Onondaga County Health Department 14 th Annual Quality Improvement Summit January 28, 2011
14 th Annual Quality Improvement Summit January 28, 2011 AGENDA 8:30 8:45 a.m. Welcome Remarks: Cynthia B. Morrow, MD, MPH, Commissioner of Health Housekeeping & Announcements: Catherine Unger, MPA, Director of Operations, MEO 8:45 10:05 a.m. Presentations by: Dr. A. Philip, Stacy Fontana, Wendy Kurlowicz and Elizabeth Cornell, and Dinae Ward 10:05 10:20 a.m. Break 10:20 11:40 a.m. Presentations by: Lisa Letteney, Jean Reilly, Merilee Mohr-Twardowski, and Jeffrey Till 11:40 1:00 p.m. Lunch Break 1:00 2:20 p.m. Presentations by: Sara Holmes, Bethany Starkweather, Tim Guhl, Beth Machan and Amy Pilacky 2:20 2:30 p.m. Closing remarks: Cynthia B. Morrow, MD, MPH, Commissioner of Health
TABLE OF CONTENTS 1 Medical Examiners Office Optimize X-ray Image Quality and Timeliness Using a Digital X-ray System Abraham T. Philip, MD, Medical Examiner 2 Bureau of Disease Control, STD Clinic How does a Prevention Counseling Intervention Tool Affect Clients Revisits/Re-attendance to the Sexually Transmitted Disease (STD) Clinic? Stacy Fontana, RN, NP, Nurse Practitioner 3 Health Promotion, Lead Poisoning Control Program The Impact of an Intervention on the Lead Hazard Control Plan Return Rate Wendy Kurlowicz, RN, Sanitarian I, & Elizabeth Cornell, PhD, Environmental Health Technician II 4 Fiscal Examination of Health Department Professional Services Contract Process Dinae Ward, Contract Manager 5 Environmental Health, Animal Disease Determination of the Effect of a Change in Guidance for the Answering Service on the Number of Unnecessary After Hour Calls to Rabies Staff Lisa A. Letteney, P.E., Director of Environmental Health Assessment 6 Family Planning Will Additional Efforts to Provide Patients with Appointment Reminders Result in a Decrease in the No-Show Rate for Family Planning Service Clinics? Jean Reilly, MSW, Project Director 7 Women Infants and Children Strategies to Reduce Service Times for WIC Participants Merilee Mohr-Twardowski, MSRD, CDN, Program Coordinator 8 Environmental Health, Public Health Engineering Assessing Compliance with Obtaining Onondaga County Health Department Approval of Equipment Changes at Regulated Swimming Pools Jeffrey A. Till, P.E., Director of Public Health Engineering 9 Facilitated Enrollment, Public Health Insurance More Accurate and Complete Access NY Application Sara Holmes, MS, MPA, Program Coordinator 10 Health Information Technology, Freedom of Information Lead FOIL Request Process Improvement through Use of Electronic Tools Beth Starkweather, MS, RN, Program Coordinator & Tim Guhl, BS, Office Automation Analyst 11 Maternal and Child Health, CHN, SHS, CHW Impact of Mandatory Prenatal & Infant Referrals from Children s Division to Healthy Families Home Visitation Programs Beth Machan, MS, Program Coordinator 12 Maternal and Child Health, Special Children Services Physician Referrals to Early Intervention Amy Pilacky, BS, MS, CAS, Program Coordinator PAGE 1 5 7 11 13 15 17 19 21 23 25 27
MATERNAL AND CHILD HEALTH Healthy Families, Special Children Services Physician Referrals to Early Intervention (EI) Brief Description: We receive approximately half of our referrals from physicians. In looking at these referrals, there are a significant number of families that we can not locate, or who refuse EI services prior to even receiving an evaluation. We initiated a system whereby written referrals would have to be signed by the family in the hope of verifying both the interest in EI and the family s address. Standard/Benchmark: Compare written physician referrals for a three month period that were not signed by the parent as an acknowledgement of the referral with a three month period where the referrals were signed by the family. Study Size & Time Period: Written referrals received between January and March, 2010 (preintervention):150. Written referrals received between April and June, 2010 (post-intervention): 109 Method of Monitoring: The KIDS program, which is the NYS Early Intervention computer program, can not track referrals as specifically as we needed, so we hand counted the written referrals for each time period and then compared the results. Date Last Studied: New study Findings: The initial time period, January through March had 150 written physician referrals. Of those, 26 families refused EI (17%) and we were unable to locate 20 families (13%). For the second time period, we had 109 referrals. 16 families refused EI (15%) and we could not locate 18 families (17%). The database indicated that the vast majority of referrals for the families who either refused EI or could not be located came from Saint Joseph s MCH, Syracuse Community Health Center, and University Pediatric and Adolescent Center.
