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Story of Measurable Improvement in Public Health


 
 
Name of Health Department/Agency: Tooele County Health Department
State: UT
Contact Name: Jeff Coombs
Contact Information: jrcoombs@utah.gov
Date Added: 11/30/2011
Program/Topic Area: Internal policy review
QI techniques/tools:  Fishbone Diagram, Flowchart, PDCA, Brainstorming, Nominal Group Technique,
Description of the process and intervention: Upon completion of the PHAB self-assessment process as a part of the PHAB beta test, Tooele County Health Department identified a need to review, update and train employees on departmental internal policies. The goal of this effort was to increase the percentage of departmental policies reviewed, updated and presented to appropriate staff from 6.6% to 35%. Using a fishbone diagram, a root cause analysis revealed that the issue centered around the lack of a scheduled process for review of internal policies. The improvement theory was that if a staff member was assigned the responsibility of tracking policies for regular review, an SOP for policy review and training was developed, and a policy and procedures checklist was developed, then policies will remain updated and staff will be trained on all relevant policies. As a part of the intervention, an SOP for policy and procedures review was developed, policy and procedure review was tracked for specified time frames, and a spreadsheet was developed to track which policies and procedures were reviewed and presented to appropriate staff. To determine whether an improvement was made, the status of policy reviews and training dates were recorded and compared to baseline data.
Result/outcome: As a result of the SOP for reviewing policies and procedures, the percent of policies and procedures that were reviewed and updated increased from 6.6% to 56%.
Next Steps: A staff person was permanently assigned to track policy and procedure reviews and trainings and the policy and procedure tracking database will be used to facilitate continued monitoring and improvement.


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