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Brian Lentes:
Okay, we’ll go ahead and get started. I hope everyone can hear me out there. Good. Okay, good. So welcome everyone to this session. We’re very excited to have you here. Good afternoon, too, and thank you for joining us here at this convening and for this breakout session. We’re very excited to have you discuss our topics on performance improvement. And this is our session today titled, “Accelerating Public Health Transformation, Strengthening Public Health Infrastructure Through Strategic Investment and Process Improvement.” So those of you who are PM and QI experts and just focused on process improvement, you’re in the right place. My name is Brian Lentes. I am from ASTHO.

I’m the Senior Director for public health infrastructure, working within the PHIG grant, specifically focused on foundational capabilities and performance improvement. Before I get started today, I did want to specifically thank the CDC Lauren Bartel Billick, who really helped us pull together, pull this event together, and worked closely with our speakers from our different states. She was unable to join us today, but I believe she may be on the line today. She really helped pull the content together. So thank you, Lauren. Just a few notes before we get started, I wanted to give a little brief introduction about what our content will be today.

So in recent years, the public health landscape has faced unprecedented challenges. Obviously, as we’ve talked about in the opening sessions, they’ve exposed long-standing gaps in our systems, gaps in data, infrastructure, workforce, capacity, coordination, and sustainability on all fronts, such as workforce and performance improvement, programs, and policy. But within all of the challenges lies a great opportunity, which is the reimagination and rebuilding of a more resilient and effective system based on the whole ecosystem, not just the health department, but the full public health system.

So this session is not just about recognizing opportunities for change, but it’s also about mobilizing the ideas and the resources and the partnerships needed to transform through performance improvement. Process improvement, or performance improvement, isn’t just a technical exercise; it’s streamlining those works, eliminating what doesn’t work, and then creating a system that can adapt and scale based on the work that we’ve learned, tested, improved, and rolled out at a larger scale. Today, you’ll hear from leaders who are not only shaping the transformation but living it through their health departments by means of this infrastructure grant. And we’re very grateful to have them all here today. So thank you to all for being here and for your vision. And we’ll go ahead and get started.

So today, we’re joined by our great health department leaders who will share their stories, their expertise, and hopefully you can take something away from this and take it back to your health departments. So I’ll first introduce Todd Brushwood and Stephanie Ross, both from the Florida Department of Health, Hillsborough County. Christina Brown from the Multnomah County Health Department. Michael Gedeon from Seattle, King County Department of Health, and Brooke Campos from Utah Department of Health and Human Services. So with that, we’ll take some time and begin our presentation. Todd, I’ll let you begin.

Todd Brushwood:
We’ll go ahead and stand, because I can’t see everybody. Hey, good afternoon. We’d like to tell you a little bit about Stephanie, and I would like to tell you about where we’re from, what we’re doing, and how we’re using the PHIG infrastructure grant to improve quality improvement. We’ll tell you a little bit about ourselves. My name is Todd Brushwood. I’m the performance and quality improvement manager at the health department in Hillsborough. Stephanie is a Senior Public Health nutritionist. Also, a new Greenbelt because of this program. And we’re both from that’s right, the Florida Department of Health in Hillsborough County.

So, where is Hillsborough County? So let me tell you a little bit about us. We are in the western part of West Central Florida, a county close to the water, and our health department is located close to the city of Tampa. Is within our county. Our county has about 1.5 million people, and probably about 400,000 in Tampa itself. That’s a view of Tampa from the Hillsborough River. Not as nice as the river we got outside, but it’s a pretty good river. Our mission is to promote, protect, and improve the health of all people in Florida through integrated state, county, and community efforts, and the work of this through the state is done through the 67 county health departments. We are one of them.

We’re the fourth largest in Florida. We have about 500 employees, and work through 10 different locations in our county. We provide WIC and nutrition services. We provide health education, Epidemiology, public health preparedness, STD, HIV, TB, Refugee Health immunizations, vital statistics, and we even staff the special needs shelters when the occasion arises. Which, for us, means. You guessed it: hurricanes. The Department of Health is an integrated public health system. We are accredited by PHAB, so continuous quality improvement is one of the things that drives us at the state level, and it also drives us at the local level.

How many people are familiar with the NACCHO self-assessment and the QI roadmap? Okay, so we use that as a tool to kind of determine where we are in establishing our culture of quality improvement. About every three to four years, we take the assessment. In 2020, we took the assessment and found out we were at phase four, which means in our health department, there were some formal quality improvements going on. It was in some places, not others, but we were on the right path. It also pointed out a couple of areas of improvement. One was quality improvement infrastructure. That’s what are the systems structures and the resources in place for doing quality improvement? We needed to bump that up.

The second one was continual process improvement. That’s the never-ending quest to make things better, to do root cause analysis and implement improvements. We needed to do better with those, and we knew that because we always had challenges with QI projects. Now, not that there weren’t projects going on. There were plenty of projects going on, but they were sporadic and kind of started and stopped, or sometimes they took too long. So we realized that to get more projects going, we needed to put more resources into it, and the NACCHO staff helped us discover that one of the problems was that we didn’t have enough of those resources, which meant to us, the staff.

We wanted more staff to be able to lead quality improvement projects, to go through training, introduce that, and carry those on, and that would give more staff the opportunity to participate and experience quality improvement through those projects. And so we decided to use the PHIG funds as an opportunity to do that. So here was the plan. In each of our six divisions, we were going to have at least one staff person identified to do training at the green belt level six sigma green belts. Each of them would identify a person and a project. So part of this training included that they must complete a project.

