A productivity improvement program for the Department of Correctional Health Services of the Justice and Law Enforcement Agency of a county in the western United States required ten months and two full-time consulting staff.
As with the Health Services Agency program, two goals were established for this program: the first, a commitment to a participative approach to productivity improvement; the second, to train Organizational Development staff.
Three individuals from the Office of Organizational Development were selected to participate on this project. This group received extensive training in the techniques mentioned above. Also receiving training was the management team from each of the areas within the Department of Correctional Health Services. Focus groups were established in each of sixteen project areas to develop and implement process improvements and organizational changes.
1. Correctional Health Services provides medical and psychiatric services at eleven sites within the County jail system. This includes five outpatient medical clinics serving the adult population, two outpatient medical clinics serving the juvenile population, a twenty-three bed infirmary for intermediate care, two sixty-bed inpatient psychiatric units, and an intake area to assess arrestees’ medical condition before they are accepted into the jail system. CHS also operates a dental clinic, a pharmacy to distribute medications throughout the jail system, and a radiology room for taking and developing x-rays.
2. Nine of the eleven sites operate twenty-four hours per day, seven days per week. The two juvenile sites operate sixteen hours per day, seven days per week.
3. The department operates with a $12,000,000 budget and approximately 190 permanent and contract employees. Slightly more than half of the employees are registered nurses and licensed practical nurses. The remainder of the employees include contract medical doctors and physician’s assistants, psychiatrists, psychologists, counselors, pharmacists and pharmacy technicians, dental assistants, and support staff.
4. The County’s Correctional Health Services is one of the largest accredited correctional health care settings in the country.
In each of the sixteen project areas, the following methodology was followed:
1. All work processes were flow-charted and, where appropriate, mapped.
2. All essential tasks performed by area staff were identified and 1) observed to establish the time required to complete the task and 2) monitored by area staff to establish the number of occurrences during a representative period of time.
3. Project staff developed tables to correlate the number of staff required with anticipated measurable work volumes and reviewed task assignments to balance workloads.
4. The process flow charts and process maps were compared with the task lists and were reviewed with area staff and supervision. Work simplification and methods and systems analysis was applied to all essential work and numerous recommendations were presented and implemented to improve productivity and service levels. When appropriate, staffing tables were modified to reflect the new work requirements.
5. Simple reporting systems were installed to record accomplishment and balance staff based on actual workloads.
Throughout the department, project staff worked with area supervision and management to analyze processes which crossed area boundaries and to assess organizational structure and supervisory span of control.
Project staff identified and scrutinized all activities and processes in each area to necessity, time requirements, and frequencies. The development of Key Volume Indicators provided management with tools to staff based on measurable work volumes for all major processes. The result was a more efficient and productive department through slimming of staffing levels and simplification of processes. In addition, CHS added nurse recruiter and training facilitator functions without hiring or additional expenditure.
Focus groups and project staff uncovered numerous organizational change opportunities which improved accountability, utilization of non-supervisory resources, and supervisory span of control. Nine Nurse Manager positions were consolidated into four Nurse Manager positions, two Shift Supervisor positions, and two Staffing Coordinator positions. Administration positions were redefined to clearly place responsibility for Medical Cost Containment, Quality Control, Education and Training, Procurement, and Recruiting. The addition of a full-time Recruiting position was expected to reduce the historic reliance on nurse registry positions and its related costs.
1. Task assignments were shifted to balance work loads and reduce staff (see charts following).
2. Re-engineered processes reduced cycle times and redundancy and improved service levels.
3. A staffing model based on measurable work volumes allowed better management control over staffing needs and allowed reduced use of registry nurses.
4. Initiation of utilization review reduced county costs for laboratory and hospital services.
In the words of the then-Acting Director of Correctional Health Services:
“In looking back over the project, the features that stand out and also addressed my concerns were the attention to process detail, the organizational change recommendations, and finally, the relating of task time to workload determiners – all of this leading to a more efficient and productive department through slimming our staffing levels. We even added functions that were not being performed, but were vital to our future such as nursing recruitment and a training facilitator.
The subject of re-engineering typified this project and extended from re-identifying the major workload “driver” from encounters to sick calls, through balancing our mix of LPN’s and RN’s per shift, to studying medical and psych provider needs, to finally recommending supervisory presence on second and third shifts.”