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QI Leaders Academy Kaizen Program: “There’s Got To Be a Better Way!”: Getting Vaccination Records into NextGen
Summary
Impact Statement:
Columbus Public Health (CPH), a local health department in Ohio, was bogged down by a slow, costly process to administer vaccines to children at schools. By using PDSA and a Kaizen event approach, CPH increased the timeliness and efficiency to document the immunization services and decreased its administration costs. As a result, vaccination records will be more accurate and universally available to other providers, CPH can free up staff to help more children receive immunizations, and revenue from insurance billing will be received faster.
Summary:
CPH used the Kaizen event approach to complete all steps of the improvement cycle in 5 days. The steps were as follows:
- Understand the gap/goal and the current state in order to identify waste in the targeted work process.
- Analyze the root causes of the prioritized issues to identify solutions.
- Develop and test solutions to learn.
- Continue to develop and test solutions to learn.
- Install improvements and create a system for ongoing improvement.
As the event progressed, many QI and change management methods and techniques were applied.
Documentation of vaccinations administered in schools was taking too much time, producing potential errors, and costing money because contract employees are used to do the data entry. The staff wanted to remove all need for external workers and to incorporate the work so that the records would be entered in real time.
Organization that conducted the QI initiative:
CPH
Citation:
Dietsch, MPH, L. Public Health Quality Improvement Exchange. QI Leaders Academy Kaizen Program: “There’s Got To Be a Better Way!”: Getting Vaccination Records into NextGen. Thu, 11/16/2017 - 14:30. Available at http://phqix.org/content/qi-leaders-academy-kaizen-program-%E2%80%9Cthere%E2%80%99s-got-be-better-way%E2%80%9D-getting-vaccination-records. Accessed April 25, 2024.
Background and Aim
Aim statement:
The aim statement goals were as follows:
1. Decrease the amount of cycle time spent getting records into the NextGen electronic management system (EMS) for submission to the insurance companies for reimbursement by 50%. (The overall process begins with a letter to parents and ends when records are submitted to the billing department to be processed. The portion of the overall process targeted for cycle time reduction was the time from completion of vaccinations at a school to the electronic records being saved into NextGen. The project scope is influenza and TDAP.)
2. Absorb the need for contract labor and associated resources used in the past without adding personnel to CPH.
Need For The QI Initiative:
Public Health Accreditation Board (PHAB) QI Leaders Academy Kaizen program: This project was selected for Kaizen training and application.
Timely and efficient inputting of records into the EMS is a revenue-generating process. If the records are not submitted to the insurance companies without errors and within a set amount of time, then the reimbursement is rejected. From October 1 to December 31, 2014, 4,578 influenza vaccines were administered by CPH’s Strategic Nursing Team. Data entry staff required more than 85 days (680 hours) to enter the records and submit them to the billing department. These vaccinations occurred during the 2014–15 school year at various Columbus school locations outside CPH's main building.
The immunization data entry process involves a slightly different procedure for entering data as it does elsewhere in CPH. Instead of a record being entered at the time of service, the data entry forms are brought back to CPH and given to a temporary staff member or contractor to enter. The data entered by these people affect not only internal customers (such as billing and nursing staff), but more importantly the external customers. The current process is pulling staff from their regular jobs to prepare the documents and train the rotating contractor staff, which is a time-consuming process. This year, there were eight different data entry contractors. This pulls staff from being able to process the records for submission to the insurance companies for reimbursement. Accommodating the current process results in a large amount of wasted staff time and resources.
Area for Improvement:
The need (e.g., outcome) or gap that caused this project to be considered in the first place is discussed above in the "Need for the QI Initiative" section.
The billing staff and staff from the Strategic Nursing Team established the need for the QI initiative.
The need is being measured using the following parameters:
• Number of children vaccinated or forms counted to measure volume
• Number of records entered (including the number of demographic records per day, the number of administration records per day, and the total records)
• Amount of staff time involved (e.g., training contractors, preparing work for contractors, answering questions, logistics)
• Amount of time and money paid for data entry staff time
• Lost revenue or error rate
• Duplicate vaccinations due to lost records
Data and analysis used to establish that this project will make a key impact were as follows:
• Number of students is 49,000.
