 50%.  All of this work was identified and executed in rapid fashion by the most valuable resource in any improvement activity--the Team!

…and what did the team members have to say about the experience?

“Going from current to future state blew my mind – you have to experience it.”

“It is nice to see how proud people are and how they own these improvements and new process.”

“This kaizen event was a roller coaster—after I got off, I’m ready to do it again!”

“We dealt with a lot of personalities; emotionally trying but very successful.”

One particular team commented on their progress:

From: “We’ve never been asked our opinion before, we’re just told what to do,” “I have much more capability than people realize but feel looked down on because I’m just an operator,” “you’re just trying to get us to do more work,” “we expect when all this is done you will tell us we don’t have a job”.

To: “ In the end we got hugs from everyone, and they made comments like it turned out right like you told us on Monday,” “Sorry I was mean to you,” and “We’re sorry you are leaving.” “We ended up receiving positive feedback from everyone. Of course in 1 week it did not eliminate issues completely, but it was a powerful example of kaizen’s ability to generate positive energy in people!”

Other organizations with compelling “Team stories” during their Kaizen events can be found below:

Kaizen events lend themselves to rapid improvements in routine health department processes. Tazewell County Health Department utilized Kaizen tools to full advantage--reducing administrative time related to food establishment inspections dramatically, exceeding the project aim. In the first month, they achieved an 80% reduction in both time and materials.

Untreated chlamydia (CT) and gonorrhea (GC) can lead to serious health problems in men and women. In order to effectively track and treat these two sexually transmitted infections, CDC guidelines require that low-priority CT and GC reports be processed by health departments within 30 days of receiving a reporting form from a laboratory or medical provider office. The Chicago health department had been experiencing a large backlog of these reports, and used a kaizen event and PDCA approach to dramatically reduce the processing and backlog time in order to improve the surveillance and control of these infections. The staff was able to reduce the backlog time of low-priority CT and GC reports, receipt to closure in INEDSS, from 86 days to 30 days and anticipate further improvement. he STI Surveillance Program immediately changed the method for how incoming reports were sorted and bundled for assignment to data entry staff; developed a revised morbidity reporting form and standardized laboratory reporting form to reduce data entry time; and determined that data entry staff was keeping up with incoming reports and the backlog was perpetuated year after year and proposed a solution to management so that the backlog could be permanently addressed. Additional outcome was improved staff morale!

Wednesday, September 10, 2014 - Who are your customers? How can you better satisfy their expectations?

Written by PHQIX Expert Panel member Chris Bujak and his business partner Pam Vecellio, of Continual Impact LLC. Visit the Ask an Expert page for more advice from PHQIX Expert Panelists.

The COPPHI Kaizen Event Program recently completed foundational QI and kaizen training, coaching, and co-application of kaizen events at 10 health departments. The program was funded by the Robert Wood Johnson Foundation (RWJF), and managed by National Network of Public Health Institutes (NNPHI); training and expertise were provided by Continual Impact LLC. Four of these kaizen events focused on customer relations and improving satisfaction.  

Kaizen is simply a term that means “change for the better”.  A kaizen event is a team-based approach that enables improvement to be made by stepping through all phases of the improvement cycle effectively and rapidly.  Before the event, a kaizen-appropriate problem is identified along with goals in areas such as customer satisfaction, cycle time and labor reduction, and error elimination. The team is then mobilized and a kaizen event begins. A typical event uses a systematic process to identify waste in the targeted work process, enable the team to understand and analyze the root causes, identify and test solutions, learn, install improvements, and create a system for ongoing improvement. As the event progresses, numerous QI and change management methods and techniques are applied. The event enables the team to accomplish all this work quickly, typically in 5 days with full benefits achieved within 1-3 months!

Team members commented:    

“Did not realize before the waste in our processes—we do now.”

“This was a rollercoaster—after I got off, I wanted to go again.”

 “Learned how we are going to improve our processes.”

“We exceeded our goal through our kaizen!”

 “Wealth of information that we can apply to our lives.”