It had to incorporate the DMAIC process. Who is familiar with DMAIC? Okay, here we go. It had to incorporate the DMAIC project. It should also include skills and facilitation, such as how to organize a team and how to lead a team. And so they began that training. They would be expected to complete a project as part of their training. And then each year, those folks would be equipped to lead a project in their own division. Starting from then on, we thought that this would be a gradual way to build up our QI infrastructure. Not only could the new green belts lead projects every year for their own division, but they could serve as experts and kind of help people and teach about quality improvement and how to use different tools.

The strategy was to do it gradually, like I said, because we didn’t want them all, you know, working on one project. We wanted them to work on little projects themselves on something that was tied to what they were doing, something in their own divisions, so QI didn’t seem like extra work or an extra burden, and we knew that this would better increase our capacity and hopefully the enthusiasm for quality improvement. And we had a good first year. After the first year, we hit some milestones. We have one person in each of our six divisions trained at the green belt level. That was good. We got six projects started in the first year, one of them you’re going to hear about in just a second.

Unfortunately, we only had five completed, but you’ll hear about that in our challenges and struggles as well. We got staff members the opportunity to be on one of these projects and participate and generate some enthusiasm, and we had more people trained with the tools and the techniques of Lean Six Sigma. And the benefit of that is we had this greater pool of knowledge to draw from. Each one could now serve as an advisor to their own division. And we began to build on this, to build our infrastructure on this knowledge base. We also, when we took the SAT in 2024, you see, we saw. Increases slight increases in both of those areas. So it confirmed that we were on the right track, but we still had a way to keep going. But as an example of one of those projects, I’ll turn it over to Stephanie.

Stephanie Ross:
Thank you. Well, as stated before, I was one of the individuals selected to complete that green belt Six Sigma certification. And I do just want to start by saying how grateful I am to be able to have been provided that opportunity to complete that training. It’s helped progress our quality improvement projects in my division at the WIC program, but it has also helped with my professional development. Now, the title of my project was called working in Collaboration, which directly addressed enrollment in the WIC program.

From December 2022 to December 2023, the Hillsborough WIC program rate dropped from 75.1% to 59.8% that had us asking, what happened? What events occurred to cause that extreme decrease in our enrollment at the WIC program? So, using the Pareto chart, which you can see in the top Pareto chart on the slide, we were able to identify that the main driver was a decrease in children enrolling in the WIC program. Now this was a very big surprise to us. We identified that 5272 fewer low-income eligible children were receiving those WIC benefits, which decreases the community’s access to those healthy and nutritious foods.

To analyze this further, we were able to map out our current certification process. Using the fishbone analysis, we were able to identify two root causes, which were validated using the chi-square test. One of those was that changes made to the appointment matrix did not leave enough appointments for those child certifications. The next was that clients did not have the correct information about the WIC services, as their documents needed. Using the countermeasure matrix, the team was able to develop two feasible countermeasures.

The first was to adjust that appointment matrix. We needed to include additional certification appointments for the children to meet the demand in our community, create and implement a standard operating procedure for virtual Child Certification appointments being able to target those children and their enrollment in the program showed an initial increase of 1492 children enrolled by April 2024 which is shown on the bottom of the Pareto chart, the initial increase started a trend leading to a WIC program participation rate increase from 59.8% to 68.6% as of November 2024 now, of course, this is still requiring some monitoring, further evaluation, by using the control step in that DMAIC process, but we are now heading in the right direction. And as I learned in my class, do not go into paralysis by analysis. Thank you.

Todd Brushwood:
Okay, so lessons learned. We did have a lot of success, but there are a lot of things we learned. One of the things that we learned was that the greatest lesson is that improvement is continuous. You’ve got to keep going. You cannot stop you cannot stop trying. You’re never done. We also learned that progress is not linear. Two steps forward and one step back, there were stops, and there were stops. There was forward momentum, and there were great pauses in our progress.

For example, we lost one of our green belts right after they started the program and couldn’t finish their project. One step backwards. Turnover affected some of the project groups and some of the teams. They built up momentum. They were doing really well. A couple of people got new positions, one step backwards, but we kept going. And as mentioned, we work in Florida, and the special needs shelters are a real thing, especially after hurricanes Helene and Milton, and so some of our resources had to be diverted away from Quality Improvement back to their regular duties for hurricane recovery. That’s a reality we face. So we learned.

We learned that not every project needs demand. The bank is very data-intensive, very analytical. The process can take longer than you have sometimes, but the value of the training is that you learn the tools and you learn the techniques, and you learn that way of thinking, and you learn how to apply it. And the challenge is always, how do we apply it? How do we use that in our work?

But we keep going, because continuing to train staff in Lean Six Sigma is a way that we all improve, and it’s improving the agency little by little, we actually this year we have six new people who are signed up for training. That will mean six new projects in the next 12 months, six new opportunities to participate. We’re continuing to explore the best ways to provide that training, and we’re even working as a region now with other counties to see how we pull our resources and see what the whole region needs. And so we keep going, because the most valuable thing that we learned is that we can always keep improving how we handle quality improvement. So thank you very much. That’s our contact information, and I’m sure we’ll be taking questions later.