• Number of data entry forms or vaccinations administered is 4,911 influenza immunizations and 433 TDAP immunizations.
• Timing is October through January for influenza immunization and April through May for TDAP immunizations.
• Cycle time is approximately 85 days (680 working hours).
• Work content is approximately 1,150 hours for contractors.
• Demographics programming is approximately 50 per day. Administrative programming is approximately 50 per day. Total per day is 25.
The scope (e.g., geographic, organization, customer) that the project is expected to affect is as follows:
• The process begins with a letter to parents. The Strategic Nursing Team administers the vaccination to students in the school, collects the data entry forms, and submits them to the lead registered nurse to double check for completeness or errors. The lead registered nurse then turns the forms over to the billing department to prepare for data entry.
• The process ends when the record is submitted to the billing department and is ready for processing for the insurance companies.
The following conditions are being placed on this project (leadership requirements or boundaries):
• The project is not allowed to violate civil service or union rules.
• All solutions with associated costs need to abide by City of Columbus rules and to be approved by leadership.
• The solutions must fit within resource or budgetary availability, but the project ideas are not to be limited simply on the cost aspect.
• The project does not include the billing review process and submission to the insurance companies.
The team envisions a fast work process that enables them to help more children receive immunizations. They envision documentation in the EMS that is complete and correct the first time without being a hindrance. All areas that use the EMS are paper free.
The current state is as follows:
• Customers: Difficulties in filling out forms may make parents less inclined to have their children immunized. If the process of submitting information is clearer and simpler, the immunization rate may be improved.
• Financial
• There is currently a cost to hire contractors to enter the records (roughly 3 people for 3 months, 4 days per week).
• There is a cost to train and manage the contractors.
• The amount of money reimbursed from insurance companies may be less than the doses administered.
• The contractor cost is $12,775 (not including training and management).
• The team
• Staff spend a large amount of time preparing records for contract staff.
• Staff spend a large amount of time training contract staff in NextGen only to have some of the contractors not return the next day—the process starts over again.
• If a mistake is made in the data entry process, the billing staff need to fix it before submission to the insurance companies.
Root Cause:
Root causes are as follows:
• Issues with communication with schools
• Unclear roles and responsibilities
• Staffing options at CPH and on site
Planning and Execution Details
QI Implementation:
Kaizen event (Confirm, Prepare, Perform [July 13–17], Institutionalize)
A team of 10 individuals sequestered themselves in a room for 5 days in order to conduct a Kaizen event.
Day 1: The first day was spent drilling down into the current state and truly understanding the process. The team walked through the entire process. There were various times when statements such as "you do that," "I didn't know we did that," and "why do we do that?" were shared.
Day 2: The team started to identify value and waste throughout the process. "We spend time at the schools checking the forms for completeness and accuracy and many times have to call parents to get questions answered." "This form is getting checked multiple times when it gets back to CPH. Are all these check points looking at different things or is it redundant?" The team was not looking for solutions yet; they were simply identifying potential areas of waste. The team ended the day by starting to look at the new state, understanding that if they were going to eliminate the work of the contractors that their tasks would need to be absorbed into the process somewhere.
Day 3: The team performed a root cause analysis, looked at a waste analysis spreadsheet, and started to draft the new state diagram. The team also came up with three areas where solutions could be implemented: clinical components, school coordination, and EMS solutions.
Day 4: The team developed the job aids necessary for making the solutions viable. The second part of this day was spent testing the time it would take to enter the data in real time. The tests were successful in demonstrating that each electronic record could be entered three separate times in the process. Now the data would be entered by CPH staff and would be more quickly available for the billing staff to inspect for submission to the insurance companies for reimbursement.
Day 5: The team continued the testing and learning phase, then made an action plan for the rollout. The team then took turns and presented the findings to the leadership. This included a list of needs from leadership in order to succeed.
