KDHE 2019 Reported QI Projects

Protect and Improve the Health and Environment of all Kansans
2019 QI Projects Summary
Created February 3rd, 2020 from projects reported by KDHE staff

Instructions:
The following slides contain project information for
the QI projects reported by staff in 2019.
For additional information regarding projects, please
contact the Team Leader or other Team Members
listed on the project.
2019 QI PROJECTS SUMMARY

Project: K-SERV Data Cleanup
Team Leader: Stephen Tierce (DPH-BCHS)
Team Members: N/A
Summary: The Kansas System for the Early Registration of
Volunteers (K-SERV) user database was overflowing with out of
date profile information, users that were no longer active, users
who had moved out of state etc. K-SERV is a system that pre-
identifies volunteers before an emergency event to supplement
local response partners if needed. To have the most robust
volunteer base, data cleanup must take place.
I propose that messages are sent to all users in K-SERV with the
requirement to acknowledge receipt of the message or have
their account terminated. More than one message will be sent
due to users going on vacation, sickness, etc. With each round of
messaging the number of non-confirming users should be all
that remains.
In total 1,628 delinquent accounts were removed from the
system. After the data cleanup took place the response rate
improved by 29% to a new high of 56%.

Project: Project Tracking and Management
Improvement
Team Leader: Chris McGinley (OITS)
Team Members: Amy Crotinger
Summary: The KDHE Project Management office
manages dozens of projects a year. These projects cover
many gametes of business. They require a lot of
paperwork to track, document, and manage. Our current
management and documentation processes are
antiquated, and they are inefficient. We needed to
develop a new process that aligns with KITO and makes it
easier for PMO staff and customers to request, document,
track, and report on projects. We developed a new
process that aligns with KITO. All project paperwork that
is initially completed can be sent to KITO should the
project be required to report to KITO. This will allow KITO
reportable projects to be started much quicker. This
process will create more paperwork at the beginning of a
project, but allow for better tracking and accountability
throughout due to the increased planning and tracking.

Project: Updated Processes Tracker
Team Leader: Amy Suggitt (DOE-KHEL)
Team Members: NA
Summary: There are often numerous
process updates regarding laboratory or
secretary type work. These updates are
often communicated through email. I
created an Updated Processes Tracker
where anyone in our unit can go and
double check what the current practice is
on how to do something, or the current
funding numbers we need to use, etc.

Project: Initial Media Set Up Form
Team Leader: Paige Drury (DOE-KHEL)
Team Members: Carissa Robertson, Phil Adam
Summary: New media was added to our
initial sample set up culture. A quick
reference guide that supplements the
SOP allows analysts to quickly set up
media for infrequent tests. A quick guide
was made and implemented, and helps
reduce task time by limiting analyst
questions.

Project: Shipping Guidance for Quarterly
and Semi-Annual Shipments
Team Leader: Paige Drury (DOE-KHEL)
Team Members: Carissa Robertson, Phil Adam
Summary: Guidance document to reduce
errors during infrequent shipping tasks.
Photo source: https://www.abetterlemonadestand.com/shipping-boxes/

Project: Laundry Form
Team Leader: Stacy DeHart (DOE-KHEL)
Team Members: Kyle Thompson
Summary: The laundry form was unclear
and being filled out improperly. The
laundry form was redone to so it was
clearer and easier to use. The outcome of
this was a success.

Project: Refrigerator Labels
Team Leader: Stacy DeHart (DOE-KHEL)
Team Members: Paige Drury, Carissa Robertson
Summary: The refrigerators in the kitchen
and bacteriology didn’t have media that
currently reflected in the revised Media
Manual. The labels were redone and
placed. This is relevant to production to
make media easier to identify.

Project: Media quality control
documentation overhaul
Team Leader: Carissa Robertson (DOE-KHEL)
Team Members: Brandon Heinson
Summary: Previously 3 different media QC
worksheets that entailed the entire process had
been combined into one very generic
worksheet. This generic worksheet was difficult
and confusing for most users. This project split
the combination worksheet into 2 different
worksheets. One of these worksheets was then
individualized for each type of media in which
quality control is performed. This was very
successful for our unit and has reduced the
confusion for everyone involved.

Project: Weekly Spore Test Records
Update
Team Leader: Kyle Thompson (DOE-KHEL)
Summary: The goal of this project was to
create a single, centrally located
spreadsheet that contains all necessary
spore test information for each of the
autoclaves. In consolidation of records,
entries are less likely to be lost during the
sterilization process.

Project: 2019 Updated Accessioning List
Team Members: Brandon Heinson, Paige Drury, Carissa
Robertson
Summary: The goal of the project is to condense
the information recorded on the form into a
more efficient amount of space, remove tests
that are no longer performed and/or are
recorded onto a different form, include a place
to record useful information not yet included in
the current accessioning log (e.g. current
Acodes, a distinction between E. coli and E. coli
O157, a place to indicate Norovirus, a box to
check if the specimen should be rejected
because the time of collection is out of date,
etc.).

