Paul Kuehnert, RN, MS, became executive director of the Kane County Health Department in Illinois in 2006, the same year the county became one of 15 health departments to receive a Informatics Capacity grant (ID# 59788).
Common Ground was a three-year, $15 million national initiative of the Robert Wood Johnson Foundation that awarded 31 grants to help state and local public health agencies develop information system requirements and designs, and begin the process of implementing these systems so they could better respond to health problems. The Informatics Capacity grantees received awards of up to $30,000 for 15 months.
Kuehnert, who had spent the previous seven years building integrated public health information systems for the Maine Bureau of Public Health, saw that Common Ground could be "transformative for Kane County. It was an opportunity to bring some new and badly needed tools to assess and redesign emergency preparedness, response, and recovery business processes."
Baptism in Public Health: Kuehnert's interest in informatics stems not as much from a love of technology as a dedication to community health. After earning his RN degree and working in acute care nursing in Illinois for two years, Kuehnert returned to his hometown, St. Louis, in the late 1970s.
There he had what he calls his "baptism" in public health. He worked first as a nurse in a Head Start program and then spent the next six years in the St. Louis Public Health Department, involved in school health, sexually transmitted diseases, and lead poisoning.
Back in the Chicago area in the late 1980s, he joined the Village of Oak Park Health Department where he helped found Community Response, Inc., a community-based health agency that became one of the largest HIV/AIDS housing and social services organizations in the Chicago area, serving about 250 clients. During this time, he completed a master of science degree, with concentrations in public health nursing and public health, at the University of Illinois in Chicago.
A Systems Approach: In 1999, Kuehnert joined the Maine Bureau of Public Health. His early work involved developing a grassroots presence in the state to strengthen the public health infrastructure. "But with the anthrax attacks of 2001," he said, "We saw this approach was insufficient to meet the challenges posed by the threat of bioterrorism. We needed to be able to do infectious disease surveillance and have a governmental tie into emergency management and law enforcement, which we did not have with community-based organizations."
At the time of the attacks, Maine employed "only three epidemiologists for the entire state, and they were all in the state capital. We had no direct infrastructure on the local level. Providers were reporting data to the state headquarters, but it was all by telephone or paper-based."
After receiving emergency preparedness funds from the Centers for Disease Control and Prevention, Kuehnert helped to develop a regional infrastructure connecting public health and medicine and to create six regional epidemiologist positions within offices of emergency medical services.
These experiences taught Kuehnert some important lessons. "I've been at a time and place when developing new systems was necessary. This was true when I helped our health department respond to the HIV/AIDS epidemic in the 1980s. It happened again when I was with the state health department in Maine during the 9/11 attacks and bioterrorism threats. We saw that, to respond rapidly to threats, one of the principal needs was a better communication infrastructure connecting the health system and public health."
Building a Preparedness Infrastructure: Kuehnert brought these lessons to Kane County's Common Ground project. The health department, located in Aurora, Ill., 40 miles west of Chicago, serves a diverse, rapidly growing population of 480,000.
It is the only county in Illinois where the health department director also has executive leadership of two departments critical to emergency preparedness. One is the Office of Emergency Management; the other is Animal Control. Animal control is critical, Kuehnert noted, because so many bioterrorist threats and emerging infectious diseases are transmitted from animal to human.
In 2006, the three departments were not communicating effectively. The problem was "silos," said Kuehnert. "Each department had its own stream of categorical funding. There really wasn't an overarching strategy or focus for the entire organization."
With the resources of Common Ground, Kuehnert had a unique opportunity to assess and redesign interdepartmental communication and other business processes related to emergency preparedness, response, and recovery plans and operations. The idea was "to take down some silos."
Operation Heatwave. In the upper Midwest, as in many parts of country, heatwaves pose significant threats to human and animal life. "A tremendous result of our Common Ground project has been the creation of a systematic, coordinated plan for a county-wide response to heat emergencies," Kuehnert said.
The first step—using business-process analysis to understand the county's current response to heat events—led to some important discoveries. The three critical departments were engaged in parallel but separate responses, often duplicating their public information efforts and, as a result, sending out slightly different messages.
"Pet owners would get one set of advice from animal control about how to take care of animals during a health alert or watch. The health department would use slightly different language, as would emergency management when it communicated to police, fire, and EMTs [emergency medical technicians]."