Christina Brown:
All right, we advance this slide, might just have to go up there. Okay, apologies for that. My name is Christina Brown. I am from Multnomah County in Portland, Oregon. I am a PHIG project manager, and I am here to talk about how our organization streamlined recruitment and interviews where we are. So, a little bit about Multnomah County. We have 36 counties in Oregon, but we are the smallest and most populous county in Oregon. We have about 800,000 residents. Since we’re going to be talking about HR processes, I’ll talk a little bit about our HR. We have a centralized HR unit, and our HR recruitment team works in coordination with the programs in our health department.

I have up here our mission statement, and I also have a visual of our values as an organization, but I really want to focus in on the dark blue circle, which says connection our success as an organization really starts with our staff and the wisdom and the brilliance that they bring into their work in connection with community and in connection to the other staff that they work with. So again, everything really starts with our staff. So one thing in 2022 that we were facing was the post pandemic workforce crisis, and we were facing significant staff burnout and high turnover rates.

And what we were finding was that we had a really inconsistent and cumbersome hiring process that made it really difficult to hire critical positions, and that was a really huge barrier to stabilizing our workforce and retaining staff. We had a new deputy director who came into the organization around that time, and he was tasked with fixing this issue. He conducted some interviews and looked at data, and found that it took about 146 days to hire someone, which is about five months.

And so from there, he saw an opportunity. This is something that we need to fix. If we are going to function as an organization, we need to be able to alleviate burnout, and we need to improve the ability to hire staff. But in order to get to that point, we need a systematic way to fix the hiring process. We can’t just use a temporary patch. He is very familiar with a lot of quality improvement processes, but he’s very familiar with Kaizen, and was very enthused to create a standardized and efficient system for everyone to use.

So let’s talk a little bit about Kaizen. As we started planning for our Kaizen, it was important for us to build a foundation. So, for some folks who are unfamiliar with Kaizen, it is Japanese. That means change for the better, and that was a really great starting place for us. And Kaizen is based on a few key principles: good process creates good results. Now, good results aren’t. Just a matter of luck. It is a direct outcome of a well-designed process. Improvements are based on small changes. So small, continuous improvements are much more effective than big, sudden changes.

Another one is that improvements must be measurable, standardized, and repeatable, and then lastly, empower the employees. Everyone in an organization has valuable insights and should be involved in the improvement process. Another tool that we used was the A3 tool, and this was something that we used to help frame our work as we developed the Kaizen. And what’s neat about the A3 tool is that it’s really based on the Plan Do Check Act cycle. Or, as some people know, the plan-do-study act cycle. And we decided to use that framework because it helped provide a day-to-day structure for our Kaizen and can be used as a step-by-step template. We also liked it because it was a great communication tool, and it was easy for folks to understand.

So let’s talk about our Kaizen now. We knew we needed to improve our recruitment process, so we took that A3 framework and applied it over the course of a week, and I have our week-long itinerary there now. We recruited folks from across the health department who have engaged in the recruitment process to participate in that week-long Kaizen retreat. On day one, we mapped out the current state, and I have an image on the top there that shows our mapping of the current state. And then on day two, we mapped out that target state and really looked at what that feels like to folks. And there’s an image there that shows for folks that feels like having a more manageable workload and being able to take a vacation. And then on the third day, we did a gap analysis and solution approach.

And here on this last image, on the bottom right, there is a picture of a gap analysis of one team doing the five whys tool to look at salary, doing a salary determination for candidates. And then we moved into the home stretch on day four by doing what we call rapid experiments and creating solutions. And in that, we broke up into small groups and based on some of the themes from the gap analysis, each group used that data and developed a specific solution and a process. The final day was all about creating a plan of action, determining a go-live date, and measuring success.

Nine months later, folks met back up to give feedback on where things are at and check in on those success measures. And what we found was that the overall recruitment process has improved, but there are still areas of improvement, and one area of improvement was the interview process. That was actually the longest part of the recruitment process. And so we decided to do another Kaizen around the interview process, and we used the same framework. We took that A3 framework, applied it over the course of five days, and we recruited folks from across the health department that have engaged in the interview process, and then we mapped out the current state on the first day, mapped out the target state on the second day, did that gap analysis and solutions approach, and then broke out into small groups to do those rapid experiments and create solutions.

Here you can see in the bottom right, a rapid experiment around doing panel orientations and debriefs, and then on the last day, we did an action plan to determine our success metrics, what our go-live date is, as well as reflecting on our journey. So let’s talk about our outcomes and results. So, for the first Kaizen, our go-live date was February of 2023. We met back up again nine months later at the end of October and determined that our time-to-hire was reduced from 146 to 72 days. So we were able to cut that in half, which has been a significant improvement for us.

Another significant improvement for us was the time to determine salary, so that the five whys tool, the process that was developed from there, helped us go from taking three weeks to determine a salary to now being able to do that in one day. Now for the interview, Kaizen, we were able to follow up with recruiters on the interview process, as well as candidates who were recently interviewed by recruiters. And we heard from them that no matter what team they work with around the interview process, the process is the same, and it’s pretty standard.

We also heard from them that their workload is much more manageable, and that is a huge win for us, because one of our goals was to alleviate their workload and their burnout. When it comes to candidates, we heard from them that they felt more respected and that they felt like they were getting good information. But we have room for improvement in some areas, and this is where we can take that information back to our Kaizen team and do a PDSA cycle to improve on that particular area.