Study Impact: The sample size for each time period was small, so therefore it is not possible to draw significant conclusions. It is, however important to note that when referrals were signed by the parent, both the refusals and the inability to contact them decreased. Recommendations: We will continue to have families sign written referrals from physicians for 2011 and then review the results. Additionally, more training needs to be done with the primary referrals sources regarding the message being given to families, and reviewing the addresses on file. If this occurs, this should reduce both the refusals and our inability to locate families. Action Taken: Follow-up Monitor: Report: Submitted by: Amy Pilacky, Program Coordinator Date: 1/6/2011
MEDICAL EXAMINER S OFFICE Comparison of Conventional Film and Digital X-ray Systems: A Forensic Perspective Objective: To optimize X-ray image quality and timeliness using a digital X-ray system. Study Description: The Onondaga County Medical Examiner s Office (OCMEO) routinely takes X-rays in all cases of homicide, child deaths, vehicular accidents, decomposed bodies, and victims of house fires. X-rays are also taken at the discretion of the individual medical examiners, to document specific findings. X-rays in medicolegal death investigations are used primarily for the purposes of: (1) establishing identity; (2) evaluating trauma; and (3) occasionally to evaluate soft tissue disease process. The process of identification uses information from X-rays that includes pattern of frontal sinuses, dentition, features within the chest and vertebral column, old fractures and prior orthopedic or surgical interventions. Finding the projectiles in an autopsy is routinely facilitated by taking preautopsy X-rays. X-rays also play a valuable role in decomposed bodies with firearm trauma, because entrance and exit wounds may be masked by changes of putrefaction. The list of foreign bodies that have been detected by pre-autopsy X-rays include, but not limited to bullets, fragments of leaded glass, pieces of explosives, needles in drug addicts, teeth or dentures swallowed around time of death, small toys, magnets, etc. Wound track evaluation has been occasionally done by injecting contrast media through wounds, and especially within vertebral blood vessels. X-rays are invaluable in the evaluation of children with non-accidental blunt force trauma (battered baby) as the X-rays demonstrate not just the recent skeletal trauma, but are also useful for documenting the varying ages of fractures. Certain medical conditions and soft tissue disorders too can be demonstrated, for example pneumothorax, aseptic necrosis of femur, gas embolism, patency of stents and ducts. In late October 2009, the OCMEO was awarded $95,000 in National Institute of Justice (NIJ) Coverdell Forensic Sciences Improvement Grant funding to upgrade our conventional film X-ray system to a digital X-ray system. We also received $11,775 in Onondaga County Technology Venture Capital funds for this project. Funds were used to purchase a digital panel that connects to a computer workstation in the X-ray room as well as software to capture the X-ray image that is later saved to the computer network. The new system replaced the need to use film, film cassettes, an X-ray processor, processing chemicals and a chemical mixer. Method: Case selection: From January October 2009, 57 cases (with a total of 748 X-ray films) meeting the following criteria were selected: (a) obese (BMI >= 30); (b) decomposed bodies; (c) children 10 years of age and younger; and (d) those cases where X-rays were taken through the body bag. Bodies from suspicious or homicide cases were sealed in body bag and X-rayed prior to supervised processing of the cases for autopsy. These special categories of cases were identified by the morgue technicians as the ones more challenging to take X-rays. An identical process was used for selection of 69 cases (with a total of 1,133 digital X-rays) from January October 2010, meeting the same criteria. X-ray selection: Of the 57 pre-intervention cases: All 748 film X-rays were numbered sequentially in each case file film envelope. 497 X-ray films were randomly selected for evaluation using randomization software. Of the 69 post-intervention cases: the 1,133 digital X-rays were automatically numbered by the software based on the sequence in which the X-rays were taken. 576 digital X-rays were selected for evaluation using the same process.
Evaluation protocol: The X-rays were evaluated on two areas, quality of images and technical process issues. The quality of the X-rays, both film and digital were evaluated on 3 aspects; the image of the bones, definition the soft tissues and the focal spread or area covered by the x-ray image. For the evaluation of image quality, a scoring scheme on a scale of 1 to 3 was utilized; where 1 image was not acceptable; 2- image acceptable and 3 image quality was excellent. The technical process issues were evaluated on 3 items: the presence or absence of processing artifacts, whether the case information or demographic information was displayed in the appropriate space, and whether the marker to indicate side of the body was present on the image. A 2-point yes or no scoring scheme was utilized for the process issues. Reviewers: All images were reviewed by a forensic pathologist and a forensic investigator both of whom graded the images on the scheme outlined above. Time study and cost savings: Morgue technicians taking the X-rays were instructed to document the amount of time required to complete the task of taking X-rays. Data were available for 87 cases in 2009 and 38 cases in 2010. In addition, an analysis of the cost savings incurred by conversion from conventional film to digital X-rays was performed. Results: Image quality: The scores assigned were calculated as a percentage of the maximum possible scores for each case and criteria within the case. There were noted differences between the reviewers; however, overall findings demonstrate a significant increase in digital X-ray quality over film X-ray quality. See Figure 1, below. Process data: The findings for processing data regarding artifacts, demographics and orientation markers demonstrate a slight increase in procedural accuracy in digital X-ray compared to film X- ray. There was no significant difference between the reviewers for film images, but a significant difference between reviewers was noted for digital images. See Figure 2, below. Image Quality - Pct. Of Max. 100 90 80 70 60 50 40 30 20 10 0 ***p<.001 Fig. 1: Mean Image Quality Score by Image Type and Reviewer MRK ATP 45.34 54.99 69.32 62.63 Film*** Digital*** Procedural Accuracy - Pct. of Max. 100 90 80 70 60 50 40 30 20 10 0 *p<.05 Fig. 2: Mean Procedural Accuracy Score by Image Type and Reviewer MRK ATP 91.11 92.48 97.57 98.48 Film Digital* Time study: The median time in minutes to take X-rays per case dropped from 55 minutes using the conventional film system (on 87 cases) to 21 minutes using the digital X-ray system (on 38 cases). This is a 61.8% reduction in median time spent taking X-rays per case.