Project: Carbapenem Resistant Organism
Worksheet Update
Summary: The goal of this project is to update
the CRO bench worksheet to include a
checkbox indicating whether the MALDI-TOF
mass spectrometry quality control /
meropenem disc quality control log have
been filled out and to provide a location for
antibiotics minimum inhibitory
concentrations and interpretations to be
recorded for all carbapenem resistant
organisms.
Photo source:
https://www.google.com/url?sa=i&source=images&cd=&ved=2ahUKEwjZjrLB_bX
nAhU3B50JHQkbD8AQjRx6BAgBEAQ&url=https%3A%2F%2Fwww.flickr.com%2Fph
otos%2F71195909%40N03%2F28955874330&psig=AOvVaw01lAPCDCYoffwLCRpJv
txS&ust=1580839849787777

Project: Referral Worksheet
Summary: The goal of this project is to
create a worksheet solely for Referral
specimens. This sheet could be used for
the accessioning of referral specimens as
well as the record for date frozen,
shipped, amended, reviewed, and added
to the specimen tracker.
Photo source:
https://www.google.com/url?sa=i&source=images&cd=&ved=2ahUKEwiV65rW_bXnAhUGXc0KHUhwAb4
QjRx6BAgBEAQ&url=https%3A%2F%2Fwww.osiaffiliate.com%2Fblog%2Freferral-
rate%2F&psig=AOvVaw0Cf7k9Zz3Jwh83Rh3pvp6J&ust=1580839891154620

Project: Pipette Verification and
Standardization
Team Members: N/A
Summary: The goal of this project is to
inventory all the DM pipettes and input a
serial number, unit, and location into the
Artel PCS. Also, annual verification for all
DM pipettes will be synced to the same
month and changed to a twelve-month
verification cycle.

Project: Encouraging facilities to update
Laboratory Report delivery method
Team Members: N/A
Summary: The goal of this project is to preserve
government resources and provide a faster, more secure
delivery method by encouraging facilities to update their
Laboratory Report delivery method to an electronic one.
An excel sheet was created to track the Laboratory Report
delivery method for the facilities that regularly receive
reports from DM in response to CRO specimen
submissions. Most of the facilities receive their
Laboratory Reports electronically, but there are 14
facilities that receive physical copies of Laboratory
Reports. For these 14 facilities, once specimens are tested
and results are generated, reports are printed and mailed
to the facilities’ locations via USPS.

Project: Submitting Data Files to EPA
Team Leader: Michelle Probasco (BOW)
Team Members: Chelsea Paxson
Summary: The Kansas Department of Health and
Environment (KDHE) must submit Total Maximum Daily
Loads (TMDLs) to the Environmental Protection Agency
(EPA) Region 7 for review and approval. Previously, drafts
and supporting documentation were submitted through
email. At times, this has resulted in confusion over
missing or overlooked files and misunderstandings about
the most current revision, which introduced error and
increased the amount of time needed for approvals. In
order to improve data submission and tracking for this
process, alternative submission systems were considered
and discussed with EPA. OneDrive was selected as the
best option because it allows file-sharing. It is currently
being used successfully for all submissions and revisions
and has reduced the issues previously seen with email
submissions.

Project: Working Healthy Increased
Enrollment
Team Leader: Madeleine Bowens(DHCF-Medicaid & KanCare)
Team Members: Shannon Beat, Sherri Marney, Shelli Nyambane, Billie Crawshaw,
Marsha Patterson, Earl Williams, Dawn Goertzen, Nancy Scott
Summary: Our program enrollment has lagged for a few years but our
team is committed to sharing information, providing opportunities,
busting myths about disability and employment, and increasing the
number of members in Working Healthy. They provide accurate
information about how earnings will affect a person's current
benefits and provide people with informed choices. Through their
work enrollment has increased by 84 members this year. That
means that 84 new members who happen to have a disability are
working in integrated and competitive employment settings. Most
are paying a premium instead of a higher spenddown amount.
Research shows that Working Healthy members will increase their
earnings over time and at the same time will decrease their medical
expenses.
I'm so very proud to be part of the Working Healthy team who are
knowledgeable, trusted and respected across the state.

Project: Transition of Elderly, Disabled and
Long Term Care Eligibility Processing
Team Leader: Kim Burnam (DHCF)
Team Members: LaTonya Palmer, Breanna Dohrman, Rachelle Altman
(DHCF - Clearinghouse, KEES, KDHE IT, KDHE HR)
Summary: Beginning in early 2016, several challenges emerged related to the
successful processing of Medicaid assistance related to elderly, disabled, and long
term care programs. To address these challenges, KDHE requested and was
granted approval from the Governor and the Kansas Legislature to gradually
transition responsibility for these programs from the current eligibility contractor,
Maximus, to KDHE. On January 1, 2019, KDHE assumed training and quality
oversight responsibility for all eligibility staff, both state and contractor.
With the support of the Administration and Kansas Legislature, KDHE was provided
the budget to insource eligibility processing for the elderly, disabled and long term
care medical assistance programs effective January 1, 2020.
The conclusion of the transition occurred a month of ahead of schedule with the
last programs phased over on December 1, 2019.

Project: Document Storage
Team Leader: Debbie Lusby (DOE-BWM)
Team Members: Julie Jones, Jamie Packard, Linda Dale
Summary: It came to our attention that there's a
possibility that those documents in boxes will
need to be identified, therefore a spreadsheet
was developed with the contents of the scanned
box and taped to the top of the box. Documents
in boxes are now identified of its contents. Ln
case a hard copy document needed to be
located, each box will be identified with the
contents with the following listed for the facility:
ID Number, Name, Document date, created, &
Subject. This will be an ongoing project.