So in terms of some outcomes, we felt like it was a huge win to be able to standardize our recruitment process and create different job aids for the recruitment process, and we were also able to identify other areas for process improvement, including the interview process. And for that, we were able to standardize the interview process. One of the pieces of improvement for us was having improved recruitment efficiency. And recruiters were also able to work better with the programs that they work with. They were also able to utilize technology that they’ve always had available to them, but they just never fully utilized.

In terms of lessons and recommendations. You know, if your organization is interested in a quick change management process, think about doing a Kaizen. It is something that has been really meaningful for our organization. Another recommendation from us is having leadership buy-in, which has been really key for the initiation of our kaizen. It’s also key to doing Kaizen, and it’s key to the sustainability of it.

And then lastly, consider hiring a lean-trained facilitator. Our first Kaizen, our deputy director was our Lean-trained facilitator, but it was difficult for him to both facilitate and participate in it. It was difficult to balance that. So we brought in a separate, neutral, lean, trained facilitator for our interview, Kaizen, and that made it better for him to be able to fully participate in that process. And with that, that is what I have. Thank you.

Audience Member #1:
For either state. Why did you guys pick the leads existing versus like a project management profession versus sigma versus like a project management profession?

Todd Brushwood:
Alright, for me, it’s Lean Six Sigma, more Six Sigma than lean, but you need both. It’s the tools, it’s the techniques, it’s what you learn. There are so many tools, it should include some facilitation, but it’s not just the project. It’s the tools you learn and how to apply them, and why we really wanted more people to have those skills and have that knowledge.

Michael Gedeon:
Okay, good afternoon, everyone. My name is Michael Gedeon, and I’m the Chief Administrative Officer for Public Health Seattle, King County. I’m talking today about reducing barriers to community contracting. In my role, I am the PI of the PHIG grant, but I also oversee and administer, kind of, the central administrative services in our department. So that’ll come into play here in a little bit. There we go. First, a little bit about King County. King County is the 12th largest in the country by population, and the city of Seattle is the county seat.

And so one of the things about the county is it’s kind of an international port and hub and a place of a lot of innovation, and a lot of tech businesses are located in King County, but the health and wealth of the county are not spread evenly. There’s pretty significant diversity in terms of health outcomes. So there are parts of the county where the average life expectancy is 10 years greater than in other parts of the county. So it’s a county with many different communities and experiencing very different health outcomes, and that’ll come into play here in a second.

Oh, yeah. A little bit about the department. We have 1700 employees and a budget of about half a billion dollars, and we provide, you know, all those foundational services we know about and foundational capabilities. A couple of other things to note are that we also probably operate more than other places, a clinic system that is spread throughout the county. So we do provide clinical services. We provide paramedic services as well. And such an interesting portfolio that we have in the department, and since we’re talking about contracting, another feature of our department is that the contracting unit is within our department.

So the county has a contracting unit, but for contracts that are going out into the community to serve the community, those contracts are managed within our department, which is a very cool thing. So we’ll talk a little bit more about that, so a little bit of history is coming out. Oh, one other fact on that slide, just to show you the amount of contracting we do. It’s about $100 million a year, and literally hundreds of community-based organizations receive funding from us. So it’s, again, a pretty big part of our portfolio. When the pandemic hit, and we were responding to the pandemic, we really leaned into working with the community in delivering the responses, so with the federal dollars, we were pushing a lot of that into the community.

So even though we historically had done a lot of work with community contracting and nonprofits and community after the pandemic, when we came back to our partners and said, how did we do? We didn’t get the best report card. And so they’re like, yep, you could do better. And so we chose to use PHIG as a place to invest some of our dollars, which they covered, and you’ll see a slide later. Out of their feedback, we ended up identifying 18 areas of improvements. There are some examples listed there. They wanted to hear about contract opportunities more transparently and just do a better job getting that out in the community.

One of the big barriers was around county requirements. And if your contracts are like ours, there’s this boilerplate with lots of legalese language describing all these kinds of requirements, and that was a big frustration and barrier, and we’re going to drill into one around insurance. Also, there were times when payments were delayed, and small organizations that don’t have a lot of cash flow could be a hardship. And lastly, the last example is building community capacity. So, how can their experience with us leave them in a place better to manage government contracts in the future? Okay, let’s see if I can get this to work.

So we launched in 2003 a project to improve our community. Contracting and the PHIG funding helped us invest in a few key things. One is, and this will be a theme you’ve heard, is a facilitator with Lean experience. So this is what’s really critical, and we’ll talk more about that later. We were able to bring on. More capacity to the contracting team so they can get the day-to-day work done and work on this project at the same time, so that was really helpful to have the PHIG investment for that and to support a community advisory group, so things like stipends.

This chart shows us, at a high level, our project flow. We went through the process with the community to prioritize a long, long list of potential improvements and then develop a schedule, which we are now working our way through. At the same time, we started working on improvements that we could do in parallel, which is shown there. So, around speeding up payments, we had some quick wins there. And we also started digging into the insurance issue.

This is a map of our very high-level map of the contracting process. And what’s hard to explain here is the number of people who touch a contracting process is enormous when you include all the people on the program side, the contracting team, and insurance attorneys. It is, it is quite large. And so there you’ll see this, the high-level map that we are representing the current state with the 18 improvements listed at the bottom. And what circled is our focus on today is insurance requirements. I am not going to go through every step in this, but I just wanted to show you a current state map. So, one of the tools here is a current state map. And so this is around the insurance requirements.