El Dorado County Health and Human Services Agency improved their customer satisfaction and reduced labor time in the county “Request for Information” process. The team used a kaizen event to understand the problem, identify issues and waste, identify root causes of the issues, and then develop, test, and begin installing the solutions in 1 week. To achieve the improvements, the team created a list of information subject matter experts, standardized work for answering phone requests, developed a live transfer process and internal service-level agreements for returning customer calls; added key information to the county website for self-service, and clarified and simplified the phone tree. Customers can now get their needed information faster and at less labor cost by the team! 

Other organizations that targeted customer improvements during their kaizen events can be found below:

Washington County Public Health Division conducted their kaizen event to improve the volume of childcare facilities that used the LHD for their state required inspections. This improvement work was completed in a one-week intensive improvement effort and resulted in: (1) implementation of a scheduling and preparedness call by the Environmental Health Specialist (EHS), (2) introduction of service standards for scheduling, (3) elimination of a redundant log and data entry system, (4) creation of standardized work and job aids, (5) creation of policies and protocols for areas in which ambiguity exists, and (6) introduction of a protocol to set a 5-day calendar window with the customer for inspection as part of the scheduling and preparedness call done by the EHS.

Clackamas County Public Health Division conducted their kaizen event to design and implement a customer feedback system for the entire public health division. The process and tools used for the project are well described and easy to adapt by other health departments. While Clackamas has not yet achieved their targets for the improvement, they increased completed client feedback forms from 8 to 21 per month, and the lessons learned while conducting the project and the examples of tools and methods makes this project well worth reviewing.

The Fond du Lac County Health Department increased the number of children being screened for developmental delays from 5 to 9 per month, allowing more children to be appropriately connected with services to enhance their early childhood development through early intervention and minimize potential developmental delays.

Monday, August 18, 2014 - Would you like to have more speed, involvement, and results for your improvement projects?

Written by PHQIX Expert Panel member Chris Bujak and his business partner Pam Vecellio, of Continual Impact LLC. Visit the Ask an Expert page for more advice from PHQIX Expert Panelists.

Kaizen is a QI method that can help. The COPPHI Kaizen Event Program recently provided training for individuals from 10 health departments, through a competitive process, for intensive kaizen education, onsite coaching about application of the kaizen methodology, and participation in a learning community. The program was funded by the Robert Wood Johnson Foundation (RWJF), and managed by National Network of Public Health Institutes (NNPHI); training and coaching were provided by Continual Impact LLC. 

Kaizen simply means “change for the better”.  A kaizen event is a team-based approach to problem solving that flows through all phases of the improvement cycle effectively and rapidly. Before the event, a kaizen-appropriate problem is identified along with goals in areas such as customer satisfaction, cycle time and labor reduction, and error elimination. The team is then mobilized and a kaizen event begins. A typical event uses a systematic process to identify waste in the targeted work process, to enable the team to understand and analyze the root causes, to identify and test solutions, to learn, to install improvements, and to create a system for ongoing improvement. As the event progresses, numerous QI and change management methods and techniques are applied. All of this work is accomplished in a brief period of time, typically 5 days, with full benefits achieved within 1-3 months!    

To prepare, the event leader team completed 48 hours of face-to-face foundational QI, kaizen, and facilitation education using an application-intensive, “Tell, Show, Do, Recycle” (receive feedback) approach to solidify the learnings. During the preparation and post-event, each event leader received personalized coaching.  Ten kaizen events were then conducted (one at each site) where each event leader co-led the event with an onsite Continual Impact LLC coach helping and providing feedback. Each event team completed all phases of the improvement cycle and then immediately followed up by rolling out the new process and installing an ongoing improvement system for monitoring progress and creating even more improvements!

Kaizen events can also be a powerful way to support Public Health Accreditation Board accreditation, engage people, and help develop a culture of improvement in your agency.  Kaizen leverages the power of the people who perform the work; engages leadership in a meaningful and supportive fashion; focuses the improvement so it aligns with the organization’s needs and can be done rapidly; uses learning from the work site to identify practical solutions; applies numerous, detailed improvement methods during the event to empower the individual and effectively solve problems; and implements the solutions quickly and sets the stage for further improvements. 

See the program summary of the event results here. Over the next few weeks more information on the 10 Kaizen projects will be highlighted in future articles.