Project: Temperature/Humidity Log Update
Team Leader: Lauren Hutley (DOE-KHEL)
Team Members: Tonya Phifer, Lorenzo Stawarz
Summary: The current temperature/humidity
logs being used for the VSM unit had the
narrowest acceptable ranges applied universally
to all rooms/appliances and some
rooms/appliances were not being monitored at
all. The logs were updated to reflect
room/appliance specific ranges and include the
previously unmonitored rooms/appliances. All
rooms/appliances are being monitored,
ensuring all specimens, reagents, and
equipment are being stored and manipulated in
the required temperature and humidity ranges.

Project: Orphan Sites Huddle Board
Team Leader: Kevin Moon (DOE-BER)
Team Members: Alexa Goers, Bryce Zirfas,
Matthew Ptacek
Summary: Needed to track Orphan Sites
using Huddle Board.

Project: Dry Cleaning Facility Registration
Files
Team Leader: Debra Walters (DOE-BER)
Team Members: Angela Booth
Summary: A3 style project to clean up
facility registration files.

Project: Dry Cleaning Superfund QDIP -
Site Progress
Team Leader: Ben Haring (DOE-BER)
Team Members: Chris Hase
Summary: Continue tracking progress for
Superfund Sites utilizing Huddle strategy.

Project: Federal Facilities Statement of
Basis Process - QDIP
Team Leader: Margaret Townsend (DOE-BER)
Team Members: Mandi Chace, Jesse Saegert,
Carthryn Mallonee, Marc Radloff
Summary: Statement of Basis Checklist as
well as other phases.
Team creates a step list of different
processes.

Project: Voluntary Cleanup Program (VCP)
QDIP - Site Progress
Team Leader: Deanna Ross (DOE-BER)
Team Members: Brad Johnson, Russ England,
Brittany Bennett, Chri Girardi
Summary: This was the 1st BER program to
implement the QDIP process for the
huddle boards. See Huddle Board
Responses Attachment.

Project: Site Assessment Program - QDIP
Sites
Team Leader: Darryl Morgan (DOE-BER)
Team Members: Creenen McGuire, Andrew
Jennings, Chantry Klaus, Lisa Beattie, Delbert
Smith, Mayria Sanders
Summary: The Site Assessment Unit has
begun huddling and they created a
Huddle Board. Please see 2019 Huddle
Board Summary attached.

Project: Tanks Streamlined Bidding
Process - A3 Project
Team Leader: Scott O'Neal (DOE-BER)
Team Members: Brett Tavener, James Snow, Emily McGuire, Jeff Swanson, Stephanie
Pfannenstiel, Matt Kuffel, Lacey Laird, Chris Anderson, Marcia Morgan, Julie turner, Brandy
DeArmond, Ashley Allen, Matt Lawhon, Cory Ingham, Mark Totty, Tamy Simmons, Tammy Sund
Summary: Significant effort is spent during the bidding process reviewing bids sheets,
contacting Vendors concerning questions about submitted bids and disqualifying bids
due to math errors. It was decided that if comprehensive coded bid sheets were
developed, much of the effort of bid review would be eliminated as well as
eliminating the possibility of math errors. Not only would this save significant staff
time, it would also save money by not having to eliminate a low bidder due to a math
error. Since Contractual Services Unit staff currently transcribe bid information by
hand, automation would also eliminate the possibility of transcription errors. An
additional added benefit is that the spreadsheet coding work could also be used to
set up the reimbursement spreadsheets that are used to keep track of expenditures
from various funding sources by the Contractual Services Unit.
An A3 process tool was utilized to develop a coded bid sheet. Current implementation
is being tested.

Project: Remediation Unit Huddle Board
for document tracking
Team Leader: Daniel Newman (DOE-BER)
Team Members: Mary Daily, Pamela Green,
Courtney Stallman, Laura Metheny
Summary: The Remediation Unit
developed a Huddle Board Process
involving multiple steps and using
different markers to designate the
progress of reports. Contact Pamela
Green for more information.

Project: Change in OSHA Tracking
Team Leader: Marcia Morgan (DOE-BER)
Team Members: Julie Turner, Tamy Simmons, Tammy Sund,
Kerri Yocum, Pam Tyner, Archie Patel, Ben Haring
Summary: The KDHE Bureau of Environmental Remediation requires
contracted workers to have OSHA training and 8-hour HAZWOPER
Refresher. The Contractual Services Unit was tracking external vendors
training records and sending reminder letters and e-mails.
The team has since stopped asking for expired OSHA renewals, stopped
tracking all OSHA forms except for new vendors with new bids. The new
KEIMS System, which will be implemented in the next year, will empower
the Unit to notify vendors by postcard or mail of the need for up-to-date
training records.
The CSU team used the A3 method using the tools 5 Why’s and a Fishbone
Diagram to identify root causes. Because of this change, staff no longer
need to send out 12 monthly e-mails, track over 250 vendor staff, and print
off and file OSHA renewals. This will save a total of approximately 106 hours
of KDHE staff time this year!
Article was written in Friday Flash Newsletter 11/22/2019.
106 hours of staff
time saved!

Project: Restoration Unit Huddle Board for
document tracking
Team Leader: Maura O'Halloran (DOE-BER)
Team Members: Alex Richards, John Cook,
Bailey Lonnberg, Ken Diediker, Julie Manders
Summary: Created huddle board for
tracking document progress.