So, this one little slice of the contracting process, you can see the complexity of the process has many steps. And so again, with the skills of our Lean folks, to be able to go through that process, identify opportunities for improvement, use root cause analysis to try to get to a change that is both manageable and will have an impact. A little bit about the insurance, so when we do contracts, we require insurance documentation from the community-based organization. It’s typically around things like general liability, professional liability, workers’ comp, if there’s driving involved, there’s automobile, and now in today’s world, things like cyber insurance, and if they’re handling a lot of cash, there may be even insurance around fraud, criminal insurance.

And so the challenge we were hearing from our community providers is that they are often small organizations. They don’t have the attorneys, and also they don’t have the bandwidth to read through all of these requirements. Try to make sense of them. Work with their insurance companies. Get us the endorsements and the documentation for some of the smaller organizations. This was a really significant barrier for some, which put them in a place of, do we even want to do business with you this. Is this really worth it?

Out of this work, we dove into three areas, and so at the top you’ll see the project team that led this improvement work, the lean project manager, some a representative from our county risk office, somebody from the legal department, somebody from our central contracting team, a program staff person, someone who is working directly with the community organizations and a representative of our community advisory committees. We had a representative from the community on the team, and we dove into three areas.

One was around assessing our requirements, and at one point, we even dared to ask ourselves, do we even need to require insurance in some circumstances? And big credit to our county risk department, they were willing to kind of participate in some of these, you know, difficult discussions, which kind of challenge, kind of the foundation of why they’re there, why. Do we even need to do insurance? And so we actually found an area of contracting where we decided we were willing to accept a certain amount of risk and did not believe we needed insurance.

And on an earlier slide, I had something called a risk appetite statement. So we have, we use Enterprise Risk Management. So we have a risk appetite statement, which we really intentionally look at, what are the risks and the benefits, how you weigh the two, and where are times where we need to lean into taking risks, taking on more risk to achieve the benefits. And so there were contractors who were individuals, those who were serving us. They were not part of a large organization. They were individuals.

For example, this came out of the pandemic community navigators, individuals who are working in specific communities. Back to what I was saying earlier, one size is not going to fit all in a diverse county and to be as effective as we can in serving all communities, we brought voices in from within the community to work with us to get public health messaging into the community and to build the networks into the community for any public health work, so for something like extreme heat or smoke, these navigators were really critical to go into community.

Well, that was a case where we looked and saw over a number of years. We did not have a single claim. So getting to the data side of the work, you know, well, did we have claims? Is there a history claim? We had not had a single claim. And so that’s an area we’re very likely now to move forward and say we won’t need insurance, and we’ll continue to look at other areas to see what’s possible. A second area is around plain language. So how can we take all of the long, legal-sounding words in our contract and boil them into something understandable?

So we have a draft, it’s nearly final, working with the county risk office, working with our legal department to develop this plain language FAQ about insurance requirements, which could be helpful, also for our staff who are working with the community organization. The last area of improvement is to develop a guide for the insurance process, that complex map we had shown earlier, which is going to make it much clearer about roles and responsibilities. What are the handoffs, and where can we create exceptions in the process?

So there are times when their insurance is coming through, and even though there is a preferred requirement, we will make an exception to that insurance and may lower the requirement or give the nonprofit more time while the contract gets going. So this is a guide for our staff to hopefully streamline the process, make the handoffs work more smoothly, and start earlier in the contracting process, and create opportunities for exceptions, using that risk appetite and lessons learned.

As you’ve heard this theme, you know, having someone lead the process who is lean-trained is really important. And I think so. One reason I think it’s really important is I think it builds trust with all of the partners and the people around the tables, these are really large tables, and they want to go in there and go, is my time really going to result in something that’s going to be meaningful, and when you can bring folks with the proper training and some resources, I think that really helps with engagement.

Also, it was really critical to increase the capacity of our contracting team with this PHIG investment so they can continue to do their daily work. And to have really meaningful community involvement, it was important to honor their time in this work and provide stipends and staffing support for their work. I also wanted to. So, as I was thinking about this, it did take longer to bring the community folks up to speed about this complex process.

They each had a view into part of it, but we really invested the time to help them get to a level of fluency about the process so that they can participate. And I think this will pay off, kind of go slow to go far. We’re going to now have this group that is going to be able to advise us for years to come as we work on more and more improvements. Lastly, are internal partners building those relationships, as was mentioned earlier? That’s where leadership plays a really critical role in being able to reach out to partners to get them to engage in this work, even when it could be uncomfortable.

Brooke Campos:
All right, hi everybody. My name is Brooke Campos. I am the Workforce Development Director at the Utah Department of Health and Human Services. I will give a little prefix to Nicole York. She’s our DMI director. She is the brain and has done all the work behind this. She actually had a conflicting meeting that she is presenting at in a different room. So I will do my best to try to represent her today, but talking a little bit today, we are looking at an approach to grants and government governance workflows.

To give a little bit of context, the Utah Department of Health and Human Services. We recently merged. We used to be the Utah Department of Health and Human Services, which was separate, and in the last couple of years, we did merge. And we serve over 3.4 million people in our communities, within the Beehive State, specifically within our division of Population Health and Family Health, there are 91 grants that are currently being processed and managed. The process to do that is roughly, I would say, on average, about six to eight weeks. Though some grants need an expedited timeline.

