Minnesota Death Data Delivery (QI Forum: Cross-Jurisdictional Project)

Summary

Impact Statement:

For health department services that have a major impact on citizens, ensuring high client satisfaction is important to the public’s understanding and support for these services. Three state health departments teamed together to improve the timeliness of death data, using the Kaizen method for improvement. The initial problem was an unnecessary delay in releasing death data that affected multiple beneficiaries negatively. The QI project team worked to decrease elapsed time from fact of death registration to issuance of a death certificate to families, to improve availability of certificates within 10 days, and to decrease elapsed time from the MN Office of Vital Records receiving ICD-10 coded records to sharing real-time death data. The QI team improved data availability from 18 months to 1 week and improved auto-coded ICD-10 codes to 85% (9/15) from the 2015 average of 72%.

Summary:

The Robert Wood Johnson Foundation sponsored four QI projects to increase the effectiveness and efficiency of federal agency public health programs delivered at the state and local levels. The projects focused on achieving measurable improvement results to benefit affected stakeholders at all program levels, while increasing the knowledge and enthusiasm for continual QI. The four focus areas are as follows:

Data utilization: Decrease time to transfer applicable, accurate death record data from state to local health departments.
Data utilization replication: Decrease time for complete death record data and to transfer applicable, accurate death record data from state to local health departments.
Grant application: Improve the efficiency and effectiveness of the grant writing process.
QI spread: Accelerate progress toward a culture of quality in public health target areas.

The Minnesota Death Data Delivery project was a slight replication of the North Carolina Death Data Utilization project. The Minnesota team used the Kaizen event approach to complete all steps of the improvement cycle in 5 days. The steps were as follows:

Understand the gap/goal and the current state in order to identify waste in the targeted work process.
Analyze the root causes of the prioritized issues to identify solutions.
Develop and test solutions to learn.
Develop and test solutions to learn.
Install improvements and create a system for ongoing improvement.

As the event progressed, many QI and change management methods and techniques were applied.

Additional benefits included the following:

Quality improvements of in-process data and reductions in labor (e.g., system-generated e-mails)
Incorporated cremation authorization in the new process
Increased efficiency and use of the electronic vital records system (Minnesota Registration & Certification [MR&C]) (improved system navigation and decreased paper processing)

Organization that conducted the QI initiative:

MDH

Citation:

Crawford, M. Public Health Quality Improvement Exchange. Minnesota Death Data Delivery (QI Forum: Cross-Jurisdictional Project). Mon, 02/29/2016 - 14:40. Available at http://www.phqix.org/content/minnesota-death-data-delivery-qi-forum-cross-jurisdictional-project. Accessed October 10, 2024.

Background and Aim

Aim statement:

TO: Reduce the time for a death record to have complete death data (fact and cause of death) and to be available to families for issuance of a certificate. a. Reduce the time for real-time literal cause of death data to be available to data consumers. b. Reduce the time for real-time coded cause of death data to be available to data consumers. TO: Create a systematic, automated process to regularly and routinely share real-time coded cause of death data. FOR: Families of decedents; federal, state, and local health departments; epidemiology departments; program areas; vital records and vital statistics teams; the National Center for Health Statistics (NCHS); and users of the MR&C system. SO THAT • Families of decedents can conduct estate activities and have closure sooner. • MR&C system users can complete their activities related to filing accurate and complete death records sooner. • Federal, state, and local health departments have data for surveillance, program planning and evaluation, making informed decisions, guiding programs, and ultimately improving health outcomes. • Vital records and vital statistics tasks are more efficient and require less labor. • Federal, state, and local employee relationships are improved. • Health departments benefit by meeting Public Health Accreditation Board (PHAB) standards and accreditation. • The MDH Office of Vital Records achieves its vision of informing public health and improving lives, one record at a time. • MDH achieves its mission of improving all Minnesotans' health. CONDITIONS • Ensure customer participation from the Kaizen state. • Comply with data collection regulations and statutory requirements, data practices, and the Health Insurance Portability and Accountability Act. • Comply with state law and do not attempt to standardize legal requirements from state to state, so no one goes to jail. • Establish synchronicity with other improvement activities (e.g., informatics, data governance). • Ensure that there are no statutory changes. • Negotiate and approve system change as a priority among other IT project and maintenance needs. • Ensure that MDH Office of Vital Records staff have the training, tools, authority, and support to take action and implement change. • Ensure that the project aligns with the MDH and Office of Vital Records mission, vision, and values.

