Business Process Improvement: A Territorial Public Health Agency Perspective

October 21, 2019 | ASTHO Staff

Catherine de la Cruz-Duran, RN, BSN, MS, is Puerto Rico’s Territorial Health Official Designee and Secretary of Planning, Development, and Federal Affairs. She was born in Buenos Aires Argentina and grew up in Lima, Peru until the age of sixteen when her family immigrated to the United States. She recently retired after 30 years in the U.S. Army, serving in multiple locations during her military career. She was stationed in Puerto Rico at the time of Hurricane Maria and worked as a liaison between the Comfort Naval Hospital and the Puerto Rico Department of Health (PRDOH) to evacuate critical care patients from damaged hospitals on the Island to the naval hospital ship. Her experience during Hurricane Maria was a significant event that led her to stay and work for the people of Puerto Rico. Her goal is to advocate for health equity and create opportunities for everyone in Puerto Rico to feel empowered to achieve the highest level of health.

In 2019, ASTHO provided technical assistance and capacity building to the PRDOH to support efficient and effective financial grants management. Puerto Rico focused on standardizing current business processes and developing standard operating procedures in key areas that impact financial grants management and spending of federal hurricane crisis funds related to property, travel, and purchasing. Below, de la Cruz-Duran reflects on her experience in leading the PRDOH’s work in this area.

How is the process improvement work supported by ASTHO and CDC helping Puerto Rico recover from the hurricanes in 2017?

As one can imagine, recovery from Hurricanes Maria and Irma in 2017 has been a top priority. Funding from CDC has been used to rebuild and strengthen our infrastructure, systems and processes so that we are in a better position to recover if we encounter such a disaster in the future. Specifically, the process improvement initiative is helping to increase the efficiency and effectiveness of the use of federal funds. Without this work, we wouldn’t have been able to target key areas for improvement to expedite key processes post hurricane Maria. The three key areas targeted include the purchase of capital equipment greater than $500, procurement and purchase of items between $10,000 and $24,999, and off-island travel authorizations that support our operations and development of the workforce. ASTHO’s technical assistance workshops allowed our staff to engage in open conversation, surface issues, and begin problem identification and solving. In the short term, this work will lead to development of standard operating procedures. Over the long term, we will need to work on continually improving our processes and put sustainable systems in place.

What role do Puerto Rico’s chief health officials play in championing this work and ensuring it is an organizational strategy?

Health officials and senior leadership play a critical role and I don’t think it can be successful without leadership at the highest levels setting expectations for engagement and employee buy for the organizational strategy and goals for this work. Other important areas for leadership include ensuring a qualified workforce to support the work. We are engaging partners such as ASTHO and others with experience and expertise to train and coach staff through quality improvement processes. We also must promote a positive and productive culture and environment for our employees for unification, collective problem solving and ownership of the process improvement which is ongoing work. And finally, we as leaders must encourage employee engagement and buy-in for quality and quality improvement so that improvements are continuous and sustainable. This can sometimes be challenging given competing priorities, daily activities, and periodic interruptions in business due to unanticipated events such as natural disasters.

Why is process improvement work important for the Puerto Rico Department of Health? What is the return on investment?

We know that inefficient processes cost us in terms of money and time and that is why we have made this work a priority. It is important that through efficiencies and timesaving in administrative processes, funds are used adequately and maximize resources to help get more done faster. I expect that it will also help the health department’s footprint in terms of making a larger impact in communities. We are interested in increasing productivity, providing quality services to build healthy, resilient communities, as well as customer and employee satisfaction. Over the long term, we anticipate seeing a return on investment in these areas.

How is the Puerto Rico Department of Health collaborating across agencies to help Puerto Rico recover and accomplish the shared goals of process improvement?

Through the process improvement work and ASTHO, we are trying to engage other agencies that play a key role in these processes such as the Office of Management and Budget of Puerto Rico. There are several other governmental agencies that we interact with that could also benefit from participating in process improvement. Although it remains a challenge, we hope the progress we are making at the health department can be used to establish engagement and buy-in from our key external agencies. Engaging these external agencies is also important for sustainability of administrative process improvements.

These challenges are not faced by the Puerto Rico Department of Health alone. What recommendations do you have for other public health departments looking to undertake similar activities?

My recommendations are to:

  • Share successes and challenges with peers in other territories, and similarly geographically isolated, insular areas so that you build a support network for problem solving and identifying new approaches for the similar challenges we are all facing.
  • Connect with knowledgeable and qualified partners that can help guide this work and build your agency’s capacity in quality improvement.
  • Create a foundation for engaging key, external administrative agencies through sharing of successes and challenges in your own process improvement work.
  • Work to ensure systems put in place are standardized and sustainable. This tends to be overlooked; however, in Puerto Rico we chose to make it our focus.