Project: Project Manager (PM) Handbook
Folder and PM Assignments
Team Leader: Brittany Bennett (DOE-BER)
Team Members: Joe Dom, Ben Haring
Summary: Brittany Bennett used a system
similar to the Voluntary Cleanup Program
(VCP) to create a "Project Manager (PM)
Handbook." "The Project manager
assignments" Excel Spreadsheet was a unit-
wide initiative led by Ben Haring with
assistance from Joe Dom and began in 2018.
The spreadsheet is utilized to inform project
managers of their site assignments.
See Just-Did-It Form and Screenshot
attached.

Project: BHP - Request for Applications
Team Leader: Daina Zolck (DOPH-BHP)
Team Members: Vitaliy Kroychik
Summary: There was not a standardized
process in the bureau for offering,
reviewing and awarding requests for
application for mini-grants to sub-
recipients.

Project: Accessing key elements and contacts
for the Essentials for Childhood Initiative
Team Leader: Daina Zolck (DOPH-BHP)
Team Members: N/A
Summary: The Essentials for Childhood Initiative has
several critical partners and moving parts. I was
broached with "If you were coming into a new
position with Essentials what would you first want to
know?" At the time, this cooperative agreement was
less than a year old but there was no one place to
find contact, role and focus information. A simple
one page document was developed which had
pertinent information to identify contacts for CDC,
the leadership team, data workgroup and sub-
recipients as well as the role of the Kansas Power of
the Positive coalition, focus areas and overall goal.

Project: Abstraction Training/Update
Team Leader: Jeff Wilhelm (DOPH-BHP)
Team Members: Alicia Padillia, Ashlee Barklee, John
Fletcher
Summary: Abstractors entering data were
leaving fields blank or entering "unknown"
frequently even though the information was
in the source materials. Narratives were far
too lengthy and missing important
information. Abstarction and entries were
differing from abstractor to abstarctor.
Standardization of methods and responses
could be improved.

Project: Expired Permit Initiative
Team Leader: Matthew Steele (DOE-BEFS)
Team Members: Tamera Teeter, Glenda Newquist, Virgil Cane, Cindy Hotovy,
Alan Sharp, SaLia Potter, Jim Anstaett, Helen Redden, Tonya Lucas, Julie
Hooper
Summary: Central office Livestock Waste Management staff
identified with the 5 Whys that a sub-set of expired permits
needed an extra incentive to either be classified as closed or
submit fees and paperwork necessary to renew the permit.
Permittees were notified and staff throughout the districts
performed ground truthing and additional contacts with
permittees to move the permit to closed or to a renewable status.
Total expired permits are down from 313 in January to 227 in mid-
December. Backlogged permits (workable) are down from 132 in
January to 22 in mid-December. The team was also able to identify
gaps in process that have streamlined the permit renewal process.
A pareto chart was being used to track reasons for the permit
being unworkable and areas like no Waste Management Plan were
identified and steps taken to collect these are being made.

Project: Bureau of Air SharePoint Site
Team Leader: Jayson Prentice (DOE-BOA)
Team Members: Rick Brunetti, Linda Vandevord, Doug
Watson, Gyanendra Prasai, Connie Ellis, Mike Martin
Summary: With the transition to cloud-based OITS
services the Bureau of Air is working towards
utilizing the Office 365 Platform to develop a
Bureau SharePoint site that will replace our
current locally-hosted shared network drive. The
SharePoint site will allow for improved
integration with the Office 365 platform;
Provide availability of bureau documents while
being off-site; Allow improved communications
between District Staff and Local Air Agencies;
And reduce annual operating costs for the
bureau by eliminating additional charges for
cloud-hosted shared drive(s).
Photo source: https://www.cleanpng.com/png-
sharepoint-online-microsoft-office-365-microsoft-i-
3330362/

Project: Technology Improvements
Team Members: Rick Brunetti, Connie Ellis, Gyanendra Prasai,
Doug Watson
Summary: With upcoming changes in computer support,
including the transition to Windows 10, the bureau
reviewed our current technology inventory and
assessed future needs. The bureau found that it must
purchase numerous new computers for staff to
support Windows 10, including desktops, laptops, or
tablets. As a part of this purchasing process, primarily
field-based staff will utilize tablets and docking stations
to reduce costs and improve operations. A template for
software will also be produced to streamline efforts of
IT/OITS to install software upon initial computer setup.
The outcomes are expected to be reduced support
needs, improved efficiency for field staff, and reduced
annual technology costs for the bureau.
Photo source: https://www.microsoft.com/en-us/windows/features

Project: SLEIS - Emission Factors
Team Members: Barb Bangert, Lynn Deahl, Ann Spitz
Summary: Emissions Inventory staff must annually update process
and operating information from the regulated community, and review
submitted information to ensure accuracy. The bureau utilizes a cloud-
based platform for the state emissions inventory which continuously
undergoes revisions and improvements. A new feature for this
platform involved the addition of a database of emission factors -
formulas or values used to calculate emissions from process and
operating information. Emissions Inventory staff worked with the
developer to incorporate this database, and provide the addition of
dozens of locally known emission factors and conversions. This
provided improved accuracy and improved QA/QC capabilities, and
provided the regulated community with known emission factors that
are automatically generated if proper processing information is
provided. Additional QI project(s) will likely be generated focusing on
improved QA/QC utilizing these changes.
https://kdhe.windsorcloud.com/sleis/