Need For The QI Initiative:

Data are an important part of helping federal, state, and local health departments achieve better health outcomes for their constituencies. Gaps exist in the timeliness, accuracy, and usability of vital record death data, which hampers effectiveness in its use. Evidence indicates that real-time, preliminary, and provisional death data are indicative of final data (currently averaging 18 months from death to available data). Unnecessary delay in releasing death data affects multiple beneficiaries negatively. Consumers of death data place value on availability. The demand for real-time death data is growing. Internal and external customer demand is increasing because of the climbing number of customers and their demand for data sooner. Because local public health agencies may be compromised in their ability to perform surveillance activities by the length of time it takes to receive death data, they have requested death data sooner than what has regularly been available to them. Local public health agencies from multiple jurisdictions want death data in real time to intervene and take preventive actions sooner so that Minnesotans' health is better protected, maintained, and improved. Representatives from local public health associations have voiced their frustration with leaders. Families are sometimes forced to wait for long periods before a death record is finalized with the fact and cause of death. The availability of a complete death record affects access to death certificates that satisfy estate settlement needs and provide emotional closure. Within MDH, multiple programs rely on accurate and timely reporting of death events. Some programs require data to be shared in real time so that the program can carry out its duties and obligations. The MDH Office of Vital Records authorizes data users and multiple agreements and must adjust resources to meet the increasing demand for death data. Historically, MDH released only final data in annual vital statistics reports and summaries.

Area for Improvement:

Project Scope • Start: The fact of death for an individual who died in Minnesota is filed in the MR&C system, a death record is created, and the record is assigned a state file number. • End: When ICD-10-coded records that contain statewide death data are available in real time.

Root Cause:

Issues/Wastes: Root Causes 1. Wrong physician or medical certifier • Roles, responsibilities, and expectations are unclear for process partners, particularly funeral homes • Knowledge and guidance for selection are incomplete or inconsistently used • The process and system allow the wrong information. 2. Wait time for the complete record set from NCHS and wait time for upload until annual data are collected • Perceived historical lack of need for real-time data • Reconciliation of a statistical data set • Perception that more work is required • Traceability concern 3. Physician access • There is no mandate to use the system • There is no law about filing the cause of death within a certain time frame • It is seen as more work, and its importance is not understood • Infrequent use makes effective use difficult • The need for disposition authorization (cremation) creates urgency over record filing, and system workarounds (paper) are used. 4. Follow-up system • Expectations and accountability for performance are unclear in process partners • The process and system do not encourage defect-free behavior • Roles and responsibilities for follow-up within the office are ill defined and unclear

Planning and Execution Details

QI Implementation:

Issue > Improvement > Expected Results 1. Work processes are inconsistent. IF… the QI team improves the processes of obtaining cause of death and ICD-10 codes (by having medical certifiers start the process, entering the cause of death earlier in the process, and having the funeral home more involved in providing accurate and timely data) AND installs this process effectively AND communicates to users that data are available, THEN first-time quality of information will be improved (because of an incorrect medical certifier or late or incorrect cause of death) AND wait time will be reduced. 2. Usable data are not easily available. IF… the QI team processes the ICD-10-coded data that are auto corrected from NCHS immediately (“80%” TRP file) AND creates a process for uploading data (once per week) AND creates a place for users to access the data AND communicates to users that data are available, THEN the wait time for data will be reduced from annual to weekly AND local use of data will increase as users understand that real-time data are available. 3. Expectations and roles are not clear. IF… the QI team establishes clear expectations for roles, tasks, and time frames for completion, and clearly communicates expectations AND provides help where appropriate (e.g., how to identify an appropriate individual for providing the cause of death), THEN the time to provide complete, accurate cause of death and other death data will decrease. 4. The system’s usability deters some medical certifiers. IF… the QI team makes the MR&C system more user friendly (e.g., improved triggers, focused data entry, screen access, work queue improvements), THEN users will require less time to complete tasks and be more likely to use the system rather than workarounds. 5. A manual process is used to move stalled records along. IF... the QI team establishes clear instructions AND content in e-mails and other messages uses plain language, THEN users will understand what is being asked and required, and why and when they need to act. Testing During the Kaizen Event • Project rollout: Staged implementation to continue momentum from Kaizen while allowing time for IT changes and higher-effort deliverables to be accomplished. • Launch: Now through June 12 (get the SharePoint site up and upload the first file, communication plan, training plan, stakeholder analysis, measurements, and project tracking information; present information about the project at the National Association for Public Health Statistics and Information Systems [NAPHSIS] conference innovation session on May 31) • Phase 1: June 15 through July 3 (communications) • Phase 2: July 6 through July 31 (new MR&C system features and functionality, e-mails, more MR&C system features and functionality, more e-mails) • Phase 3: August 3 through September 2 (physician password reset, performance management, stakeholder input, training, outreach, more MR&C system features and functionality) • Phase 4: September 6 through November 1 (performance management, stakeholder input, training, communication, outreach, more features and functionality) • Continuous improvement: ongoing

Focus activities

Data collection, Epidemiology and Surveillance:

Vital statistics

Other Public Health Services:

Medical examiner’s office

Vital records

Administration:

Data collection and management/Information Technology

QI Methods:

Business Process Analysis

Kaizen

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

Rapid Cycle Improvement

QI Tools:

Affinity Diagram

Brainstorming

Cause and Effect Diagrams

Interrelationship digraph

Prioritization Matrix

Process maps

Root cause analysis

Other QI tools:

Working with others, goal statement, measure definition sheet, stakeholder analysis, communication strategy, daily newspaper, PrISM, value/waste analysis, single-topic guideline, ROAMMM, action item worksheet, lessons learned

QI Tool Documentation:

Sub-process maps

All project documentation throughout the improvement cycle

Initiative Dates:

3/14/15 to 6/14/15

Initiative Duration:

Less than 6 months

Methods of evaluation:

See the attached PrISM document. MEASURES • Decrease the percentage of records that require rework to obtain ICD-10 codes. • Increase the percentage of records that NCHS auto codes with ICD-10 codes on the first pass. • Reduce the time it takes to share ICD-10-coded death data. • Share death data within 1 week of death data coding being complete. • Reduce the time it takes from fact of death registration to availability of issuing a complete death certificate. • Increase the percentage of records that take fewer than 10 days from fact of death registration to cause of death registration. • Increase by 10% the number of Minnesota death records filed and available for issuance with cause of death within 10 days of registering the fact of death.

Other Information:

The project was presented at the following venues: NAPHSIS Conference in June 2015, MDH Performance Management Workgroup in July 2015, NAPHSIS/NCHS Vital Statistics Cooperative Program monthly telemeeting (webinar) in September 2015, MDH Health Policy Division in September 2015, and Community of Practice for Public Health Improvement Open Forum in October 2015. The project was nominated for the Minnesota Governor's Continuous Improvement Award in October 2015. The project was used as the QI example for the MDH PHAB annual accreditation report.

