The Spokane Regional Health District—one of 34 local public health agencies in Washington state—serves a population of more than 400,000 in Spokane County. The district was one of six health departments around the country to receive a public health preparedness grant in 2006 under the Robert Wood Johnson Foundation (RWJF) Common Ground: Transforming Public Health Information Systems program. Common Ground was a three-year, $15 million national initiative that awarded 31 grants to state and local public health agencies to to develop information information-system requirements and designs, and begin the process of implementing these systems in order to meet the challenge of preparedness for bioterrorism, emerging infections, and potential pandemics—and the burgeoning rates of chronic disease.
Lloyd Lee (Torney) Smith, MEd, is Spokane's health district administrator. With degrees in economics and health education, he is accustomed to asking business questions about public health. "What can we do to assure that we are using public dollars as wisely and effectively as possible?" is one of his key questions. "What is it that makes one agency stand out beyond others when we are all in the same field?" is another.
Smith is interested in using technology as a quality improvement tool, but he is cautious about how to do that. "We have all kinds of tools in terms of quality improvement but they should be there to serve us, not the other way around. We shouldn't be slaves to technology. Tools should make routine jobs more efficient and reduce the time it takes to complete mundane tasks."
That goal, coupled with Smith's commitment to collaboration, helped influence information systems not just in Spokane, but across the state of Washington at the local, regional, and state levels.
The Challenge: During infectious disease outbreaks and other communitywide health emergencies, state and local public health agencies need a sophisticated system that can coordinate the exchange of information with community partners, such as fire, police, and hospitals. In Washington, that system is operated by the state health department, through a federally funded Public Health Emergency Preparedness & Response program that encourages coordination and resource-sharing. It conducts its emergency preparedness activities through nine regions, with one local health jurisdiction in each region designated as the lead agency.
The Spokane Regional Health District is the lead for Region 9 which covers Spokane and nine other counties in eastern Washington. As its administrator, Smith works with a regional emergency response coordinator to help each public health jurisdiction create a local preparedness plan and to collaborate on a regional plan that ties the local plans together. In 2006, Smith saw a great need for an improved information system to support the region's preparedness program.
By participating in Common Ground, Smith hoped to address the underlying issues that prevented interoperability between public health, the health system, and other community partners. "One of the places where downfalls occur during emergencies is a lack of effective communications. In emergency situations, it's important to share information effectively across systems, but we were doing that in less than stellar fashion when Common Ground came along."
Building an alerting system for the state and county. In the first year of the Common Ground Spokane grant, health district staff coordinated business-process analysis trainings for community partners, including health care providers, local emergency responders (fire and police), mental health providers, and nursing and pharmacy schools. Representatives from the Washington Department of Health participated in the training as well.
State public health leaders quickly saw involvement in Common Ground as a way to meet a critical need for a more interconnected, robust, and, efficient alerting system through which to communicate. Earlier, the health department had implemented an online alerting system to improve emergency response, but it was costly to maintain and difficult for some of the partners to use.
The state's director of informatics knew that the first step to improve the existing system was a better understanding of the state's information needs. Becoming more fully involved in the business-process analysis initiated by the Spokane Health District was an invaluable way to gain that understanding at a statewide level.
In 2008, Smith and his regional team joined staff of the state health department and other public health agencies to form a 16-member Statewide Alerting Communications Advisory Group. Using Common Ground tools, the advisory group agreed on an alerting communication context diagram, 11 task flows describing the current work flow, and a business-process matrix.
Next, the group identified 124 functional requirements of a sustainable alerting communication system capable of efficient, two-way information exchange. After approving the functional requirements in June 2009, the Public Health Information Technology workgroup engaged an information technology expert to draft information system requirements.
Political and financial realities intervene. The advisory group evaluated existing systems against the functional requirements and provided a cost-effectiveness/benefits analysis of various options. After a 2010 meeting, members concluded that the best approach would be to build a new system, rather than to modify existing ones. However, as they made their recommendations, they learned that the governor had issued a directive to the department of health that, given the current bleak economy, no new systems could be built.
At the end of 2011, Smith reported that the alerting project is on hold while the state continues to use its existing system. He remains optimistic that the project will eventually move forward.
Regardless of the outcome, Smith believes that Common Ground has left behind an important legacy—an effective methodology for improving work efficiencies and determining user needs for information technology. Because of it, state health department staff has institutionalized the methodology that they will use before building or purchasing any information technology product in the future.
Spreading Quality Improvement Agency-Wide: In addition to the state alerting system project, Smith has integrated business-process analysis into the Spokane Regional Health District's quality improvement efforts. A cross-divisional Quality Council, established in 2007, works on continuous quality improvement both agency-wide and program by program. The Quality Council was recognized as a Model Practice by the National Association of City and County Officials in 2009.
"Common Ground allowed us to educate more people in our own agency around business-process analysis," said Smith. "As people understood it better, they were able to evaluate the current state of affairs, reach consensus about what they would prefer and dialogue about how to get there through system redesign.
"We also recognized that business-process analysis is just one of the tools we are adding to our toolbox. Business-process analysis is phenomenal for some things, while other tools, plan-do-study-act, for instance, work better in different circumstances. Early on, people were somewhat confused and would ask, 'Why or when do I use one over the other?' We became more sophisticated in how to decide which tool to use in what circumstances.
"In my estimation," added Smith, "business-process analysis is valuable when you're looking at creating change across an organization or division because it engages many people in the decision-making process. People are much more likely to support implementing a change down the road if they've had a say in identifying the need for it.
"Business-process analysis can be deceptively simple," added Smith. "When you are doing a context diagram, for example, it seems elementary—putting circles and lines together—but as you build it, there is always an 'aha!' moment."
As an example, Smith pointed to the Women, Infants, and Children (WIC) program. The team decided to use business-process analysis to examine reception services and client flow to make sure there was consistency across program sites.
"As the receptionist described the client referral process, the program manager, a bright, talented woman who had run the program for more than 15 years, realized she had been unaware of what was going on. That led to important dialogue about how clients should be referred and why. The manager understood the receptionist and vice versa. You don't have that happen in other methodologies.
"We see employees react with surprise when they see they are doing a task in three different ways in different places. It's blatantly obvious when you're going through the tasks using business-process analysis. In the redesign phase, we ask, 'How should we make it work and why? When you have engagement of all the folks and their agreement with the redesign process, implementation is a piece of cake."
Other programs that have used business-process analysis to improve efficiencies and cost recovery include methadone, breast and cervical health, and the sexually transmitted disease reporting and investigation program.
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."