Project: SLEIS - Online Only Submissions
Team Members: SBEAP Staff
Summary: An online cloud-based platform for the required
annual emissions inventory has been available for the past
five years. Over these prior five years facilities have had the
opportunity to submit their operating information either
through this online platform, or via paper forms. This results
in months of time spent by Emissions Inventory staff to
transfer paper form information into the online platform for
proper submittal to EPA. Beginning in 2020 facilities will only
have the option to submit their inventory via the online
platform. The result is anticipated to be more accurate
operating information from the regulated community, a large
reduction (potentially 400+ hours) of staff time converting
paper forms, and an increased return on investment into the
online cloud-based platform.
https://kdhe.windsorcloud.com/sleis/

Project: Air Monitoring - QAPP & SOP
Team Members: Kathleen Waters, Joyce Markiewicz,
Gary Ficklin, Yao Tang
Summary: The Ambient Air Monitoring Staff utilizes a Quality
Assurance Project Plan (QAPP) and Standard Operating
Procedure (SOP) documents as a part of the EPA approved
agency Quality Management. Prior document version included
many duplicated sections, outdated information, and lack of
documentation of changes between versions. The bureau QMP
representative and air monitoring staff revised and added
proper information, removed duplicate information (adding
proper references), and updated the formatting to ensure both
documents are easier to follow. Utilizing 'track changes' these
documents can also be updated as needed throughout the year,
and formalized at a regular interval to ensure documents are
updated as necessary. Improved accuracy of the SOPs also
provides an improved learning tool for new field staff.
Photo source: https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.smartsheet.com%2Fstandard-operating-
procedures%3FiOS%3D&psig=AOvVaw1cyq_ylaicGLd3-
DlOGcYk&ust=1580848499042000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCJjK7tudtucCFQAAAAAdAAAAABAE

Project: District Staff Intranet Page
Team Leader: Michelle Probasco
Team Members: Jayson Prentice, Britini Jacobs, Adam
Blackwood, Jennifer Nichols, Allison Herring, Jeffrey Janzen,
Jason Koontz (KDHE DOE QMP Reps)
Summary: Utilizing program level QMP/SOPs as framework, some
sampling documentation has been generated for district staff (e.g.
HAB, Fishkill). However, there is no common location where staff can
access these guides nor is there a strategy for updating them when a
change occurs. As a result, samples have been rejected at KHEL when
sampling protocols changed but sampling guides were not updated
and communicated. Due to the diverse nature of district sampling
activities combined with the geographic location challenge, it seems
the DOE QMP representatives in the central office can assist by
establishing a common location on the KDHE Intranet and by assuming
responsibility for updating the guides in response to protocol changes.
Additionally, the guides would be reviewed by district staff as part of
the annual QMP review. The outcome results in a central location for
field staff to access documentation, provides a means of
communication, and ensures proper updates.

Project: KEIMS - BOA
Team Leader: Connie Ellis (DOE-BOA)
Team Members: Mike Martin, Jayson Prentice,
Ashley Eichman, Amy Seeds
Summary: KEIMS is a new online data management system
built to improve communication, enable sharing of site
information, and increase the ease and accessibility of
business conducted between various regulatory programs
within KDHE and the regulated community. KEIMS can be
accessed by both internal users (state employees) and
external users (site owners, consultants, etc.) to create and
manage permit applications and compliance reports online.
KDHE is combining multiple databases in the Division of
Environment to create efficiency to benefit both state
employees and the public. This ongoing project allows for a
more transparent process, decreased employee hours,
improved communication, and improved tracking of
processes. In 2020, the Bureau of Air plans to go 'paperless'
for all permit applications and many compliance submissions
which will further improve efficiencies and increase the
return on investment for the online system.
Photo sourcehttps://www.gadgeon.com/iot-services/process-automation/

Project: Guideline and Template for Preparing a
Small Arid Landfill Facility Operating Plan
Team Leader: Blair Yount (DOE-BWM)
Team Members: Heather Merritt, Michael Selm
Summary: Landfill managers are intimately familiar with their
operations. The perspective and knowledge of these individuals closely
reflects landfill operations. Landfill regs require an explanation of
facility operations to be written in a facility operating plan (FOP).
However, landfill managers often don't feel qualified to write these
documents and therefore rely on consultants to prepare their FOPs.
FOPs prepared by consultants can be expensive for a facility.
Additionally, consultant prepared FOPs can contain misinformation due
to cut and pasting from other facilities or inadequate knowledge about
a site.
This guideline and associated template creates a way for landfill owners
to prepare their own FOPs. The template prompts users to fill in
information about their facility, and the guideline provides additional
information about how to answer questions. These documents
empower landfill managers to fulfill requirement, and create a
document for their staff about how to run the facility.

