In 2006, the Mahoning County District Board of Health in northeastern Ohio became one of 15 health departments around the country to receive a Common Ground Informatics Capacity grant (ID# 59783). Common Ground: Transforming Public Health Information Systems was a three-year, $15 million national initiative of the Robert Wood Johnson Foundation (RWJF) that awarded 31 grants to help state and local public health agencies to develop information system requirements and designs, and begin the process of implementing these systems.
Matthew (Matt) Stefanak, MPH, health commissioner for Mahoning County, saw Common Ground as an opportunity to update the county's environmental health permitting process. The goal was to make it easier for consumers to meet the requirements for septic systems, wells, and plumbing in new homes and businesses.
Stefanak and his partners found that the Common Ground tools of business-process analysis and redesign enabled them to do a lot more than just update the permitting process. They also used the Common Ground methodology to respond faster to reports of communicable disease, better track public health violations, and eliminate lead paint exposure.
Background of Matt Stefanak: Matt Stefanak became Mahoning County's first full-time health commissioner in 1988, at age 31. One of his motivating factors in taking the job was the chance to live near the Pennsylvania farming region where he had grown up and where family members are fourth-generation farmers. Another factor was the chance to apply lessons about population health that he had acquired in the very different landscape of sub-Saharan Africa.
In 1985, after earning an MPH from Johns Hopkins University, Stefanak moved to Africa where he began working on famine relief for a nongovernmental organization under contract with the U.S. Agency for International Development. His duties included nutritional surveillance and managing feeding stations for malnourished children. Later, as a Peace Corps volunteer, he was assigned to a UNICEF-funded child immunization program in Zaire, where he was part of a vaccination team working on a measles eradication campaign.
The team established a system for hospital distribution of immunizations and conducted mass vaccinations in the city of Goma, achieving a very high coverage rate. "I saw what an impact an efficient system could have on population health. It was quite dramatic in terms of reducing measles and related illnesses among hospital patients."
The Common Ground Project: The 175,000 residents of the villages and townships in Mahoning County are very different from the people of sub-Saharan Africa, but to Stefanak they have much in common, including the need for an efficient, consumer-oriented public health system. In 2007, that system wasn't in place for builders and prospective homeowners.
"Homebuilders in Mahoning County may need to obtain permits or licenses from as many as nine different regulatory agencies. One is the District Board of Health, which issues permits for septic systems, wells, and plumbing. In 2007, hundreds of new single-family homes were going up each year, each representing a new customer encounter with the regulatory systems and with public health. The fees from the permits were a major source of revenue." Changing environmental standards and an organizational commitment to continuous quality improvement made Stefanak eager to revisit the permitting process.
A new road map. A mix of public- and private-sector players came together to analyze and redesign the approach. The "usual suspects" in government included representatives of the zoning department, sewer district, planning commission, soil and water conservation district, the Ohio Environmental Protection Agency, the road department, and the building inspection department. Also invited were home builder associations, realtors, and septic contractors.
"Sitting with other regulatory agencies, we realized we lacked a common understanding of how these moving parts fit together." The partners used the tools of business-process analysis to review the existing permitting process and found opportunities to improve efficiency and effectiveness. "Thanks to the patience of our partners, we put together a picture of how we are related and how a customer moves between agencies.
"Struggling with these partners to grasp the way things were was really a lot of fun, and we appreciated their willingness to make changes. Realtors and industry representatives were delighted that we invited them to sit down and that we were sincere in our efforts to understand how the regulatory process affects them and then take steps to make the process more efficient."
The struggle paid off with a new web-based "roadmap" for obtaining the necessary regulatory approvals. In June 2008, 80 copies of the guide, called Building a Home in Mahoning County Townships, Villages, and Cities of Campbell and Canfield: A Guide to the Regulatory Permitting Process, were distributed to home builders, realtors, and zoning officials.
Reducing response time to telephone-based disease reports. Stefanak also used business-process analysis and redesign to respond to a very different challenge in 2008. A RAND study had reported that fewer than one-third of sampled local health departments were able to respond to telephone-based communicable disease reports within 30 minutes, the standard recommended by the Centers for Disease Control and Prevention (CDC).
Mahoning County decided to gauge its own performance. Staff at the regional crisis call center telephoned the health department to test scenarios such as a school nurse calling about a potential infectious disease or an emergency room physician calling after hours about a raccoon bite. A team of health department staff, including nurses, secretaries, epidemiologists, and managers, then met for four one-hour sessions to review the agency's process for responding, using Common Ground analytical tools.