There will be a projected $21,557 in cost savings after three years, as shown in Table 1, below. Table 1: Projected cost savings: PROJECT FUNDING: 2010 2011 2012 TOTAL NIJ Coverdell Forensic Sciences Improvement grant 95,000 0 0 95,000 County Portion - Technology Venture Capital 2,775 4,500 4,500 11,775 X-ray equipment auction 1,500 0 0 1,500 Funding subtotal: 99,275 4,500 4,500 108,275 COST SAVINGS: Film System Annual maintenance fee savings 2,100 2,226 2,360 6,686 Annual supply and materials/misc. savings 1 4,200 4,452 4,719 13,371 Cost savings subtotal: 6,300 6,678 7,079 20,057 DIGITAL X-RAY SYSTEM COST $97,775 $4,500 $4,500 $106,775 TOTAL PROJECTED SAVINGS 2 : $7,800 $6,678 $7,079 $21,557 1 Includes x-ray film, envelopes, copies, and film storage. Per vendor, assuming a 6% annual increase in costs each year due to less economies of scale as most customers are switching to digital. 2 Estimated savings is calculated by adding funding and cost savings and subtracting the cost of the system. Conclusion: The results clearly demonstrate an improvement in overall X-ray image quality over the conventional film system. Bone, soft tissue and focal spread or area are critical quality indicators that ensure decedents are scientifically identified in a timely manner, and to document the effects of trauma. The quality of the digital images, without additional manipulation was superior to the film images, as was documented in this QI project. The crispness of images, depth of focus and additional detail enhanced the timeliness with which the identity could be established or confirmed. This was especially significant as comparison with X-rays received from area hospitals and other physician providers could be compared on computer without major disruption to routine work flow. Identification and retrieving foreign object during autopsies were facilitated by the improvements in image quality and enhanced details available on digital images. Another obvious improvement was the markedly decreased time the morgue technicians spent on of taking X-rays. This advantage in increased speed of completion of the task is also significant for varying body sizes, specially the markedly obese bodies, which were very difficult to X-ray using the conventional system. There have been clear advantages, not just in time to completion of X- rays, but also in availability of technician time to perform their other numerous tasks. The other areas where the new X-ray system has proven itself of tremendous value is at the level of the end user the physicians utilizing the X-rays in the performance of autopsy. The X-rays can be viewed while in the autopsy room itself, or at morning conference when case details are discussed. One does not have to go hunting for an X-ray view box or a darkened room to see the X-rays. This increases the time to review the X-rays, as well as makes them available while teaching residents and interns, or highlighting points of interest to colleagues and investigators during daily morning case conferences. Digital storage of the X-rays images also gives us the ability to incorporate and integrate X-ray studies from hospitals that we use for comparison purposes while establishing identity.