And with that, a little bit of background, any grants that have any funds that go to our local health departments need to go through our governance process and have approval from those local health officers. All right, so our problem and opportunity, we and I can vouch for a lot of our grant coordinators, I used to be one, is that it is a very cumbersome, cumbersome process. It’s very duplicative. It’s very time-intensive. And there are several frustrations along the route that have been brought to leadership from Grant principal investigators with that.

We’ve really looked at how to streamline this process, especially since the merger. There were two kinds of processes that were going on. And we wanted to look at increasing the efficiency of this process, also with the idea and coming from more of that workforce development background of really improving our staff burnout. Because a lot of these processes take a long time and there isn’t a clear process, it definitely weighs on our employees, and it makes their jobs a lot harder.

Just an example of one, Nicole had brought this to me as well. Due to this long process, it had caused a lot of opportunities to go, to be missed. One instance, they said the juice was not worth the squeeze because this process is so long, and when you look at it, $400,000, they didn’t think that would be too much, but that’s $400,000 that could be used by CBOs in our communities. And because of this process, and the tight time frame that we had, we’re missing those opportunities.

See, okay, and going with this, am I saying it right today? DMAIC, thank you. Methodology, looking through this of having this proposal that we sent forth to our leadership and clearly defining what was going wrong, how we need to measure that, and look at how we can improve that. This did go through a couple of revisions, but ultimately, there was a work group held that said, Hey, these are the processes that make it really difficult, really defining what our intentions were with all of this.

And so the work group, the work group, proposed the solution. Leadership approved it, and the implementation is in place with the control measures outlined. There we go again. I don’t expect you to be able to see or understand any of that, but I do want to, as just a visual representation. This was our old process, and the key thing to pick up on is that when it branches out into the two different parts from those first three ones, those are simultaneously happening at the same time. So these are two different conversations with two different groups on the same project.

So it really caused some duplication process, that if it was making it through on one end and not on the other, you’d have to start back at the beginning of the process. So, they’re doing two things at once, and there’s not a lot of communication going forward with that. And you can’t see very well, but there are about seven areas that have the red outline. Those are all manual processes that have the opportunity to be automated. So with this new one, Nicole wanted me to say to ensure everyone that this does look like it’s longer, but it is not with this. It is just a straightforward, straight line, and the communication process is a lot more streamlined with the grant coordinator and the folks who are submitting this to be able to see every process along the way.

If there are questions, they can be sent back for clarification, all of the little triangles, or I guess they’re diamonds, those are all of the points where approvals need to be made. So there are, there are a lot of approvals in this process, but with this, it allowed it to be more streamlined with one person being able to be that point of contact, and it really being able to hopefully make it a lot more efficient. So I will state that this has not yet been rolled out. It was supposed to be rolled out, but with some things that have happened, our rollout is for November.

So, as far as an evaluation and results, we do not have that yet, but when we roll this out, we will ensure that the evaluation will be a part of this process. Yeah, this process, and with this integration, we want to make sure that our work group is still very involved, and that those who are working on this have that feedback loop. If there are things that can be improved along the process, they have the opportunity to chime in. And this goes across, across departments, with our local health department staff, as well as I said the rollout date will be November 2025.

And we’re really hoping, with the sustainability, we will have those dashboards available, trainings, SOPs, and have that feedback mechanism with that are I think that really important part to reduce that burnout with our grant PIs, to improve that communication, and especially with our partners as well. If we’ve got our local health departments that are very involved in this process, and they’re getting funds, and we want to make these opportunities available, that we’re funding is not the issue; we’re all in a tricky spot with funding right now. We want to be able to have the opportunity to apply for everything that we have at our fingertips and make it so that we, as the health department, and then also our community-based organizations, and our communities can benefit. Alrighty, is all that I’ve got there? So here we go.

Brian Lentes:
Very good. Thank you all great presentations. I do have some questions for the panel, but I think, given the time, we will open it up for some Q&A. If I had time, I would try to ask some of my questions as well. Ari, I’ll give you this to pass around. So with our presentations that you heard today, are there any questions from the audience that you would want to ask of the different presenters?

Audience Member #2:
Oh, this is for the Hillsborough County folks. Hillsborough County, excuse me, I’m excited. You got all these new rebuilds going. Do you have any tips or traps about keeping them engaged when they come out all fired up after their training and certificate, and getting them to use those skills and cement those without getting distracted?

Todd Brushwood:
Projects, projects. We haven’t achieved it yet, but we’re actually trying to establish a running list of projects in each division so that when this is done, this one can move up. And also you want them to be doable. You know, they can’t be doing world peace. It’s got to be something that you can achieve. Sometimes we take on too much, and you need to take on smaller projects that you can feel successful at.

Audience Member #2:
So Stephanie is a new green belt?

Stephanie Ross:
And having been recognized for all of the hard work that you’ve put into the project, having your leadership recognize that, being able to present it further into bigger groups, and to continue to grow the project, because you become very proud of that project that you’ve done.

Brian Lentes:
Others.

Audience Member #3:
My questions for Multnomah County, sorry if I mangled it. How many recruiters did you have on your team when you started? And because you were at 144 days, and then you got it down to 146, you got it down to 72.