Project: Guideline and Template for Preparing a
Construction & Demolition Landfill Facility
Operating Plan
Team Leader: Blair Yount (DOE-BWM)
Team Members: Heather Merritt, Michael Selm
Summary: Landfill managers are intimately familiar with their
operations. The perspective and knowledge of these individuals closely
reflects landfill operations. Landfill regs require an explanation of facility
operations to be written in a facility operating plan (FOP). However,
landfill managers often don't feel qualified to write these documents and
therefore rely on consultants to prepare their FOPs. FOPs prepared by
consultants can be expensive for a facility. Additionally, consultant
prepared FOPs can contain misinformation due to cut and pasting from
other facilities or inadequate knowledge about a site.
This guideline and associated template creates a way for landfill owners
to prepare their own FOPs. The template prompts users to fill in
information about their facility, and the guideline provides additional
information about how to answer questions. These documents empower
landfill managers to fulfill requirement, and create a document for their
staff about how to run the facility.

Project: Guideline for Requesting Alternative
Cover Material for Active Landfill Units
Team Leader: Heather Merritt (DOE-BWM)
Team Members: Michael Selm
Summary: Active landfill facilities are allowed to
request the use of alternative cover material for their
operations. BWM Permit Managers may approve or
deny these requests, but must have adequate
information about the material to be able to make a
determination.
This guideline explains to owners and managers of
active landfill facilities the information which must be
submitted with requests for alternative cover
material.

Project: LIMS Verification Reports
Team Leader: Tonya Phifer (DOE-KHEL)
Team Members: Amanda Bradley, Jennifer Evans
Summary: No method existed to verify
Horizon results reports match instrument
results reports and our unit was unaware it
was a CLIA requirement. Therefore, results
reports from all LIMS-dependent
instruments were compared to Horizon
reports and verified to be in agreement. The
reports were printed and compiled on a
biannual basis as is the CLIA requirement.

Project: BEFS Employee Retention
Team Leader: Erich Glave (DOE-BEFS)
Team Members: Matt Steele, Amanda Reed, Jennifer
Nichols, Allison Herring, Dan Wells, Wade Kleven,
Tom Winn, Doug Cole
Summary: Employee turnover rate in the
Bureau is running 15%. The group gathered
reasons employees stated they left. We used
a Pareto chart to determine what our long
legs are and are developing strategies to
retain new employees. Top three long legs
were not under our control so we are
developing a career advancement proposal
and a work from home proposal.

Project: Nursing Facility Advance
Payments
Team Leader: Maria Montgomery (DHCF-Medicaid
& KanCare)
Team Members: Rolanda Ellis, Samuel Lehman
(no longer with agency), Shelly Liby, Rhonda
Kearney
Summary: Nursing Facility Advance
Payment process was created to provide
funds to nursing facilities impacted by
the delays in beneficiary application
processing.

Project: SWLF27 - Waste Tire Monofill
Facility Operating Plan
Team Leader: Joseph Hacker (DOE-BWM)
Team Members: Heather Merritt, Mike Selm
Summary: This project provides a facility operating plan (FOP)
template and guidance prepared for the specific needs and
requirements of a Waste Tire Monofill. Landfill regs require the
facility operations be explained in an FOP. This can difficult for small
waste tire monofills. An FOP prepared by the landfill owner may not
have adequate detail, while one prepared by a consultant can be
expensive for the landfill. An FOP prepared by a consultant may have
inaccuracies due to the consultant not being involved in day-to-day
operations.
This template provides a step-by-step process for the landfill owner
to prepare their own FOP. The template prompts the user to fill in
information for their operations, while the guidance provides
clarifications and definitions to assist the user.
The template also includes references to and language from
applicable BWM policies. This ensures that the owners and operators
are aware of these policies, and that they are enforceable during
inspections.

Project: Dental Supplies Ordering &
Distribution Process
Team Leader: Dr. Dayna Brinckman (DOPH-BOH)
Team Members: Amalia Almeida, Admin. Assistant
Summary: Problem: Fragmented and inconsistent dental screening supply ordering
process for community partners volunteering to complete dental screenings in school
state-wide.
5 Whys Analysis Tool was applied to the problem as follows:
1) Why were community partners not receiving their dental screening supplies in a timely
manner?
2) Why were dental supplies being ordered only once annually and then stored throughout
various locations within KDHE?
3) Why was there no inventory tracking process in place to assist with inventory management and
allocation of resources?
4) Why were monies being spent to mail or transport dental screening supplies to each individual
community partner throughout the state?
5) Why were supplies being provided without production data being required from community
partner screeners?
Action Taken: A root cause analysis was completed that identified the issue as being a
process problem. Supplies will now be mailed directly from the vendor to our community
partners.
Result: Community partners will now be receiving all of their dental screening supplies for
the year directly from the vendor and will have them readily accessible when needed. Cost
savings to KDHE-BOH in shipping monies saved and staff time processing orders.
Photo source: http://thinklistenlearn.com/346-2/

Project: Restoration of the PPE Supply Cabinet
and Natural Disaster Kits #1 and #2.
Team Leader: Renee Brown (DOE-BEFS)
Team Members: Randy Clark, Trenton
Chriestenson, Caitlin Brown
Summary: With general use and wear and tear of
PPE in the field, certain items are in need or need
replaced and are retrieved from the PPE Supply
Cabinet. Batteries are included in the Natural
Disaster Kits and often need replaced due to having
been used or expiration of battery life. Certain forms
in the disaster kits need replaced due to information
updates.
Inventory of the supply cabinet and both kits has
been completed and all missing/deficient items have
been restored.
The supply cabinet and both kits are now updated
and restored to former condition. They are complete
with all necessary items that will be needed for
everyday use and/or in the case a natural disaster
should occur.