In the same light, the many software tools to manipulate the images are of tremendous advantage. These software tools can be used to further improve the quality and usefulness of the image captured by the technician by allowing the viewer to change contrast, to focus on the soft tissues or bones, to rotate the images, and to magnify portions and parts of the image that are difficult to visualize in a larger view, etc. In addition, the doctor can annotate the images, place pointers, markers or arrows, measure thickness of tissues, or angles, place text, sharpen images, etc., to highlight points that will enhance presentations during testimony. Other benefits include cost savings on conventional X-ray system equipment, elimination of hazardous chemicals, and less time to train new morgue technicians on use of the digital system. Future Directions: We continue to strive for excellence in utilization of evolving technologies in the field of radiology to produce excellent quality work output from our office. Submitted by: Abraham T. Philip, MD Medical Examiner Date: 1/18/2011
BUREAU OF DISEASE CONTROL STD Clinic How Does a Prevention Counseling Intervention Tool Affect Clients Revisits/Reattendance to the Sexually Transmitted Disease (STD) Clinic? Objective: To test our hypothesis that a prevention counseling intervention tool used by staff and given to each client during an STD visit will decrease repeat STD client visits within six months following this intervention. Brief Description: STD clinic staff noted that a number of clients have had several repeat visits to the STD clinic within the past year. Many of these clients are found to have the same STD or a different STD on subsequent visits. These repeat visits to the STD clinic lead us to believe that clients are not abstaining from sexual contact during treatment period, having sexual contact with an untreated partner, or no change has been made in the risky behaviors these clients are taking. Risk-reduction counseling has been found to be effective in reducing the risks for STDs. The Center for Disease Control (CDC) advocates prevention counseling in its STD guidelines, however, there is a lack of training for staff to incorporate prevention counseling, and interventions vary across STD clinics. Clients who attend the OCHD-STD clinic currently complete an HIV/STD/Hepatitis self-risk assessment which is used as a basis for prevention counseling by staff during client visits. However, resource barriers, time, large number of clients, limited number of staff and cost prohibit using proven effective brief interventions such as Project RESPECT (cdc.gov/hiv/topics/research/respect/index.htm) or Sister to Sister- Respect Yourself! Protect Yourself! Because You Are Worth It! (Jammott et al., 2008) one-on-one 20 minute interventions. Methods: In June 2010, the STD staff began a structured intervention to decrease the number of repeat STD client visits within any given 6 month period. A client centered counseling tool was developed with input from all staff members. This tool Protect Yourself, Protect Others incorporates discharge instructions, prevention messages, and a brief risk reduction counseling
session that the nurse will individualize to each client. This tool is reviewed with each client and given to them to take home at the end of each visit. Baseline data on the percent of repeat STD clients in a 6 month period was collected using the STD Management Information System. Data on number of repeat STD visits has been collected and compared at baseline and at 6 months post intervention. Results: Study Date Range # of Clients # Repeat Clients % Repeat Clients Pre-Intervention 8/1/09-1/31/10 1986 203 10.2 Post-Intervention 6/1/10-11/17/10 1931 163 8.4 Numbers are unique clients and not visits. Conclusion: Results show that the implementation of a prevention counseling tool has decreased client revisits to the STD clinic; however those results do not appear to be statistically significant to the overall repeater numbers. There were fewer clients seen in the STD clinic due to the implementation of clinical restriction of client numbers when staffing is reduced due to absence. The tool has been very effective with some clients and it also serves as a good documentation of client educational points that can be taken away by the client. Future directions: Considering the moderate success of the intervention, the STD staff will continue to distribute and review Protect Yourself, Protect Others with each client during a STD visit. We will continue to collect data every 6 months to monitor appropriate decline in repeat client visits. Submitted by: Diane M. Rothermel, Director Date: 1/6/2011
HEALTH PROMOTION Lead Poisoning Control Program The Impact of an Intervention on the Lead Hazard Control Plan Return Rate Objective: The goal of this study was to increase the return rate of the Lead Hazard Control Plans for properties that were cited for lead paint violations. Brief Description: The Onondaga County Health Department s Lead Poisoning Control Program policy and procedure manual page 302.2 states that a Lead Hazard Control Plan should be returned to the Health Department by the responsible party of a property cited with lead paint violations. This is a local policy and not a requirement of the New York State Department of Health. This policy is in place to emphasize to the responsible party the importance of protecting both the occupants and workers during lead paint remediation. The Lead Hazard Control Plan addresses standards of Lead Safe Work Practices so they are easily understood by the responsible party of the cited property. By utilizing Lead Safe Work Practices, it has been proven that there is a significant reduction in exposure to lead hazards to both the occupants and workers. Lead hazards can be created from lead paint and lead dust. The Lead Hazard Control Plan also includes methods of how to remediate lead paint hazards, how to properly clean up, and also includes the timeframe for completion of the proposed work. In addition, the Lead Hazard Control Plan encourages the responsible party to have a temporary relocation plan for the occupants during the remediation work. This helps ensure that the occupants, especially pregnant women and children, are not exposed to the hazards of excess lead dust that may be generated when the lead paint is disturbed. The current procedure is to include a Lead Hazard Control Plan in the Notice of Violation mailing to property owners of inspected homes found to have lead paint hazards. This document is printed on bright orange stock for a visual effect. It is strongly encouraged that the plan be completed and returned by the responsible party who will be completing the work at the property cited. Once submitted, the plan is reviewed by an EPA-certified staff person to ensure that the responsible party
understands how to safely and correctly remediate the cited hazards and provide protection for those involved. Working safely and reducing exposure increases the protection of the occupants and workers during remediation of the lead paint hazards. To determine the previous compliance rate of returned Lead Hazard Control Plans, properties with cited lead hazards were evaluated from June 2009 through December 2009. A review of these files determined that the compliance rate was less than 10%. Therefore, this was identified as an area where a quality improvement project could be initiated. Methods: Initially, a measurement of the number of plans received from properties cited with lead paint hazards from June through December 2009 was reviewed. The number of field conferences with a responsible party of cited properties was also reviewed as an avenue of communication. From this information, it was determined that a potential project would be the creation and implementation of a modified Lead Hazard Control Plan that could be easily completed in the field. This QI project began in May of 2010 with the development of a new field form. The intervention officially started in June 2010. The success rate of this intervention was determined by measuring the number of plans received from properties cited with lead paint hazards from June 2010 through December 2010 and comparing these results with the number of plans received from the same seven-month period in 2009. Results: From the months of June 2010 through December 2010, Lead Hazard Control Plan compliance increased from of 7% in 2009 to 17% in 2010. The Lead Hazard Control Plan field form became a routine part of a field conference. The bright orange stock old form was still mailed to the owner with the Notice of Violation packet. Conclusion: By initiating the new field form, compliance for returned Lead Hazards Control Plans to the Health Department increased. This information has provided a useful tool to measure compliance and help with future initiatives. Overall the intervention was successful in increasing the rate.