Christina Brown:
Yeah, that’s a great question. So, how many recruiters did we have on our team? I believe at the beginning we probably had maybe about 12, ish, 12 to 15 recruiters, and each of them recruited in different parts of the department, and so some of the recruiters participated in the Kaizen, and then some of our recruitment Kaizen, and then some of the recruiters participated in the interview Kaizen.

Audience Member #3:
Follow-up question: How big is your agency?

Brooke Campos:
Yeah, we’re about 1600 staff.

Audience Member #4:
I had a question for the first group for your Lean Six Sigma: how did you do the training? Did you have a black belt on hand to coach them and give them the green belts, or did they send them out to another program? Did they do it online?

Todd Brushwood:
Yes, I’m the black belt, but what we did was we contracted with an outside agency. We had to do quotes and look forever would provide the training that met our requirements, and so they actually did the training. It’s their virtual classes, but it’s to the outside agency, and then I’ll work with the groups if needed. Some of them don’t need it, but that’s how we did it.

Audience Member #5:
Thank you, guys, for your presentations. My question is just for anyone who might want to take a stab at it. How does QI fall to the wayside when you have to divert resources, and how do you keep it going?

Michael Gedeon:
Great question, I think you mentioned earlier, is trying to build a culture of, you know, continuous improvement, where the staff are really empowered. So we’re trying to do things like huddles and roundings, where we’re just connecting with the staff, looking at the data and information they’re bringing forward, both to showcase as well as to highlight where there could be some barriers, and having their voices heard and then engaging them in, you know, In even small improvements, as was mentioned earlier. So, working, we’re not there yet, but that’s what we’re trying to get to.

Lola (Audience Member):
Hi. I’m Lola from New Jersey. This is really for all of you, as far as the initial process of starting to document, the processes were there originally, SOPs in place. What was the challenge of actually getting to even that old process of making sure that you could document every step? Because I think sometimes you know that can be unwieldy in and of itself, just to figure out. What are the processes are. Everybody might have a different perspective, and so I would love to learn a little bit more about that.

Todd Brushwood:
Okay, you hit a soapbox of mine. No basic process management. One of the things we don’t, we don’t do well is we don’t do a good job recording our processes. And then also, what are the metrics we’re looking at? How do we know when they’re performing, when they’re underperforming? How do we demonstrate a gap? And we only tend to do that when we’re starting projects, and we’re trying to get into a habit of doing it all the time. You know, just a simple like, we teach big block process maps, which are very high level, 30,000 foot views, but you’ve got to somehow document those processes and what they’re supposed what the results are supposed to be. How do you know you’re on track? Then you have something to go from, but that’s very hard. We usually don’t do it till the project begins.

Christina Brown:
No, I mean, I completely agree with that. I know that for our Kaizen, like that was kind of where we had to start, was to create those saps. And it was really helpful to have everyone in the room who is across the department, but also is part of doing the process to create those, because where we found ourselves was like, we don’t actually have those, and people are doing their own thing, and the process becomes person-dependent. So that was a great question.

Audience Member #6:
Anyone using any software to help you document the process, such as recording your processing, or maybe going into the, anyone have some software for anything like that?

Brooke Campos:
I know that at least within Utah, we use the Google Suite, but with how the like workflow went, Lucid Chart is what we’ve utilized so far.

Audience Member #7:
Outside of the mapping, I’m more so thinking about like, obviously, we’re storing things in a centralized place, right? Like you’re storing all of your SOPs, but if there’s any other software that you’re using to even, like Scribe, or something like that, recording, or any kind of AI or anything like that, to do processing.

Christina Brown:
I was going to answer that question. We just started using Scribe, yeah, so it actually monitors the steps that an employee does and then generates the rest.

Host:
We have a question from our virtual audience, Mae Mae Thain, around hiring timeliness, in terms of QI sustainability. Is there any hiring freeze or any other unexpected challenges? How would you plan to tackle those issues?

Christina Brown:
Yeah, so we actually just recently experienced a hiring freeze during our last budget process. And during that time, our HR kind of shifted to more retention-focused and like lateral movement of folks, so there were still, instead of the hiring timeliness, it was more around the interview portion, because we still needed to utilize that part of our process improvement. So we still have yet to see, like, what that particular data looks like, because that just happened this spring, so we’ll be really curious to see kind of what impact it has.

Audience Member #8:
Thank you to all the presenters who shared with us today. For Christina, I believe, a question for you around the five-day process, could you share more about, like, is that all day? Is that how many people, and because I’m trying to think about, like, setting expectations with leadership around, like, what is required for this type of undertaking, because we’ve had a couple instances where we start something and then it kind of drops off because people can’t commit to that time?

Christina Brown:
Yeah, absolutely. I could talk a lot about it, but I had a specific time frame. I had to, I had to say it in. Those were all day. Friday was usually more of a half-day, because it was more about creating that plan of action, just kind of wrapping everything up. Yeah, but those were all day. And our leadership, our deputy director in the beginning, wanted to use this approach, because that was something that he had used previously, very successfully when he worked at the VA. And I think for him, it was like we could do this in three days. But I think because we don’t have SOPs and how large our department is, we really need to do this as a week-long process.

