Looking Back: Experiences from 2008 till 2019
Assessment of Case Study Orange County Health Department, STD Quality Improvement
The major challenge was to access data from the last 13 years to show the evolution of reporting. Like many government programs, measurement and reporting requirements change over time. Fortunately, one of the original
Figure 7.11 Contact Index Orange County 2014-2019.
Figure 7.12 Orange County Yearly DIS Blood Draws.
supervisors is now the Area 07 Manager of Community Health and was able to work closely with the Orange County Department and Quality Managers to illustrate the evolution of the tracking systems used as the Florida Public Health system was centralized. Priorities have changed at both the Federal and State level, and epidemic focus moved from one disease to another.
The Enabler omissions were easy to include, since the stakeholders of the STD programs remain relatively constant. Audits have been performed during the entire life of the program. The original case study authors neglected to include this information in their 2008 document.
Full BEST-Tool Assessment of Orange County Health Department STD Blood Draw Process Case Study
A closer assessment using the detailed BEST-tool further clarified improvements suggested in the Quick Scan. Figure 7.7: the Results section of the BEST-tool, identified the need to list stakeholders of the Blood Draw process. The 2019 team brainstormed current stakeholders and added a comprehensive list as indicated in the above text. This review of stakeholders refreshed management’s understanding of the strategic value of the process as a support to the Orlando community.
Trends and targets for monitoring the incidence of STD are the Key Performance Indicators of the process. Evolution of the reporting process over the past 13 years has occurred, mostly due to centralization of the Florida Department of Health operations. The county health departments now report to a common leadership function at the state level. Tracking is standardized across locations for better analysis. This standardization increases the opportunity that positive performance will continue in the future (Figure 7.13).
The Enabler section of the BEST-tool reflects the Plan - Do - Check - Act cycle of process design and implementation as seen in Figures 7.14-7.17. Comments from the assessment indicate that the case study addresses each area appropriately. Since the 2006 process improvement team used the PDCA cycle as a base for their project, it is rewarding to have the BEST-tool validation of their success.
In addition to the BEST-tool assessment for internal process performance, the Maturity Model shown in Figure 7.18 identifies the process at level 4; part of a Management System. This is consistent with the recognition the Orange County office of the Florida Department of Health has received through the Public Health Accreditation Board and the high performing results of their Quality Management System.
Figure 7.13 STD Quality Improvement Best Practice OCHD case study, application of the detailed BEST-method: assessment of the results.
The management of the process, as reflected in Figure 7.19 prompted the documentation of the audit activities to the original 2006 text. Process ownership remains with the Area 07 Manager, Community Health. That the current Area 07 manager was part of the original 2006 process improvement team provides strong continuity of monitoring and results. Risk management, which was only informally addressed in 2006, is now a formal part of the Orange County Health Department Quality Management System in 2019-
The Format section of the BEST-tool reinforced the strength of the original PDCA structure of the 2006 case study. Using a standardized improvement model automatically guided the process improvement team
Figure 7.14 STD Quality Improvement Best Practice case study, application of the detailed BEST-method. Assessment of the ENABLERS (PDCA) PLAN. Source: Orange County Health Department STD Ql project report. Assessment of the enabler of the Best Practice of STD testing: PLAN. KPI: Key Performance Indicator (this has a direct relationship with the strategy of the organization). PI: Performance Indicator (several performance indicators contribute to the validity of a KPI).
Figure 7.15 STD Quality Improvement Best Practice case study, application of the detailed BEST-method. Assessment of the ENABLERs (PDCA) DO. Source: Orange County Health Department STD Ql project report. Assessment of the enabler of the Best Practice of STD testing: DO. SMART: This is an acronym and stands for Specific, Measurable, Assignable (Accountable), Relevant and Timely executed.
to include most of the components of a best practice. The BEST-tool served as a clarifying instrument to identify those few items omitted from the 2006 report and the 2008 update. The 2019 BEST-assessment alerted the process owner to areas for additional improvement (Figure 7.20). The addition of these missing components truly elevates this process to that of a Best Practice.
Current Status of Best Practice: Summer 2019
Figures 7.21 and 7.22 show the updated flowchart of the Blood Draw Preparation process. The BEST-method suggests a more complete process that identifies the Who, What, Where and How of each process step. The exercise of updating the 2006 process flow with the current process owner and supervisor provided a refresh of the value of the process and identified some areas of the flow that had changed over the years. Inconsistencies emerged and opportunities for further cycle time improvement were discovered.