Future Directions: Compliance in returning Lead Hazard Control Plans to the Health Department has improved; therefore continuation of initiating the plan during a field conference will remain a part of the field procedures. Review with staff revealed some additional improvement ideas. One possible change would be in the format of the field form by adding color to separate lines for ease of completion. The black, white, gray combination can get confusing, especially in poor weather conditions. A determination of cost effectiveness of providing two forms: one form mailed in the packet and a field form will have to be discussed. Discussion at the time of the field conference with owners, contractors, or property managers will be initiated to determine their barriers to returning the plans to the Health Department, as well to determine why the return rate remains low. Submitted by: Kathy Turner, Bureau Director Date: 1/7/2011
FISCAL Examination of Health Department Professional Services Contract Process Objective: To determine if the use of Lotus Notes and training reduce the number of steps and number of days necessary to process a contract requisition in the Health Department. Brief Description: The Health Department s internal contract process began with the submission of a paper contract requisition by the Division for approval by the Fiscal Officer. Upon approval information from the paper requisition was entered into the Lotus Notes Database to be approved at the fiscal department level and forwarded to the Comptroller s department. The intervention eliminated the paper copy and changed the original approval path. Lotus Notes was restructured to include an initiator and approver within each Division to initiate the contract requisitions within the database. For the new database users group and individual, training was provided along with hands on support as needed. Methods: Before intervention the steps were mapped by tracking the number of days to process 17 grants and 28 operating contracts in 2009. After intervention we tracked the number of days to process 31 grants and 40 operating contracts in 2010. The median number of days per step and in total time was compared as well as a comparison of the rate of contracts completed in specific categories (less than 5 days, 5-10 days, 11-20 days and greater than 20 days). Results: The previous year study highlighted unnecessary paper flow. In the original process the number of days was greater because of the paperwork going back and forth between steps and the contract manager (due to omitted information, errors, or lack of funds). The new process has shown that with the electronic system, there is less back and forth. Additionally, errors can be recognized and corrected with email. However, omitted information in the contract requisition still causes rejections. Other errors are mostly due to lack of knowledge of the database and problems within the database itself.
OPERATING TOTALS Pre Post <5 Days 1 4% 21 53% 5-10 Days 3 11% 13 33% 11-20 Days 6 21% 1 3% > 20 Days 18 64% 5 13% Total contracts 28 100% 40 100% GRANT TOTALS Pre Post <5 Days 1 6% 12 39% 5-10 Days 6 35% 6 19% 11-20 Days 2 12% 7 23% > 20 Days 8 47% 6 19% Total contracts 17 100% 31 100% Overall the elimination of the paper copy simplified the process and the database changes did shorten the turnaround time of to process a contract. These changes also enabled the initiators, approvers and others in the unit to view and track a contract in the contract database. Future Directions: The recommendations are to conduct group training and include a section on the understanding of the basic information required within a contract as well as the database training. Training must stress the importance of the initiator receiving the complete required information in order to create the contract requisition in the database. It was also revealed when the contract involved grant funding the original restructured process caused confusion and delays in moving the contract requisition forward. Currently there is an alternative grant approval path being tested and reviewed. With future training and guidance the process should improve. Submitted by: Ellen H. Wilson, Fiscal Officer Date: 1/7/2011