By creating a task-flow diagram, the team saw the confusion that occurred at each level when a telephone report was received during regular business hours. Multiple entities could be involved, increasing the likelihood that the call could be routed to the wrong person or to a voice-mail box not continuously monitored—or simply lost.
In contrast, the after-hours process was more straightforward. A caller followed prompts to leave a message in a designated voice-mail box that in turn automatically called the cell phone of an action officer. The team identified this as a useful model, redesigned a similar process for normal business hours, and trained health department staff in its use.
In successive rounds of test calls, median response time fell from 42 minutes to about 13 minutes in the second round of calls and to one minute in the third round, meeting the CDC standard. The study was published in Public Health Reports.
Tracking public health violations. Public health departments also serve as "health cops, taking people to court for violating public health regulations," Stefanak said. The two most common violations in Mahoning County are discharging pollutants into water and open dumping of solid waste.
Charging people involves a complex process of working with county courts and filing claims, and the caseload is large—more than 200 at any given time. "We didn't know where a lot of cases were, and it was important to find them so we started by mapping the process from when a complaint comes and following it through an internal administrator to the court. We developed a tracking tool that allows us to locate cases, find out how long they have been in court, and what adjudication was issued. That was a massive improvement," said Stefanak.
In the last three to four years, the tracking system has helped with another problem—an influx of housing complaints related to abandoned properties. With the complaint tracking system, the county has been able to tell the story of blight to funders and legislators through numbers and pictures. This helped the county win $3 million in federal aid to demolish abandoned structures.
"The county hasn't won the war on blight, but we're halfway through," said Stefanak. As land banks take title of abandoned properties they transfer them to neighbors for a larger footprint or give them to community groups for use as community gardens, helping to stabilize neighborhoods.
Preparing for accreditation. Mahoning County was one of 30 health departments around the country selected to test a national voluntary accreditation program for public health funded by RWJF.
Mahoning County submitted the roadmap for regulatory approvals developed under Common Ground to fulfill its requirements as a beta test site and went on to submit documentation to apply for full accreditation at the end of 2011. Now, said Stefanak, "we're at the head of the line and will be given expedited review by the Public Health Accreditation Board. We hope to be first public health department in Ohio to receive accreditation."
Grantee Perspective: Stefanak retired as health commissioner in June 2012, but before he took this step, he said he "wants to make sure child lead poisoning is a threat of the past." Once again, Common Ground business analysis tools are helping.
"Process maps are powerful tools. The data that we have mapped and shared with city councils and mayors shows the extent of disease. Toxic houses, houses that have lead hazards are evocative images for policy-makers, like the mayor, who has appointed a special prosecutor to investigate the problem."
After retirement, Stefanak plans some writing and some part-time farming, but the "other part" will be public health. "I want to stay involved in exciting initiatives like promoting accreditation and quality improvement in public health and encouraging the use of best practices." Stefanak is working on an RWJF-funded grant that runs through the end of 2012 to advance education, training, and financial analysis in public health. (Grant ID# 67015 in Robert Wood Johnson Foundation Practice-Based Research Network in Public Health. The grant will formalize and expand a growing relationship among public health practices and researchers in Ohio. The network's first project will investigate the capacity, nature, and extent of local health department member use of public health informatics for measuring and improving quality of service, and for community health assessment and surveillance.)
Business-process analysis is "one of most important tools in our toolbox," said Stefanak. "It had a tonic effect on quality improvement teams, who thought that the pace of quality improvement was too slow and costly for improvements gained. We were able to show that business-process analysis could make measureable changes with a more modest investment of time."
RWJF Perspective: In funding Common Ground, RWJF wanted to strengthen state and local public health departments to help them perform better in the face of increasing challenges of bioterrorism, emerging infections and potential pandemics, and burgeoning rates of chronic disease. To meet these challenges health departments needed to develop and use more sophisticated information systems than they currently had.
Public Health Informatics Institute's methodology offered an innovative process and set of tools that enabled health departments to improve their use of information systems. But, as Matt Stefanak and many other state and local health department leaders found, the tools of business-process analysis and redesign could be used not only in the design of information systems, but in quality improvement as well.
"That was a benefit that we weren't anticipating," said RWJF Senior Program Officer Pamela G. Russo, MD, MPH. "The application of business-process mapping to process improvement was a huge step toward quality improvement in public health."
Former RWJF Senior Program Officer Terry Bazzarre, PhD, MS, agrees. "Over time, it became clear that the Common Ground approach was an alternative way of doing quality improvement, focusing specifically on how the work gets done and the business processes that contribute to it."