Using business-process redesign, the three departments came up with an enhanced plan that has three levels of response to varying degrees of heat severity—watch, advisory, and, at the highest level, warning—meaning an extreme heat emergency posing a threat to life or property. A communications protocol included a clearly identified spokesperson and harmonized messages for the general public, health care providers, and emergency responders.
The redesigned plan was finalized in the winter of 2008 and has been implemented every summer since. "Fortunately, said Kuehnert, we have not gone beyond the advisory level, but we had periods in summer 2011 with three to four days of excessive heat with power outages. The great thing about the Common Ground tools is the way they allow us to fine tune the plan every year to improve our response."
Communication: the Achilles heel. With the success of Operation Heatwave, Kuehnert was ready to apply Common Ground tools to improve communications, which can be the Achilles heel of a timely response. "We have the second and ninth largest cities in Illinois (Aurora and Elgin). The rest of our municipalities are relatively small (25,000 to 50,000 people) and we have still larger rural areas. As part of Common Ground, we wanted to use information technology to do a better job of communicating and coordinating with our 29 different jurisdictions during a disaster."
The solution Kuehnert and his team came up with was a virtual Emergency Operations Center. "Typically the way Emergency Operations works during a disaster is to create a command center for centralization of information and coordination of resource requests. That's a problem in a jurisdiction like ours. A virtual center would avoid making everybody come to the same location.
"We would be able to have the Aurora fire chief join in a coordinated response from his own desktop, instead of dispatching staff or coming to the County Emergency Operations Center during a heat or other emergency."
A countywide planning group explored the use of a web-based platform to enhance communication and resource requests, and ultimately customized and tested a software system—the Disaster Management Information System—countywide.
The economic downturn prevented the planned implementation of the program, according to Kuehnert who, in 2012, became team director and senior program officer for the RWJF Public Health Team. Thus, he rates the project a "partial success in that the Disaster Management Information System was implemented for a period across the county, but it was never rolled out to the municipalities and has not been maintained as a tool outside the County Emergency Operations Center."
Getting ready for accreditation. Since 2007, Kane County has institutionalized Common Ground tools and used them to make a significant culture change around quality improvement. "That has helped us in the last couple of years as we faced significant downsizing and reorganization. It has also enhanced our readiness to take on public health accreditation."
Illinois was one of 16 states funded under the RWJF national program, Lead States in Public Health Quality Improvement, which ran from 2006 to 2012. Kuehnert was Kane County's representative on the state's accreditation task force and participated in statewide efforts organized by the Illinois Public Health Institute to prepare for accreditation and improve quality. Of some 90 health departments, Kuehnert notes that Kane County was among the most active in advancing the conversation about quality and accreditation.
Grantee Perspective: For Kuehnert, Common Ground was proof that a "relatively modest grant" (Kane County's award was $29,649) could have a "huge impact. Starting out small with a very concrete project like Operation Heatwave was a very good gateway to quality improvement for an organization that had not done process improvement before, let alone tried to implement management information systems. Getting leadership, staff, and stakeholders involved, we were able to move from Operation Heatwave to a shift in culture.
"I trace that back to the impact of Common Ground. It demystified business-process analysis and made it very accessible to us. It gave us tools to engage our stakeholders by opening up our internal processes to them which gave us very important feedback and direction. Oftentimes people are hesitant to share their internal processes publically, afraid that stakeholders will see mistakes and inefficiencies. Instead the reaction was, 'Now I can see what you've been doing.'
"The Common Ground methodology is compatible with the idea of transparency. If you are serious about serving the community, you need to have a way of letting people understand what you are doing and allowing them to give their input. The good news is people like that and give you credit for trying to make improvements."
RWJF Perspective: In funding Common Ground, RWJF wanted to strengthen state and local public health departments so that they could perform better in the face of the increasing challenges of bioterrorism, emerging infections and potential pandemics, and burgeoning rates of chronic disease. Meeting these challenges required health departments to develop and use more sophisticated information systems than they currently had.
Many state and local health department leaders ultimately found that the Common Ground tools-business-process analysis and redesign-could be used not only to design 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 Program Officer Terry Bazzarre agrees. "Over time, it became clear that the Common Ground approach was an alternative way of doing quality improvement in public health, focusing specifically on how the work gets done and the business processes that contribute to it."