ENVIRONMENTAL HEALTH Animal Disease Determination of the Effect of a Change in Guidance for the Answering Service on the Number of Unnecessary After Hours Calls to Rabies Staff. Objective: To determine if a clear set of guidance for the answering service will reduce the number of unnecessary calls dispatched to rabies staff. Brief Description: The Bureau of Animal Disease Prevention uses an after hours answering service in order to address possible rabies issues on a 24 hour basis. Environmental Health staff respond to calls on a rotating basis. The types of calls that the bureau should be answering include veterinarians offices requesting a specimen pick up or having an animal related question, calls from residents with questions about a person or pet that was bitten or scratched by another pet or wildlife, and all calls concerning bats. Staff reported that a significant number of the calls being put through by the answering service were not rabies related. An intervention with the answering service would likely reduce the unnecessary calls and save staff time. Methods: In order to get an accurate picture of how many and what types of calls staff were receiving, each call generated during January through May of 2010 was logged and analyzed. Staff met directly with the answering service and a compete flow chart set of questions was developed in order to guide the operators through various types of animal related concerns that the public calls about. The protocol even gave the operator some alternative suggestions to give callers on issues that the bureau does not deal with. After the various operators had been trained in the new protocol in June, the calls were again logged and analyzed to determine if an improvement had been made. Results: From January through May there were 36 calls out of the total of 75 calls (48%) that were related to issues that the Bureau does not deal with. Examples of calls that staff should not be receiving
include: stray dogs, wildlife in residential yards that has had no contact with a person or pet, dead or dying wildlife including birds in a yard or in the street, unusual acting wildlife with no contact with a person or a pet, or inquires such as dates and times of rabies clinics. After the new protocol was in place and training completed (June 1, 2010) the calls were monitored closely. From June through November, 2010 there were a total of 16 calls out of 101 (16%) that were unnecessary. Month Jan. Feb. March Apr. May June July Aug. Sept. Oct. Nov. Dec. Total Calls 18 8 9 18 22 18 22 16 18 14 9 5 # of unnecessary calls (% of total) 8 (44%) 2 (25%) 6 (67%) 11 (61%) 9 (41%) 6 (33%) 3 (14%) 2 (13%) 2 (11%) 2 (14%) 1 (11%) 0 (0%) Conclusions: There was a significant decrease in unnecessary calls after the new protocol was applied. The reduction of calls resulted in staff earning approximately half the comp. time as they had in the past and therefore able to devote this time to their regular duties. After careful review it was determined that many of the unnecessary calls that still came through after the intervention were from one particular operator or a new operator. In these cases an e-mail is sent to the supervisor and she can address the problem immediately with the operator. There are some situations in which the caller insists on speaking with someone and it is expected that a few of these calls will continue to come through to staff. Future Directions: The after hours calls put through to staff will continue to be monitored and unnecessary calls will either be addressed immediately with the operator and/or with the answering service supervisor in a timely manner. Submitted by: Kevin Zimmerman, Director of Environmental Health Date: 1/7/2011
WIC Strategies to Reduce Service Times for WIC Participants Objective: To determine if a chartless system will reduce the service time for participants in WIC clinics. Brief Description: Extended service (or throughput) times create a barrier to WIC participation. In order to reduce clinic service times, strategies to streamline clinic flow were developed and implemented. A pre and post time study was done to determine the effectiveness of the strategies that were implemented. Methods: In March 2010 a leadership conference for WIC Managers was held by the NYSDOH WIC Training Center (Cicatelli Associates). Prior to this conference, WIC Programs throughout New York State were asked to do a time study to determine service times in our clinics. This information was analyzed by Cicatelli Associates and provided baseline information pertaining to service times. This analysis was presented to WIC staff and the entire staff participated in Process Mapping the steps that a participant must complete during a WIC appointment. From the Process Mapping, all staff had input as to how the chartless system should be designed. Along with the chartless system, several revisions were made to consolidate required paperwork and signatures of WIC participants and to cut down on redundancy. The changes in paperwork and the chartless system were implemented in August 2010 at the West Onondaga Street clinic site. Several revisions were needed in order for the system to meet the needs of the staff and participants. After these changes were discussed with staff and implemented, a post chartless system time study was conducted. The time study was done for one week in October 2010, then sent to Cicatelli Associates for analysis. Results: A 16% reduction (13 minutes) was seen in the total time a participant spent in clinic from March 2010 (82 minutes) to October, 2010 (69 minutes). Conclusion: Based on the time study results, the interventions were successful in reducing total time spent at a WIC appointment.