Project: Sample Cabinet/Equipment
Organization Project
Team Leader: Jason Schultz (DOE-BEFS)
Team Members: Kitty Rhynerson, Morgan
Pearman, Alan Sharp
Summary: Organized/cleaned the sampling
cabinet and calibrated sampling
equipment.

Project: SWLF271 - Industrial Landfill
Facility Operations Plan Template
Team Leader: Will Fraundorfer (DOE-BWM)
Team Members: Michael Selm
Summary: This project provided a facility operations plan
(FOP) template and guidance prepared for the specific needs
and requirements of an industrial solid waste landfill (IDLF) in
Kansas. These facilities are required by permit conditions to
have and follow FOPs that govern all operations. These FOPs can
be particularly difficult for facilities and their consultants to
prepare because IDLFs tend to be unique due to varying waste
types and disposal practices.
The template will make FOP development easier for permittees
and more consistent in terms of content and format with FOPs
from other types of solid waste facilities. The template is fillable
which makes it easier for permittees to write their own plans
without relying on a consultant. The template will make it easier
for permit managers to review FOPs, and easier for inspectors to
perform compliance evaluations at IDLFs.

Project: Kansas Perinatal Community
Collaborative DAISEY Dashboard
Team Leader: Stephanie Wolf (DOPH-BFH)
Team Members: James Francis, Lawrence Panas, Kelli Mark
Summary: We did not have a way for KDHE staff or local agency
staff to track performance and outcomes measures for the
Kansas Perinatal Community Collaboratives throughout the year.
We were only providing an annual report, which due to data
linkage time constraints are published with a year lag time (2018
reports published December 2019). We decided to build a
dashboard for KPCC site performance and outcome measures
that will be populated on a quarterly basis. This will allow local
sites to see their performance throughout the year and make
adjustments in a much more timely fashion. It will also allow
KDHE staff to monitor the sites much more closely and reach out
to the sites with technical assistance when/if
improvements/adjustments are necessary. The first version
(stage 1) of this project is complete. We are ramping up to start
stage 2 where this dashboard will be built in Tableau and live in
on our online platform so the measures can be reported in real
time.

Project: Hazardous Waste Permit Application
and Permit Writing Process Mapping Exercise
Team Leader: Julie Coleman (DOE-BWM)
Team Members: Ann D'Alfonso, Ben Haring: Facililtators; Nancy
Ulrich, Maura O'Halloran, Gary Blackburn, Steve Sellmeyer,
Richard Flanary, Akhter Hossain, Everett Spellman, Holly Burke,
Jesse Higginbotham, Ryan Pfeiffer, Katy Schwinghamer, Gilbert
Tabares
Summary: Permits are not being issued in a timely manner.
The application and permitting process was mapped out
to identify inefficiencies and pain points. An ideal process
was constructed and discussed.
At the end of the project, work groups were formed to
address sub-processes to ease pain points, update forms,
develop guidance for project managers, and create a
repository for guidance documents. In two weeks we will
meet again for a process flow chart presentation and to
report on work group progress.

Project: Re-Organization of File Shares
Team Leader: Roger Zornes (DOPH-BEPHI)
Team Members: Akram Karimi, Mohib Sheikh
Summary: File shares are to be reorganized by
eliminating some file share levels along with file share
renames.
Evaluation of current file shares and possible file
compilations, identification of files that will require
immediate fixes upon reorganization due to broken links,
developed a standard sub- level file share structure to be
used in each primary level file share for the Vital Statistic
Data Analysis (VSDA) group.
Awaiting for IT to implemented the reorganization for the
VSDA group as of 12/19/19. Development of the standard
sub-level structure ahead of the actual reorganization by
IT, will allow for a more expeditious file location fix.
Flow charting was used to visualize the different file share
levels and how the reorg would have an effect.

Project: BHP Grant Budget Tracking
Team Leader: Alex Russo (DOPH-BHP)
Team Members: Toni Merril, Vitaliy Kroychik, Magen Salley,
Jamie Medaris
Summary: The Problem: With new Section Directors in nearly
every section of BHP, it was difficult for them to get a solid grasp
on their budgets. With each Section Director being in charge of
multiple grants, it's a lot to learn on top of everything else they
do.
Action Taken: I spent nearly a full month coordinating with
several people to put together a spreadsheet to track all
spending for each grant and each Project ID. It is still a work in
progress and changing a lot as new demands appear.
Outcome: So far the spreadsheets are very useful and fairly
successful. While they are difficult to create, they are easy to
maintain and can give a fairly accurate current balance for each
Project ID. With limited SMART access, I rely heavily on the BHP
team to keep me informed on all Contracts, Travel expenses,
PO's and other expenses.

Project: Filing Relief
Team Leader: Wendi Kessler (DOE-BEFS)
Team Members: Helen Holm
Summary: Administrative assistant is charged with
filing for the water program inspectors. Many
documents do not contain the permit number
which is a key for the filing system. Historically
the admin would have to reserve those
documents and wait until an inspector could
query the appropriate database to discover the
permit number. The project simply requested
access to the database for the admin to discover
the permit numbers without having to utilize
inspector resources. Admin doesn't have to wait
to complete filing, water staff who no longer are
required to spend time discovering permit
numbers.