And so he actually met with a lot of the senior leaders to really create that buy-in for folks, and he did that months in advance. So this was really on people’s calendars, really far in advance. And the same with the interview Kaizen, and to include folks from across the department. So it wasn’t just senior leadership, it was other folks who were involved in recruitment and interviews. That leadership piece was really, really key for us, because it just really showed how important it was to invest on the front end for this process.

Brian Lentes:
Others.

Audience Member #9:
I have a question. You mentioned in both Kaizens that you followed up nine months later. Is that part of the schedule?

Christina Brown:
It wasn’t necessarily part of the schedule. We were about six months after the original kaizen. We wanted to actually follow up on those success measures. And originally it was going to be with just these, the smaller HR team, but we, the Deputy Director, wanted to expand that out to include folks from across the department and get broader feedback. And so it was almost like a mini Kaizen follow-up, in essence, and that’s where we got feedback that led to the interview Kaizen as well. As you know, our classification and compensation process is pretty cumbersome as well. Maybe we should do a Kaizen about that, too. So we got a lot of different ideas from that follow-up.

Brian Lentes:
Okay, I have a question here for Michael: What advice would you give to other departments trying to modernize administrative workflows without slowing down critical operations, given that you’re the CAO?

Michael Gedeon:
Good question. A couple of things come to mind. One is from the mind. One is around the resources. It is really most people are working long hours, and as you were just talking about with the Kaizen, getting folks to step away and do this work without being planful, looking ahead, bringing in additional resources. We were really fortunate to have the PHIG dollars to be able to bring some extra capacity to the contract team for that work.

The other thing we talked a little bit about earlier is, you know, we’re really trying to bake this into continuous improvement, into our daily work, and so it isn’t an extra thing. It’s not something that you know once in a while; you know leadership comes by and uses this language that they don’t really understand. So we are really trying to find language that works with staff and then really show up in meaningful ways to showcase their work and to empower them to be able to bring ideas forward and to do the kinds of small improvements that can make a difference in their work.

Brian Lentes:
Others have any other thoughts on that question for Brooke in Utah, given your focus was on the grants management improvement, have you seen changes in the internal collaboration and accountability across teams?

Brooke Campos:
Yeah, as we haven’t fully rolled this out yet, I anticipate that it will. As the workforce director, I’m going through and talking with all of our different programs within our office, and that has been a huge theme of wanting something that is more standardized, and that there is a lot of fatigue with the process of not knowing, you know what’s next. Are things changing a lot? It’s definitely leading to that burnout. And so having those key folks that they know who to turn to. We’ve got that documentation of this is the process. I think that it’s really going to ultimately make all of those people’s lives a lot easier. But then, since so many of the grants that we’re applying for are across departments, I think that that’s a huge portion to have that point of contact and have those resources where folks can reach out and work together for these grants that span beyond different programs.

Brian Lentes:
Thank you. Yes, question.

Audience Member #10:
So was your process about the grades going out, or the grades you guys were applying for the grants that you were applying for, correct? You guys really did impact grants coming through your department, going out to community-based organizations, correct? Yeah, you bet. A follow-up question, too. Are you centralized or decentralized in your grants management? Do your programs do all the grants?

Brooke Campos:
Thank you? Yes. Jenny’s right there for me, too decentralized? Yes.

Audience Member #10:
Okay, thank you. Yeah.

Brian Lentes:
Okay. One final question. Love each of your answers given all the work that you did, what is one thing that you maybe could do differently, or you think you would change next time around in a similar project? You want to start here, Todd. Perfect.

Todd Brushwood:
One thing to change, that’s a great question. Right now. We’re just still trying to keep on. Definitely, as I said, have that list of projects available. You always have to have an idea of what you want to approve, what you want to make better. And we don’t like to do that sometimes, because we don’t want a list of everything we’re not doing well. And it’s okay to have that. So you have those ready when there’s an opportunity to do a project, have that standing by for somebody who’s got the ability and the time to work on it and wants to learn. So I would say, do that great.

Stephanie Ross:
Now, I would just say, from my personal experience, going through the Greenbelt certification as an individual was very difficult. Having a team together to have that support to get through those intensive projects would be beneficial as well, because again, you know, you’re in your daily job, doing your work, and you’re also completing this DMAIC process. So, just having a team available to help support that project.

Christina Brown:
I mentioned it in my presentation, but having a lean, trained facilitator for our first Kaizen would have been really great. It was very well designed and facilitated for our second Kaizen, but having that ability for our deputy director to participate in the process would have been really helpful for him to balance that.

Michael Gedeon:
The one thing that comes to my mind is that the project manager for this work needed more support, just the administrative work, organizing all the meetings with the community, the internal meetings, having another project manager or support would have lifted the burden off her and helped move things along more quickly.

Brooke Campos:
And not being involved in the process, but hearing second hand from Nicole, was making sure that everyone has a seat at the table. Since this does involve our local health departments, it involves governance and then those within the different areas, making sure that everyone feels that they have a say. And so I think that that’s probably what I would say on that, and more to come, hopefully once it rolls out.

Brian Lentes:
Great. Thank you very much, all of you. Round of applause. Applause. Okay, quick announcement before we depart, please make sure to join us for the reception here on the fourth floor right after this session. One thing to note is that there is a poster session on both sides. So far end over here, and far end over there. So if you walk in the side. In the hallways, you’ll see posters. Please visit those and then tomorrow, 8 am is breakfast here in the main Grand Ballroom. So thank you very much.