Future Directions: One of the objectives of this Q.I. study is to reduce the time spent by WIC staff in completing the WIC Risk Assessment requirements, therefore, allowing more time to be spent providing nutrition education. The OCHD WIC Program is one of seven (7) WIC Programs throughout New York State chosen to participate in 2011 in a year long WIC Managers Learning Collaborative. The focus of this Q.I. project is one of the goals that WIC anticipates as an outcome to this collaborative venture. Submitted by: Merilee Mohr-Twardowski, WIC Program Coordinator Date: 1/7/2011
ENVIRONMENTAL HEALTH Public Health Engineering Assessing Compliance with Obtaining Onondaga County Health Department Approval of Equipment Changes at Regulated Swimming Pools Objective: Our hypothesis is that an annual reminder to swimming pool operators and pool contractors will yield increased compliance with the Sanitary Code requirements for modification proposals to the OCHD. Brief Description: The purpose of Subpart 6-1 of the State Sanitary Code is to assure a sanitary, healthful and safe environment for the public when using swimming pools. Proper treatment of swimming pool water is critical to achieve this goal. To this end, the Code requires that all new public swimming pools be designed by a licensed professional in strict conformance with the Code. Section 6-1.8 also requires pool owners to obtain Health Department approval prior to performing any modifications or additions to existing swimming pools in order to meet the same goal of public health and safety. Based on a low number of requests received by OCHD over the years, it is our thought that many modifications, especially to the recirculation system, are being made without our involvement. Methods: We devised a simple form for our inspectors to complete during the 2010 annual safety inspection at regulated swimming pools. There are 162 regulated pools within Onondaga County. Inspectors completed 57 equipment forms for analysis. The information on these forms was compared to the approved data on file for each facility. Three categories were used to classify each pool; no modifications from the approved plan, modifications with OCHD involvement, and modifications without OCHD involvement.
Results: Based on the forms collected, it was determined that 81% of the facilities had made at least one modification to their swimming pools. 32% of the facilities involved the OCHD at the time of the changes and 49% were performed without OCHD knowledge. 19% of the facilities had made no modifications to the originally approved specifications, or made equipment exchanges on a like-for-like basis. The data was further analyzed to assess compliance by municipally owned facilities. This type of pool generally services a large population and proper treatment is of utmost importance. Only 1 out of 11 municipally owned pools had made modifications without OCHD knowledge. Conclusion: Just about one half of the permitted facilities examined performed modifications to their swimming pools without first submitting required proposals to the OCHD. This is an unacceptably high percentage of regulated facilities. Future Directions: Recognizing the critical nature of these engineered systems, a renewed effort must be taken by the Health Department to aid compliance with the Code. A reminder notice will be sent with the annual operating permits for regulated swimming pools. Submitted by: Kevin L. Zimmerman, Director of Environmental Health Date: 1/7/2011
FACILITATED ENROLLMENT Public Health Insurance More Accurate and Complete Access NY Applications Objective: Increase accuracy and completeness of the public health insurance application clients use. This may improve their chances of obtaining health insurance in a timely manner and having back bills paid. Description: The Public Health Insurance Program has Facilitated Enrollers who assist clients in applying for Medicaid, Family Health Plus and Child Health Plus. We choose Section G of the Access NY application which asks if anyone applying has paid or unpaid medical or prescription bills because many uninsured clients report having past bills. If a client is awarded Medicaid, those bills will be paid. If the question is checked Yes but bills or corresponding income is not submitted, the application will be pended and the client will be asked for the needed documentation which delays the process. Method: For 30 days in May and June, 2010 all applications that had answered yes to Section G were examined as to whether bills and matching income was submitted and data were collected. I met with the Facilitated Enrollers and they were instructed to modify their interaction with the clients. When they called to make their initial appointment they told the applicant that Medicaid may cover back bills, if bills and income were submitted. The enrollers were also asked to call clients 1 to 2 days prior to their appointment as a reminder. For another 30 days all applications were examined as to whether have bills and matching income was submitted. Data was collected and compared with the pre-intervention results. Results: Prior to the intervention the applications collected from all 5 Facilitated Enrollers were only 35% complete, whereas afterwards they were 44% complete.
Conclusion: While there was a small improvement, the number of applicants that had bills was quite small. Too much of the project was dependent on the clients. Facilitated enrollers reported they sometimes felt as if they were badgering clients by making repeated phone calls to remind them of the missing paperwork. Future Directions: Now we are using another measure of application accuracy and completeness that only examines variables under the control of the enroller. Enrollers are still asked to stress to the client the importance the inclusion of medical bills and income with the application. Submitted by: Sara Holmes Date: 1/7/11
HEALTH INFORMATION TECHNOLOGY Freedom of Information Lead FOIL Request Process Improvement through Use of Electronic Tools Objective: We want to use electronic tools to improve the efficiency of FOIL request processing. Our aim is to shorten the processing time and reduce the staff hours used to process lead FOIL requests. Description: FOIL request processing is labor intensive and the volume of requests has increased dramatically in recent years due to lead litigation. This study will establish the baseline measurement of the manual process for handling FOIL requests for lead inspection records related to litigation. The baseline measurement will allow comparison of process segments as we transition to the use of electronic tools. Methods: The manual process has been mapped into segments so that time per segment and the number of requests processed can be compared to each of the segments as they are processed using electronic tools. The proposed number of manually processed FOIL requests for the baseline is 70. Time for each segment, as well as, time between segments in the process will be recorded by FOIL request. Manual process data from January 2010 through June 2011 will be gathered into the following groups of segments for future comparison.
