Implementing Quality Improvement Tools to Address Four Challenges in Houston

Summary

Impact Statement:

The Health Department improved the process for obtaining birth and death certificates so customers weren’t forced to miss time from work or take other extraordinary steps to obtain these vital documents in a timely fashion.

Summary:

The Houston Department of Health and Human Services (HDHHS) trained 25 employees in quality improvement (QI) tools and techniques and built its internal capacity to teach QI by hosting the QI Star TRaK (Training, Resources, and Knowledge) Train-the-Trainer (TTT) series. Participants were arranged into four groups and identified four QI projects to pursue: (1) decreasing HIV pending case load, (2) new employee orientation, (3) cost of lab services, and (4) decreasing vital statistics customer wait time. All projects are actively using QI methods to address areas of improvements; however, reducing customer wait time provided an opportunity to immediately meet the needs of the customer and improve an HDHHS service effectively and efficiently. An opportunity existed to improve the vital statistics area customer flow, and reduce customer wait times through QI methods learned during the HDHHS QI Star TRaK series. Customers were waiting nearly one-half hour to process vital statistics transactions. Long waits to receive service have widespread effects, including forcing customers to miss time from work to obtain a birth or death certificate. Using the Plan-Do-Check-Act (P-D-C-A) cycle and other QI methods, the QI team implemented a pilot test to increase the number of cashier windows open to accommodate the customer demand. The pilot reduced customer wait-times by 50% from approximately 30 minutes to 15 minutes. To help maintain this reduction in customer wait-time, the program revised the standard operating procedures for cashiers, hired temporary staff to support other program responsibilities, and revised the program sick/vacation time policy to maintain appropriate staffing levels in all areas. The vital statistics program has assumed responsibility for the P-D-C-A cycle and continues to identify areas and opportunities to improve program effectiveness in servicing the residents of the City of Houston.

Organization that conducted the QI initiative:

Houston Department of Health and Human Services

Citation:

Arafat, D. Public Health Quality Improvement Exchange. Implementing Quality Improvement Tools to Address Four Challenges in Houston. Thu, 12/27/2012 - 16:08. Available at http://www.phqix.org/content/implementing-quality-improvement-tools-address-four-challenges-houston. Accessed April 19, 2024.

Background and Aim

Aim statement:

An opportunity exists to improve the Vital Statistics Customer Flow beginning with customer receipt of ticket number from information window and ending with being called by a cashier to complete financial transaction. This effort should reduce wait time by 15 minutes for the customer. This process is important to work on now because wait times are experienced between the info desk and cashier and to provide good, efficient customer service. The baseline measurement is defined as the following metric: average wait time per cashier window of 28 minutes by cashier by day.

Need For The QI Initiative:

HDHHS trained its employees in QI tools and techniques and built its internal capacity to teach QI by hosting the QI Star TraK TTT series for 25 employees. The Performance Improvement and Accreditation Team (PIAT) identified employees from six divisions and various levels of the organization to participate in the interactive training, which occurred over several weeks. Participants learned core QI tools and techniques before spliting into QI project teams. The project team assignments were randomized so that employees worked with new people on a project not directly related to their daily roles. The four groups were assigned a topic based on issues that participants knew existed within the health department; they were asked to come to the training with potential opportunities for improvement. During discussion, HDHHS participants picked four topics on which to begin QI projects, one of which was "Decreasing the Vital Statistics Customer Wait Time."

Area for Improvement:

Vital Statistics is often the only interaction area residents have with HDHHS. Vital Statistics provides residents an opportunity to receive birth and death certificates and to apply for U.S. passports on site. To receive a birth or death certificate, customers were waiting nearly one-half hour from when they received a ticket number to be called to a cashier to when they actually were called by a cashier to complete the transaction. Anecdotally, project staff learned that customers used to wait less than 10 minutes to receive a birth or death certificate. Long waits to receive a service have widespread affects, including requiring residents to miss time from work to obtain a certificate.

Root Cause:

The cause of the lengthy wait time was that not enough cashiers were available to complete financial transactions. The team recommended opening and staffing another window and adding more staff during the lunch-hour rush.

