Eliminating Delays in Identifying Children with Birth Defects

Key project goals and outcomes were as follows: Goal: Decrease the amount of time between the initial report and nurse review by 50% over the next 6 months. Outcome: The maximum number of days to completion was reduced by 53%, from 406 days to 192. The median amount of time to completion dropped by almost 27%, from 49 days to 36 days. Goal: Decrease team reviews by 25% over the next 6 months. Outcome: The number of cases sent to team review was reduced by 85% (from 40 to 6), which reduced the number of handoffs and waits. This project established a more efficient process for identifying children with birth defects and classifying these conditions consistently. Throughout the past year, staff monitored progress each month and shared ideas about what worked. The changes detailed as follows have resulted in dramatic improvements to timeliness, which results in earlier referrals to services and assurance that families of children with birth defects are well supported in their communities. • Improved transparency: This project improved transparency by process mapping, which clearly identified the tasks, handoffs, and bottlenecks that led to unnecessary delays. Program epidemiologists developed new measures for assessing the timeliness of case identification bimonthly. Box-and-whisker plots were an effective way to visually display how long the data collection process was taking because they show the range of days to completion for the majority of cases, as well as extreme values. (Please see the attached storyboard titled “Birth Defects Data Collection Kaizen.”) • Decreased process time: The median time to completion dropped by almost 27%, from 49 to 36 days; the maximum number of days to completion was reduced by 53%, from 406 days to 192 days. Regular monitoring of timeliness and increased understanding of workflows likely helped reduce the median time to abstract case information by 18.8%. The nurse reviewer achieved impressive improvements by focusing on clinical tasks and improving workflow monitoring. The median amount of time to complete nurse review, the final step in identifying a child with a birth defect, fell by 50%, from a 14- to 7-day turnaround. • Staff reassigned to more critical and appropriate activities: To focus on the critical responsibility of the nurse reviewer, extraneous tasks were reassigned to other staff. The nurse now prioritizes clinical review and quality assurance, which is largely responsible for the 50% reduction in median time to complete nurse review. • Successful implementation of a new process or tool: This project successfully implemented a new tool—a consolidated, centralized manual for consistently coding birth defects. Staff accepted the consolidated coding manual as the sole reference document and were comfortable with “retiring” their old references, which had led to inconsistent application of the coding criteria and unnecessary rework. • Increased adherence to best practices: Regular re-abstraction is a best practice for assessing agreement and consistency between coders. The consolidated coding manual was tested in late 2013 when staff resumed regular re-abstractions to ensure that data are collected and classified consistently; the team identified and reviewed three miscoding errors to ensure correct understanding of criteria. • Reduced defects, mistakes, or rework: The process of resolving coding questions changed to eliminate unnecessary handoffs—most issues are now resolved between the lead abstractor and nurse, not sent to the monthly team review meeting. The nurse now sends the outstanding questions directly to the medical specialist for consultation. Both of these changes reduced delays by weeks or months.

The team achieved the following additional outcomes: • Scheduled time for reviews and set daily goals • Consolidated codes and guidelines for abstraction • Updated MEDSS • Revised relevant standard operating procedures and policies • Streamlined meetings and monitored timeliness bimonthly • Avoidance of potential future costs: The Minnesota Department of Health contracts with medical specialists to consult on extremely rare and complex birth defects that require their specialized expertise to ensure correct classification. The contract cost has been reduced because there are no longer pro forma reviews when classification is straightforward (e.g., when a child has died because of a fatal birth defect). In the prior year, $3,150 was spent for genetics consultation, most of which was used to review cases with no specific coding questions.

It was extremely helpful to have one assigned person with data collection expertise to collect data for the project measures before and after the Kaizen event.

The team will continue to monitor timeliness of the surveillance process to ensure that improvements are sustained.