When the process was complete, the team had saved CPH $12,000 in contracting labor as well as the vast amount of time being spent to train and manage the contract staff. The desire was to absorb this labor without adding any resources, but the team did ask for a half-time clerical staff member in order to help the process. Still, the records are being entered in real time, which is a 33% reduction of cycle time.
QI Tools:
Other QI tools:
Value-stream mapping
Working with others, goal statement, measure definition sheet, stakeholder analysis, communication strategy, daily newspaper, PrISM, gather practical knowledge, value/waste analysis, single-topic guideline, ROAMMM, action item worksheet, lessons learned
QI Tool Documentation:
Initiative Dates:
4/1/15 to 12/31/15
Initiative Duration:
Between 6-12 months
Methods of evaluation:
The evaluation will be measured by the following:
• Reducing the amount CPH spends on contractors for data entry per year (target: 100%)
• Comparing the current process full-time equivalent (FTE) staff to the new process FTE staff (target: total FTE staff internal to CPH will remain unchanged [i.e., absorb contractor tasks into the same number of total FTEs])
• Reducing the time from identification of notification/form/letter to when the immunization record is saved in NextGen for billing (target: 50%)
• Reducing the time from vaccination to when the record is saved in NextGen for billing (target: >95%)
Results
Measurable QI Outcomes:
Measurable QI outcomes included the following:
• Reducing the amount CPH spends on contractors for data entry per year. (Achieved 100% reduction: $12,000.)
• Comparing the current process FTE staff to the new process FTE staff. (FTE hours were absorbed, along with adding one half-time clinical staff member during the season to assist in entering data.)
• Reducing the time from identification of notification/form/letter to when the immunization record is saved in NextGen for billing. (Issues with the school process have caused delays in receiving the records. Staff are meeting with schools to conduct an after action review [AAR]). This part of the process was not measured. However, the schools did not make sure that the forms were completed or sent to CPH in a timely manner. The schools stated that they did not know that the process was different, which was an internal issue for the schools. The AAR and planning sessions with the schools will assist in identifying what both sides need in order to implement this process more efficiently.
• Reducing the time from vaccination to when the record is saved in NextGen for billing. (Results are unknown at this time; there were connectivity issues in some of the schools, as well as incomplete forms that caused delays. However, the nurses said when the process worked as planned, it was great. Overall, there was a 33% decrease in cycle time.)
Other QI Outcomes:
Separate from this initiative, a group of people developed a clinical form that would be distributed at the beginning of the school year and would contain information on vaccinations, dental sealants, and services that Children's Hospital performs in the schools. The team planned scenarios for situations when they needed to use that form and for schools that did not use the form. The new school form was not released for use in time, so the city school nurses assumed that the process was the same, despite communications stating differently. This caused other issues to appear. These issues will be addressed in the AAR.
Lessons Learned, Observations and Insights:
Testing of the solutions during the Kaizen event demonstrated that the process could work. A clerical staff member would enter the demographic information, and a clinical staff member would open the record and conduct a screening and ordering process in the system. This was the last data entry step to be taken on site after a clinical staff member administered the vaccine. Developing job aids allowed the test performers to clearly execute the process the first time through. The pictures/screen shots in the user manual were helpful, but a check sheet or flow diagram would also have been useful. This step helped the staff to identify more unanticipated issues before the process began.
Conducting change management with the schools was helpful, but the team learned that CPH staff need to be more specific about what is needed and by when. It also might help to tell the school staff why certain decisions were made. It will also be good to hear what struggles occur on the school side so that CPH can adjust as needed.
The external immunization process and use of certain screens in NextGen need to be standardized.
The new consent form process will cause things to get more complicated. Working with the schools this summer will be crucial to the process working in fall 2017.
Future Plans:
Future plans include the following:
• Create a high-level cheat sheet for entering data, so trained users do not miss steps.
• Create a down-time (paper) process, so system issues do not stop the clinic.
