NNPHI Kaizen Program: Johnson County Department of Health and Environment—Supply Ordering Process

Summary

Impact Statement:

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.

Summary:

The Johnson County Department of Health and Environment (JCDHE) supply ordering Kaizen project focused on improving order accuracy and decreasing process cycle time. The Kaizen team included seven representatives of front-line staff and program managers to reflect the individuals who actually do the work. The team first determined the present state of the supply order process. Documenting the present state in a process-mapping format took it step by step, which allowed the team to visualize gaps and waste in the process. Next, the team prioritized the current state issues, came up with solutions, prioritized the solutions using 2x2 ranking matrices, and created a future state plan for supply ordering. The Kaizen team was empowered to make decisions for the department in the future process of supply ordering. Testing the future state of supply ordering showed that JCDHE had 69% potential improvement in the cycle time, or a decrease from 365 hours per year to 113 hours per year. Other positive results included labor time savings, including clarification time; a decrease in the number of orders from as needed to monthly; improved receiving (due to increased accuracy); improved morale and Leadership Empowers All People (LEAP) principled environment; improved inventory management; and item standardization.

Organization that conducted the QI initiative:

JCDHE

Citation:

Whiteman, D. Public Health Quality Improvement Exchange. NNPHI Kaizen Program: Johnson County Department of Health and Environment—Supply Ordering Process. Tue, 09/26/2017 - 11:20. Available at https://www.phqix.org/content/nnphi-kaizen-program-johnson-county-department-health-and-environment%E2%80%94supply-ordering. Accessed March 26, 2023.

Background and Aim

Aim statement:

The desired outcome of this quality improvement (QI) project is to identify a streamlined process for ordering supplies that will decrease the process cycle time, which will allow staff to focus on other responsibilities. A streamlined process will provide consistency across the department with clear communication to staff surrounding what is needed, when it is needed, appropriate vendors, and available budget. Once the newly developed process is in place, JCDHE staff will experience a 60% decrease in cycle time for individual orders, from identification of need to item received and purchasing card reconciliation. By conducting a 5-day Kaizen event during the week of February 3–7, 2014, order accuracy will be greater than 90% as compared with pre-project measurements.

Need For The QI Initiative:

Data considered in identifying the importance of this QI project include the frequency at which individual orders require clarity before completing the process. Clarity is defined as clear, concise, specific communication as interpreted by the accounting staff. There are many methods of placing an order, with different information fields to complete. Examples of order methods include four separate program-specific Microsoft Excel spreadsheets, electronic fillable PDF forms, general e-mail requests for items, a half-page triplicate supply ordering form that was last revised in 1991, verbal order requests by individuals who present in person, orders that present with purchasing card transactions, and a single-sheet miscellaneous receipt form. The extensive time spent on managing the organizations’ orders was another factor included in the importance of studying this administrative process. Some orders require researching an exact item, locating the best price, finding a vendor, and determining delivery times. Orders may require approval from a supervisor, which may or may not be included with the order when it is placed. Finally, the accounting staff ensure that there is a specified funding source and that the source has adequate funds to cover the cost. It was determined that the accounting staff spend anywhere from 48 to 63 hours per month processing orders.

Area for Improvement:

In 3–5 years, JCDHE would like to have an efficient, streamlined process for placing orders that has minimal room for error. Staff (internal customers) submit orders in various ways as evidenced by the assessment of current processes. Financial consequences are evident through time studies that showed an excess use of staff time to process orders, with duplicate efforts by multiple staff members. The staff members voice frustration with the current system because of the inefficient use of time, the number of different forms to process, and inconsistency in the system across divisions.

Root Cause:

Priorities 1 and 2—Issues/Wastes: It is unclear who provides the item specifics. Root Causes Why 1: Program staff are unsure where to look. Why 2: Program staff are unsure where an item was purchased in the past. Why 3: Program staff did not order the item previously. Why 4: Program staff are not privy to where the item was purchased. Why 5: There is no location to find information. Why 5: There is no protocol. Why 5: Different answers are given. Solutions • Reverse the ordering process so that the orderer places the order and accounting pays. • Organize the standard vendor list by category (item, vendor, expected price). • Create a list of items that cannot be ordered. • Distribute purchasing cards to heavy users. • Shred the nonpreferred vendor catalog. • Provide budget visibility to orderers (use the budget meeting to approve). Priority 2—Issues/Wastes: The accounting department assigned the wrong address. Root Causes Why 1: The drop-down box was changed. Why 2: All items need to be delivered to the health services building. Why 3: It has always been done that way. Why 4: Control. Why 4: Accounting procedures are not documented. Why 2: The location was marked incorrectly on the supply and equipment order form. Why 4: It has always been done that way. Why 2: Human error. Why 3: Not completely marked. Solutions • Order by site, not by program. • Update the order form to include the location. • Create one standard order form. • The location cannot be the Department of Health and Environment (DHE); it must be the DHE location. Priority 2—Issues/Wastes: Not everyone knows the budget codes. Root Causes Why 1: Historical authorization. Solutions • Create an order form (one per location) that is a standard list that staff add to throughout the month (on SharePoint), and place the order only once. • Provide all orderers with the list of budget codes. Priority 2—Issues/Wastes: Duplicate keying on websites. Root Causes Why 1: Clarify which item is wanted. Why 1: Go online to get the price. Why 1: Research the specific item. Why 1: The order form asks for this information. Solutions • The vendor website has a portal for the orderer to submit an order, then accounting can go in and pay. Improvement Hypothesis • Issue: Consistent work process—if JCDHE staff redesign the process to eliminate wastes and redundancies, provide job aids to help identify needed and correct information, and create decision-making guidelines... • Expected results: ...then defects and clarification time will be reduced, and overall labor time required (employee time) to complete the process will be reduced. • Issue: Duplicate keying—if JCDHE staff provide the program orderer with all the knowledge and authorization he or she needs (purchasing cards, standard forms, standard items list)... • Expected results: ...then the order can be placed on first touch. • Issue: Accuracy—if JCDHE staff consolidate to one order form that provides all the order elements... • Expected results: ...then staff will gain consistency and accuracy.

Planning and Execution Details

QI Implementation:

The QI approach to enhancing the supply ordering process was Kaizen, which is defined as a group of methods for making work process improvements and a planned team event conducted in the workplace that systemically uncovers waste in a work process and eliminates it rapidly. The Kaizen event took place during 1 week, February 3–7, 2014. Before the event week, an invitation was sent to the entire department to participate in a brainstorming session to provide input and identify a business practice that could be assessed for process improvement. From that session, the practice of supply ordering was chosen as the focus. Preparation for the event then took place by gathering a group of seven end users and program managers as SMEs to form the Kaizen team. This team met to identify the goal of the event and the measures by which improvement would be gauged. The future process was tested and compared with the goal and measures to determine success for process improvement. A process owner was designated to take the reins of the project for sustainability after the week-long event. Reports were provided to stakeholders and leaders of the organization throughout the week, with a final presentation given at the week's end. The process owner and QI coordinator reviewed the action item list that the team created to ensure that any open tasks were completed. This QI initiative primarily affects the accounting staff, the ordering staff, and the program managers by affecting the process time for placing orders. All of the departmental staff and clients will also benefit in that supplies will be accurate and available in a timely manner.

Focus activities

Administration:

Policies / internal procedures and processes

Purchasing

QI Methods:

Kaizen

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

QI Tools:

Brainstorming

Five whys

Flow chart

Prioritization Matrix

Process maps

Root cause analysis

Other QI tools:

Working with others, goal statement, measure definition sheet, communication strategy, daily newspaper, PrISM, gathering practical knowledge, value/waste analysis, action item worksheet, lessons learned (SRLD), continual improvement system (CIS)

QI Tool Documentation:

PrISM–project team problem-solving tool

CIS

Current and future process maps

2x2 prioritization matrix–issues and solutions

Measure Definition.docx

Initiative Dates:

11/12/13 to 3/31/14

Initiative Duration:

Less than 6 months

Methods of evaluation:

The process cycling time will be measured by tracking the time (through direct observation) that any staff member identifies a needed supply, notification to the designated orderer, batching of order requests by the orderer, placement of those orders to various vendors, electronically filing the order documentation, the receipt process of the needed supply including the verbal/electronic communication with accounting staff, and the reconciliation of the purchasing card by accounting staff. The target is to reduce the process time by 60% (from 73 minutes to 29 minutes per order) by the end of March 2014, when the implementation of the improved process was initiated. The order accuracy will be measured by tracking the number of errors between what the original requester desired and what was received. This measure is captured electronically on the purchasing card transaction form and is expected to be more than 90% accurate by the end of March 2014 for success to be accomplished. Initially, an audit of these measures will take place monthly until June 2014, when the measures will be reviewed quarterly to determine the effectiveness of this process improvement activity.