Figure 7.16 STD Quality Improvement Best Practice case study, application of the detailed BEST-method. Assessment of the ENABLERs (PDCA) CHECK. Source: Orange County Health Department STD Ql project report. Assessment of the enabler of the Best Practice of STD testing: CHECK.
This case study, as improved from the original version in 2008 is a Best Practice. As further evidence of the effectiveness of the overall system managed by this organization, the Orange County locations received full Public Health Accreditation Board recognition in 2017. The first re-accreditation audit process is occurring as of this writing.
This chapter is written by a quality professional, with the support of the current STD department and quality managers. The spontaneous presentation in 2008 of most of the criteria included in the BEST Quick Scan tool reinforces the credibility of the BEST-tool. The same quality professional
Figure 7.17 STD Quality Improvement Best Practice case study, application of the detailed BEST-method. Assessment of the ENABLERs (PDCA) ACT. Source: Orange County Health Department STD Ql project report. Assessment of the enabler of the Best Practice of STD testing: ACT.
who edited the case study in 2008 used the results of the BEST Quick Scan in writing this chapter to identify missing information that would be critical for continuous improvement within the Health Department or to those using this case study as a benchmark for their own operations. This case is the basis for writing a Best Practice as described in Chapter 4.
The Florida Health Department - Orange County is a benchmark within Florida for process definition, improvement and the implementation of an effective Quality Management System. One major factor in the continued process strength of Orange County Health Department is that their Quality Manager is an ISO Lead Auditor with extensive experience with General Electric, one of the earliest implementers of Six Sigma statistical process improvement methods. The Quality Manager developed the first Quality Management System in the Florida Health Department System and continues to be instrumental in assisting other state health departments and the centralized organization in process definition, standards compliance, and strategic benchmarking.
Figure 7.18 Assessment of the Organizational Maturity of the STD testing process. Source: Orange County Health Department STD Ql project report. Assessment of the maturity of the process of Best Practice: STD testing.
Figure 7.19 Assessment of the management of the STD testing process
Figure 7.20 Assessment of the format of the STD testing process.
The Quick Scan tool facilitated several major learning points for Orange County. The assessment immediately identified the need to study performance trends from the original case study writing. Although reporting requirements had changed at the State and National level from 2006 to 2019, the local and area managers were able to access data to recognize trends in disease patterns and demographics necessary to revisit key processes. This trend data was even more valuable considering that the area manager in 2019 was the local leader in 2006 when the original process improvement effort was chartered. His memory of the evolution of disease tracking and treatment over the ensuing 13 years was instrumental in prioritizing improvement efforts in 2019-
Another significant lesson from the Quick Scan assessment was the omission of identified stakeholders in the original case study. It was a mistake on the part of the original case study authors to only focus on the internal processes. The Orange County Health Department works closely with community, state and, national partners to anticipate changes in demographics, regulations, and resource requirements to meet a growing disease epidemic. Fortunately, the local and area managers have an excellent rapport with the stakeholders identified. This updated case study now recognizes the
Figure 7.21 Improved Blood Draw process using BEST-tool flowcharting format: part 1. Sample Process Map for Field Blood Draws, Preparation - updated April 20, 2018.
Figure 7.22 Improved Blood Draw process using BEST-tool flowcharting format, part 2. Sample Process Map for Field Blood Draws, Preparation - updated April 20, 2018.
importance of these stakeholders to the ability of Orange County to support those impacted by the disease.
Likewise, the omission of describing scheduled process audits was highlighted through the Best-method Quick Scan. Both process and management audits are a significant driver of process improvement. Again, it is fortunate that all three of the contributors to this case study from Orange County are trained in audit methods and have consistently met state and national requirements for monthly and quarterly process audits. Our omission in 2006 was to leave out the value of scheduled auditing for maintaining and improving this process.
The final lesson learned from this case study is the value of the Quick Scan to tie the daily activities of this process to the strategic goals of the organization. The Quick Scan assessment targeted the information and activities required for process definition, implementation, measurement and improvement for true Best Practice process excellence. Once the team had the focus from Quick Scan, it was a simple matter to use the full Best- method characteristics and criteria in three specific areas to drive further process improvement.