• Highlight job aids, so it is easier to find information.
• Create a role playing process and NextGen training, so performers understand all roles and have context.
• Update the NextGen manual, so it reflects the standard process.
• Create a filing process with a routing slip that matches the process, so important consent forms do not get misplaced.
• Create consistency between the screening form and NextGen, so users do not get confused and the EMS contains correct data,
• Make a wish list of needed equipment for the new process.
• Make a list of schools to add to NextGen.
• Give NextGen training to the Strategic Nursing Team.
• Perform an equipment walkthrough.
• Identify backup staff.
• Get approval of new letter/consent form for private/charter schools.
• Get the new letter/consent form translated (Spanish, Somali).
• Get multi-part immunization record cards (city printer).
• Determine how to use the “Form Completed By” and “Form Reviewed By” fields in the NextGen screening questions.
Training and Preparation
Technical Assistance Received:
The team received distance and on-site QI coaching support to co-lead a Kaizen event. The team also received additional QI coaching that covered Kaizen event preparation, foundational and advanced QI methods including Kaizen, site change management, installation of the improvements and associated results after the event, and reporting. Training was provided by Continual Impact, LLC; supported by PHAB; and funded by the Robert Wood Johnson Foundation (RWJF).
QI Related Training Received:
The team received a total of 52 hours of QI foundational and Kaizen event training, via two in-person sessions, provided by Continual Impact, LLC; supported by PHAB; and funded by RWJF.
Staff training was provided throughout the 5-day Kaizen event in order to explain the next steps in the process.
Information about the Community
Population Size:
Population Characteristics:
Columbus is the capital of Ohio. CPH is located in Franklin County, which has a population of approximately 1.2 million people.
Information about the Health Department
Local/State Relationship:
Largely Decentralized
Local Health Department Governance:
Local Governance - all LHDs in the state are units of local government
PHAB Accreditation Status:
Accredited
State-based accreditation?:
No
Annual QI Initiative Frequency:
QI activity level:
Organization Type:
QI Staff Information
Total number of Staff on QI Team:
8
Total number of FTEs on QI Team:
7.00
QI team members:
Role in the Initiative:
Team member to process owner
Role in Organization:
Director of the Strategic Nursing Team Program
FTE:
1.00
Name (Optional):
Jane
Role in the Initiative:
Team member
Role in Organization:
Manager of the Strategic Nursing Team Program
FTE:
1.00
Name (Optional):
Sherry
Role in the Initiative:
Facilitator
Role in Organization:
PI and Accreditation Coordinator
FTE:
1.00
Name (Optional):
Laurie
Role in the Initiative:
Initial process owner
Role in Organization:
Clinical Manager
FTE:
1.00
Name (Optional):
Melissa
Role in the Initiative:
Team member
Role in Organization:
Director of Immunization Clinic
FTE:
1.00
Name (Optional):
Nicole
Role in the Initiative:
Team member
Role in Organization:
Billing Specialist
FTE:
1.00
Name (Optional):
Licia
Role in the Initiative:
Team member
Role in Organization:
Immunization Data Entry Specialist
FTE:
1.00
Name (Optional):
April
Role in the Initiative:
Wildcard
Role in Organization:
Ryan White QI
FTE:
1.00
Name (Optional):
Kathryn
Role in the Initiative:
Team member
Role in Organization:
School Liaison
FTE:
1.00
Name (Optional):
Jennifer
Role in the Initiative:
Wildcard
Role in Organization:
QI Staff Person
FTE:
1.00
Name (Optional):
Ashley
Accreditation Details
Contact Information of the Submitter
First Name:
Laurie
Last Name:
Dietsch, MPH
Organization:
CPH
Submission Status:
In Progress
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Comments
Did this process impact
Did this process impact timeliness for immunization data entry into a state immunization registry? Does Next Gen and State Immunization Registry 'talk' to one another? Who enters that data into the registry, if used?
Bethany Bjorklund RN, BSN
Immunization Nurse
Cerro Gordo County Department of Public Health