Planning and Execution Details

QI Implementation:

The Vital Statistics QI project was selected by the QI team because it represented a real opportunity to improve the experience of our customers. Using the SIPOC+CM diagram, a flow chart, and a cause-and-effect diagram, HDHHS isolated the time from receiving a ticket number to being called to the cashier window to complete the financial transaction as the area of improvement. Specifically, the QI team saw staffing levels, adjustments during peak hours, and distribution of responsibilities and tasks as the main causes of long wait times. The QI team consulted vital statistic supervisors throughout our planning process during weekly meetings. The first task the group chose to take on was to conduct a summary analysis cashier transaction data. Variables included number of customers served per week and per day, and average customer wait time, transaction time, and print time. QI team members observed cashiers during several time points during the work week. Based on the transaction data and observation, the QI team selected to implement a pilot test, moving one staff person from another section in the program to serve as a cashier to keep four cashier windows open at all times during one week in June 2012. During the week of additional staffing at the cashier windows, the average customer wait time dropped to 14 minutes. In addition to the transaction data, HDHHS surveyed the cashiers to get additional feedback on their experience. One cashier stated, “We were able to assist customers faster. Continue to [keep] more windows open.” Another cashier noted, “[I] enjoyed all windows being open. [It] made everything flow smoothly and faster.”

Focus activities

Data collection, Epidemiology and Surveillance:

Vital statistics

QI Methods:

PDCA/PDSA Cycle (Plan, Do, Check/Study, Act)

QI Tools:

Cause and Effect Diagrams

Other QI tools:

SIPOC+CM

Kano Model

QI Tool Documentation:

HDHHS Vital Statistics Presentation Vital Stats Staff 9 11 12.ppt

Initiative Dates:

5/14/12 to 9/17/12

Initiative Duration:

Less than 6 months

Methods of evaluation:

The impact of the Vital Statistics pilot test was measured using transaction data captured using the “Queue-Matic” system. This electronic system timed the wait time of each customer in three segments: (1) wait time (from ticket to cashier window call); (2) transaction time (locating the certificate in online databases, completing financial transaction, and sending the certificate to the printer); and (3) print time (time to receive actual printed certificate). “Queue-Matic” allowed cashiers and supervisors to actively monitor the customer wait times and make staffing adjustments. HDHHS also measured the impact through surveying the cashiers and informal discussions with supervisors.

Other Information:

It is extremely important to involve all stakeholders (program leadership and staff) when implementing the P-D-C-A cycle or any other QI method or tool. Stakeholders often have additional ideas and insight on how a program can function more efficiently and effectively to meet the needs of customers.

Supplemental Materials:

Quote from partner/participant

Publication (e.g., news story, journal article)

PowerPoint presentation shared with vital statistic program staff on 9/17/2012.

Supplemental Files:

Attachment	Size
National Public Health Improvement Initiative-Houston.pdf	356.1 KB
HDHHS Vital Statistics Presentation Vital Stats Staff 9 11 12.ppt	2.19 MB

Results

Measurable QI Outcomes:

Customer wait time decreased by 50%.

Other QI Outcomes:

The Vital Statistics standard operating procedures (SOPs) for cashiers was updated to include maintaining staffing levels during peak hours and seasons. Temporary staff was hired to help in other areas of vital statistics and to maintain production levels of other tasks and responsibilities. Performance expectations were communicated to staff, which led to improved program functionality. A new vacation/sick time policy was implemented. Staff must request vacation at least 2 weeks prior to allow supervisors to adjust staffing levels in advance.

Lessons Learned, Observations and Insights:

QI Star TRaK (Training, Resources, and Knowledge) Series o Having a hard deadline helped the QI teams move quickly through the process. o A QI culture shift begins with a few people (25, in Houston’s case). o Share the QI success stories broadly so that all employees can understand the value, importance, and benefit. Vital Statistics QI Program o You must be aware of the effect of QI projects on other programs. o Its important to be open to change and to receiving constructive criticism. o Listening to others and accepting suggestions can help with improvement initiatives. o Improvements to not equate to failure. It is an opportunity to make processes and programs better.

Future Plans:

The pilot test results were very promising, but they occurred when all employees in the vital statistics office were present. When multiple employees called in sick, the customer wait time rose again. A workload analysis was conducted and is being analyzed so as to streamline employee responsibilities. Upon completion of the analysis and implementation of revised tasks and responsibilities, the program will create a storyboard to post in the Vital Statistics customer lobby to share with customers (residents) the QI efforts of the program. The QI team is currently serving as a resource to the Vital Statistics program, which has assumed responsibility for monitoring the P-D-C-A cycle. The QI team has recommended the Vital Statistics program survey employees to better understand their experience with the QI initiative and survey customers to gauge their experience in Vital Statistics, including wait time. The QI team will present the QI project and results to the Vital Statistics staff in September 2012. PIAT is scheduled to present all QI projects from the QI Star TRaK series to HDHHS leadership in November 2012.

Implementing Quality Improvement Tools to Address Four Challenges in Houston

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

QI Spotlight

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Implementing Quality Improvement Tools to Address Four Challenges in Houston

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

QI Spotlight