Results

Measurable QI Outcomes:

Pre-event total process time = 93 minutes Post-event total process time = 19 minutes, 47 seconds April audit total process time = 16 minutes, 37 seconds Pre-event accurate items received = not measured April accurate items received = 100%

Other QI Outcomes:

The Johnson County government has recently adopted the philosophy of becoming a high-performing organization through the LEAP program. This QI event reinforced the principles of this program by empowering staff at all levels to make autonomous decisions surrounding their daily work while challenging directors to allow end users to create an improved process that did not include obtaining their prior approval. The event reinforced the need for trust and confidence in each other. Non–Kaizen team members commented that this event had a positive impact on organizational morale as evidenced by the laughter and smiles of the team and the excitement to tell anyone who asked about the project. Staff members directly affected by the process improvement made statements about improved efficiency and obvious commitment to the project by those involved; front-line staff are empowered to make decisions and to work autonomously, are motivated, and have a vested interest. This process affects everyone, encourages accountability, created a diverse work group, allowed a vision for the bigger picture, generates positive energy, promotes team building, and supports open and honest communication.

Lessons Learned, Observations and Insights:

An end-to-end process test was performed with the use of a Kanban card system, purchase request electronic entry, and a purchase card transaction form by two of the Kaizen team members during the second-to-last day of the Kaizen event week. Success was reached as the team members understood where to look on SharePoint to complete the purchase request entry, how to place the order with the vendor, and how to upload an electronic copy of the invoice to the appropriate location in SharePoint. This process was timed, with a total process time of 19 minutes and 47 seconds with lots of coaching and Q&A. When testing the purchase request, staff learned that order items on the purchase request and some mandatory fields were not accurate. Actions taken were to change the fields to be more user friendly, such as drop-down lists for quantity descriptions. Staff also learned that the process needed to be more specific with ordering, such as e-mails being routed to the designated orderer. A status field was added for the orderer to mark to show completion. Testing of the purchasing process included communication on what a cost center is, what a task number is, and where to find the information, as well as how to print to create a PDF and upload it to SharePoint. The information on cost centers and task numbers is available on SharePoint as a living document to be updated as needed. A description for the task number is added to include grant- or project-only verbiage. Staff identified that more training on cost centers and task numbers is needed with specific process guidelines of how it is to be used to meet tax and financial management procedures. During the event, staff learned that having a printer in the room enabled printer access locally for development of templates and job aids. The participants learned that having access to the network allowed full access to files and Web-based programs for clarification of the current process in addition to having full access to documents. The event was held in a meeting room that was in the same building but not readily close to the regular work areas and daily business activities. The group learned that this distance helped with the concept that the team was not available for consultation and decreased interruptions. Directions will be to have network access available at the next event. The event schedule for the week included 15 minutes of review for the executive team at the end of each day. The group learned that this review time created a transparent atmosphere and allowed for questions or concerns to be addressed. In the future, the group thought that an invitation to the other stakeholders and having daily reports of what was accomplished would be beneficial.

Future Plans:

Steps to operationalize the new process include providing an overview to the executive team on February 12 and to the leadership team on February 19 and providing an overview to the orderers and the management team on using the purchasing card on February 21, with online training made available to new cardholders to be completed by February 28. Training on use of the accounting software system, SharePoint, and various vendor sites was held during the week of March 14. An overview of the entire process was presented to the department at an all-staff meeting on March 28, with a go-live date on March 31. A CIS is in place in the form of a poster of the future process map, which shows all process steps, the measures, the list of team members and areas to post via repositionable or taped notes of ideas, issues, identified wasted actions, or suggestions for improvement to the new process. This poster is in the accounting area for all orderers and Kaizen team members to make additions or comments on. The CIS is used in monthly team meetings to work through the notes that have been added and to make amendments to the process. The process owner will perform audits initially every month (April, May, and June) to identify sustainability of the process, then audits will take place once per quarter to ensure continued improvement. There are plans to challenge the clinic order process through the Kaizen method in fall 2014.

Training and Preparation

Information about the Community

Population Size:

500,000 to 999,999

Population Characteristics:

According to the 2010 U.S. Census, there are 544,179 people and 201,911 households within Johnson County. Johnson County is the most populous county in Kansas, with 19% of Kansans living there. Over the past decade, the population increased by 20.6%, growing at a rate nearly 3.5 times faster than the rest of Kansas and more than 2 times as fast as the United States (U.S. Census Bureau, 2011). Johnson County’s age distribution is stable and resembles that of the broader United States. There are more individuals of working age (20–64) compared with school-age and retired individuals. Many residents live well into old age (U.S. Census Bureau, 2011). There has been a slight population shift over the past decade. This shift is evidenced by the change in census tracts (small geographic areas selected for conducting census surveying that are designed to include roughly the same number of people in each block). Small census blocks indicate a high population density. Larger blocks indicate low population density. Comparing the 2000 and 2010 maps, the census blocks in the northeastern region remained roughly the same. However, in the south and southwestern regions, there was breaking of census tracts and an increased number of people within tracts that did not break. Both are indications of population growth (U.S. Census Bureau, 2000; 2010). Of Johnson County residents, 86% are white, making the county less diverse than the United States. Hispanics are the largest minority group (7.2%), followed by African Americans (4.3%) and Asians (4.2%). Johnson County became more diverse over the past decade. Nonwhite residents increased from approximately 6% of the population in 2000 to nearly 10% in 2009. The proportion of Hispanic, African American, Asian and Pacific Islander, and Native American populations have all increased in the past decade. The proportion of nonwhite individuals increased, on average, 0.35% each year from 2000 to 2009 (Kansas Department of Health and Environment–Bureau of Epidemiology and Public Health Informatics [KDHE-BEPHI], 2009). Also, from 2005 to 2009, 7.5% of Johnson County residents were foreign born (U.S. Census Bureau, 2011). In Johnson County, for 2008–2010, a greater proportion of people graduate high school and college compared with both Kansas and the United States. This is important because educational attainment is associated with poverty, and poverty is associated with almost all measures of poor health. Of young adults, 14% have less than a high school diploma, but this figure drops to 4.5% for individuals older than 25. Educational attainment is not even among races and ethnic groups. During 2008–2010, 28% of Hispanics did not graduate high school. This is 24% greater than Johnson County as a whole and 13% greater than the United States. More whites and Asians graduated from college compared with others; however, a greater proportion of all groups in Johnson County graduated from college compared with the entire United States, except for Hispanics, whose college graduation rate is similar to that of the United States. The median household income in Johnson County is $73,365. This is $8,500 and $3,250 greater than that of households in Kansas and the United States, respectively. However, income disparities are wide. Asians (+$9,000) and Caucasians (+$1,800) earn more than the Johnson County average, whereas individuals of two or more races (-$21,500), Hispanics (-$23,000), and African Americans (-$25,000) earn less. Unemployment follows trends similar to those seen among income. All groups in Johnson County fare better than their counterparts in Kansas and the United States, but Hispanics, African Americans, and individuals of two or more races experience more unemployment compared with Johnson County as a whole. Education is greatly associated with unemployment. The unemployment rate for individuals with a bachelor’s degree or more is half that of persons with less than a bachelor’s degree. Roughly 8% (43,120) of individuals in Johnson County are disabled. This proportion is less than both Kansas and the United States. The majority of disabled people are 65 years old or older. Among this group, 20% have ambulatory difficulties or issues walking or moving about, and 14% have difficulty hearing. Many languages are spoken in Johnson County. English is by far the dominant language, and at least 95% of Johnson County residents speak English as a first or second language. Of the population, 5% speak Spanish, but of this group, 50% speak English well. In fact, most people who speak a language other than English as their primary language also speak English well. The leading causes of death in Johnson County are cancer, heart disease, stroke, chronic lower respiratory diseases, and diabetes. Cancer and heart disease alone make up 45% of all deaths and strokes; atherosclerosis and chronic obstructive pulmonary disease account for another 18%. Each of these diseases is largely influenced by behaviors such as smoking, drinking alcohol, eating a high-calorie or high-fat diet, and not getting enough exercise. Suicide and car crashes round out the list. The age-adjusted mortality rate in Johnson County has been fairly stable over the past decade. Men have slightly higher death rates than women. Hispanics fare better compared with Caucasians. African Americans experience significant disparities in mortality; however, there appears to have been a large decrease in this population’s mortality rate in recent years. There are sizable health disparities across racial and ethnic boundaries in Johnson County. The age-adjusted death rate for African Americans is 50% greater for cancer, 30% greater for heart disease, 70% greater for stroke, and more than double compared with Johnson County as a whole. On the other hand, the age-adjusted death rate in Hispanics is less than that of Johnson County as a whole. This pattern is also reflected in the age-adjusted mortality trends from 2001 to 2009. African Americans have had substantially greater age-adjusted death rates consistently throughout this decade (KDHE-BEPHI). As people age, different risks become more serious. Younger people are much more affected by genetics and their parents’ health behaviors. Individuals younger than 15 years mostly die from birth defects or accidents. Adolescents and young adults have similar risks; however, a disturbing trend, suicide, begins at this age and continues throughout adulthood. More than 400 people committed suicide in Johnson County from 2001 to 2009. In addition, the leading cause of death among people aged 15–24 years is from traumatic injuries. When individuals reach middle and old age, chronic diseases are responsible for a majority of deaths.

NNPHI Kaizen Program: Johnson County Department of Health and Environment—Supply Ordering Process

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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NNPHI Kaizen Program: Johnson County Department of Health and Environment—Supply Ordering Process

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