Supplemental Materials:

Report

Storyboard

Supplemental Files:

Attachment	Size
MN State Death Data Delivery Process Kaizen Storyboard - May 2015.pdf	819.58 KB
MN PRISM DOCUMENT 2015_10_14.pdf	1.78 MB
MN Death Data Delivery_Kaizen Event Report Out R1.pdf	7.14 MB
August 2015 Vital Records News.pdf	256.74 KB
MN Governor's Continuous Improvement Nomination 2015.docx	83.46 KB

Results

Training and Preparation

Information about the Health Department

QI Staff Information

Total number of Staff on QI Team:

21

Total number of FTEs on QI Team:

0.40

QI team members:

Role in the Initiative:

Project leader

Role in Organization:

State Registrar

Name (Optional):

Molly Crawford

Role in the Initiative:

Subject matter expert

Role in Organization:

Arkansas Vital Statistics/Vital Records

Name (Optional):

Melinda Allen

Role in the Initiative:

Subject matter expert

Role in Organization:

Mississippi Vital Statistics/Vital Records

Name (Optional):

Lynn Pittman

Role in the Initiative:

Advisor; information source

Role in Organization:

NAPHSIS

Name (Optional):

Andrea Price

Role in the Initiative:

Subject matter expert

Role in Organization:

Medical Examiner's Office

Name (Optional):

Roberta Geiselhart

Role in the Initiative:

Consumer of death data; customer

Role in Organization:

Local Health Department Representative

Name (Optional):

Rick Carlson

Role in the Initiative:

Process owner

Role in Organization:

Deputy Registrar

Name (Optional):

Heidi Granlund

Role in the Initiative:

Subject matter expert; IT/system knowledge

Role in Organization:

Team Member: Field Services/User Support

Name (Optional):

Cindy Coleman

Role in the Initiative:

Data quality expert; process owner

Role in Organization:

Team Member: Data Quality and Records Management

Name (Optional):

Gloria Haluptzok

Role in the Initiative:

Process owner; data sharing subject matter expert

Role in Organization:

Team Member: Data Quality and Records Management

Name (Optional):

Nancy Bollman

Role in the Initiative:

Subject matter expert; communication, training, and education

Role in Organization:

Team Member: Field Services Representative

Name (Optional):

Kirsti Taipale

Role in the Initiative:

Observer; staff member in training

Role in Organization:

Team Member: Field Services Representative

Name (Optional):

Usha Valappil

Role in the Initiative:

Registration expert; process owner

Role in Organization:

Team Member: Registration and Amendments

Name (Optional):

Roxanne Somers

Role in the Initiative:

Registration expert; former funeral establishment staff (customer)

Role in Organization:

Team Member: Registration and Amendments

Name (Optional):

Maria Schaff

Role in the Initiative:

Subject matter expert; IT system, MR&C system application

Role in Organization:

Team Member: Minnesota IT

Name (Optional):

Otto Hiller

Role in the Initiative:

System development

Role in Organization:

Team Member: Minnesota IT

Name (Optional):

Larry Winship

Role in the Initiative:

Process owner/team member; data quality and records management

Role in Organization:

Data Quality; Nosologist

Name (Optional):

Cheri Denardo

Role in the Initiative:

Team member; national/NCHS

Name (Optional):

Matt Rowe

Role in the Initiative:

On-call team member; MDH Center for Health Statistics

Role in Organization:

Center for Health Equity, MDH Center for Health Statistics

Name (Optional):

Carol Hajicek

Role in the Initiative:

On-call advisor and resource team member; Minneapolis Health Department

Name (Optional):

Mageen Caines

Role in the Initiative:

Fiscal agent, advisor, project manager, Association of State and Territorial Health Officials representative

Minnesota Death Data Delivery (QI Forum: Cross-Jurisdictional Project)

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Health Department

QI Staff Information

Accreditation Details

Collaborations

Contact Information of the Submitter

QI Spotlight

quality improvement together.

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Minnesota Death Data Delivery (QI Forum: Cross-Jurisdictional Project)

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Health Department

QI Staff Information

Accreditation Details

Collaborations

Contact Information of the Submitter

QI Spotlight