Segments 1-4 Segment 5 Segments 6-10 Segments 1-10 Time Manual Electronic N ~ 70 Results: Search 1 Search Retrieve 2 Retrieve Copy 3 Scan Organize 4 Index Redact 5 Redact Review 6 Review Inspect 7 Inspect Approve 8 Approve Copy 9 Save Release to Requestor 10 Release to Requestor At this 14 th QI Summit, we will present the baseline data on average times for the manual process of each segments of approximate 70 FOIL requests and discuss outliers. Segments 1-4 Segment 5 Segments 6-10 Segments 1-10 Average time Average time Average time Average time Conclusion: This is a baseline study that will allow the measurement of process improvement through the use of electronic tools. Future Directions: In 2011, the effect of electronic redaction on the process will be studied. More emphasis will be put on the comparison between the manual redaction and electronic redaction (Segment 5). Future interventions with electronic tools may be measured against the baseline. The use of electronic tools may alter segments of the process. Submitted by: Tim Guhl Date: 1/7/2011
MATERNAL AND CHILD HEALTH CHN, SHS, CHW Impact of Mandatory Prenatal & Infant Referrals from Children s Division to Healthy Families Home Visitation Programs Objective: Increase rates of at risk pregnant women and families with children < 1 year of age in Healthy Families home visitation services through staff education and mandatory referrals. Brief Description: The Healthy Families Division identified Children s Division (CD) as having low referral rates of pregnant or parenting families to its home visitation services. It was identified that the CD staff lacked understanding of what services were available for this specific group of clients. CD provides services to many pregnant women and families with children < 1 year of age who are identified as being at risk for poor outcomes. Methods: In June 2010, a public health nursing supervisor and the program coordinator for the Community Health Worker program conducted an in service at Children s Division with ~ 50 CD supervisors. They were educated on all of Healthy Families programs and services and introduced to a new referral form that was to be used for all referrals. Referrals were collected from CD staff for 1 month during July 2010. The measures collected by this project included the number of CD clients that engage in Healthy Families services as a result of the referral and associated reasons. Self reported client data was used for this project.
Results: 21 total referrals were collected during this project. Of the 21 total referrals, 57% accepted services (12 clients), 33% declined services ( 7 clients), and 10% unable to be located (2 clients). The implementation of mandatory referrals from CD dramatically increased referrals. Year Referrals from CD Month Referrals from CD 2009 21 July 2009 1 2010 68 July 2010 21 Conclusion: Education of Children s Division staff and mandatory referrals of all pregnant women and or families with children < 1 year of age, provided a dramatic increase in referral numbers for Healthy Families home visitation services. Women or families that declined services overall felt that they did not need services offered to them. Future Directions: The analysis of the data will assist in developing better staff education and referral process to the Healthy Families programs and services. Communication and education that are made available to other Onondaga County departments will ensure that staff who work with at risk families will have the knowledge of services available to clients in the community. Utilizing community programs to reach this specific population, will provide education, physical and social/emotional assessments to those at highest risk for negative outcomes in pregnancy and/or early parenting years. Submitted by: Denise Barber, Director of Nursing Date: 1/6/2011
MATERNAL AND CHILD HEALTH Healthy Families, Special Children Services Physician Referrals to Early Intervention (EI) Brief Description: We receive approximately half of our referrals from physicians. In looking at these referrals, there are a significant number of families that we can not locate, or who refuse EI services prior to even receiving an evaluation. We initiated a system whereby written referrals would have to be signed by the family in the hope of verifying both the interest in EI and the family s address. Standard/Benchmark: Compare written physician referrals for a three month period that were not signed by the parent as an acknowledgement of the referral with a three month period where the referrals were signed by the family. Study Size & Time Period: Written referrals received between January and March, 2010 (preintervention):150. Written referrals received between April and June, 2010 (post-intervention): 109 Method of Monitoring: The KIDS program, which is the NYS Early Intervention computer program, can not track referrals as specifically as we needed, so we hand counted the written referrals for each time period and then compared the results. Date Last Studied: New study Findings: The initial time period, January through March had 150 written physician referrals. Of those, 26 families refused EI (17%) and we were unable to locate 20 families (13%). For the second time period, we had 109 referrals. 16 families refused EI (15%) and we could not locate 18 families (17%). The database indicated that the vast majority of referrals for the families who either refused EI or could not be located came from Saint Joseph s MCH, Syracuse Community Health Center, and University Pediatric and Adolescent Center.
Study Impact: The sample size for each time period was small, so therefore it is not possible to draw significant conclusions. It is, however important to note that when referrals were signed by the parent, both the refusals and the inability to contact them decreased. Recommendations: We will continue to have families sign written referrals from physicians for 2011 and then review the results. Additionally, more training needs to be done with the primary referrals sources regarding the message being given to families, and reviewing the addresses on file. If this occurs, this should reduce both the refusals and our inability to locate families. Action Taken: Follow-up Monitor: Report: Submitted by: Amy Pilacky, Program Coordinator Date: 1/6/2011