Project: Vital Statistics Customer Service
Kiosks
Team Leader: Jason Mathewson (DOPH-BEPHI)
Team Members: Kimberley Ortega, Linda Smith, Karla
Crith, Tammy Jellison, Rose Francis, Kay Haug
Summary: Kiosks are used to facilitate initial check-in by
individuals who are seeking to obtain a Kansas vital record
such as a birth, death, marriage, divorce, stillbirth
certificate. Individuals complete their application at the
kiosk which then verifies their personal identity. Upon
completion the individual will be promoted to the service
window where a member of the OVS staff will collect
money and complete the transaction process. The kiosks
will increase efficiency, provide convenience and enhance
security giving the customer an even better experience
within their ordering process. Typically OVS assists 140
walk-in customers daily; the first full day of kiosk
operation OVS handled 153 customers, however at the
end of July through the beginning of August OVS averaged
assistance to 242 customers on a daily basis.

Project: Sampling resource
Team Leader(s): Michelle Probasco and Allison Herring (DOE)
Team Members: Brittini Jacobs, Jayson Prentice, Adam
Blackwood, Allison Herring, Jeffery Janzen, Jason Koontz
(BOW, BEFS)
Summary: No centralized location on the sampling
protocols for responding to sampling requests, especially
HAB and fishkill events.
QI project addressing access to updated field sampling
guides/docs/handbooks for district staff
Background: Utilizing program level QMP/SOPs as
framework, some sampling guides/docs/handbooks have
been generated for district staff, i.e., HAB, Fishkill, lab
sample bottle guide. However, there is no common
location where staff can access these guides nor is there a
strategy for updating them when a change occurs. As a
result, samples have been rejected at KHEL when sampling
protocols changed but sampling guides were not updated
and communicated.

Project: Phone Procedures
Team Leader: Lorrena Steelman (DOPH-BFH)
Team Members: Pam Paden, Debi Nelson, Cassandra Child
Summary: Concerns were identified related to calls coming in
through our main office number and to whom they were being
sent to. It was identified that the front desk phone procedures had
not been fully developed, which led to frustrated staff and
individuals calling in when calls were inappropriately sent to
someone.
The Program Director developed a draft that was vetted through
the supervisor of that unit, as well as through staff that would
implement. A final procedure resulted from this work.
The program identified the change needed to be immediate,
therefore there was no formal tracking. Since implementation,
staff are reporting they receive far fewer calls in general and are
not getting calls that should have gone elsewhere.

Project: Complaint Intakes
Team Members: Karen Flanders, Krista Hurla, Beth Greene,
Lisa Walker, Roxanne Zillinger
Summary: Complaints regarding licensees that are received at
KDHE via phone and/or email were being entered into the system of
record by CCL staff instead of by the licensing surveyor. The
investigation of the complaint is conducted by licensing surveyors.
This requires follow up with the complainant. CCL staff entering the
data and making the first calls for information was a duplicate effort
and slowed the process.
The enforcement team determined that all emails should be
forwarded to the appropriate surveyor upon receipt. The email
should indicate that this is a new complaint so that the investigation
can be started within the required 5 days. Individuals calling in
receive information that the person who will be conducting the
investigation will be returning their call to obtain the details of the
complaint. The complainants name and best time to call
information is emailed to the licensing surveyor so that follow up
with the complainant is more immediate.
There is no delay.

Project: BOW - Geology Water Well
Program Lean
Team Leader: Ann D'Alfonso (DOE-BOW)
Team Members: Carrie Ridley, Bebbie Biester, Pam Chaffee, Sue Funk
Summary: Once the current state was fully mapped out, the team discussed pain
points, or areas of frustration in the process. The team was asked to ponder several
questions, including: “Is there an easier way? How can we bring this process into the
21st century? Are we required by statute or law to complete these steps? What value
does this add to our customer?”
Through team input, involvement, and willingness to incorporate change, the
discussion lead to the development of a new, more streamlined, future-state
process, using existing or readily-available agency resources. See photo for
a comparison of both current-state (blue) and future-state processes (yellow/
purple), side-by-side.
Because of this activity, Deb Biester who was previously responsible for 22 steps in the
past process will now only be responsible for three steps in the future process that also
incorporates technology and software
changes.

Project: NWDO Huddle Meetings
Team Leader: Dan Wells (DOE-BEFS)
Team Members: Aubrey Hearld, Elizabeth Pfeiffer, Jim
Anstaett, Bill Heimann, Luke Truman, Darrell Shippy,
Karen Schmidt, Anna Thiede
Summary: NWDO staff have weekly "huddle" meetings
every Monday morning at 8:15 am. Staff discuss various
projects that are occurring or where they may be traveling
during the week. Often many project involve more than one
bureau and/or program. This allows staff to keep up to date
on the projects and progress towards completion.
Communication and efficiency has greatly improved. This
also has saved extensive time and travel by staff that do not
have to travel to a specific destination if they know other
staff are already there. They will ask their coworkers to stop
by at a facility or project to help determine if certain
corrective action items have been completed and
compliance has been achieved. Staff also take turns
discussing a specific safety topic each week.

Project: Progress Report Review with
Field Staff and Regional Administrators
Team Leader: Karen Flanders (DOPH-BFH)
Team Members: N/A
Summary: Contract county progress reports were used
for reporting purposes only. Capacity prevented field staff
from reviewing with the intention of identifying trends,
positive or negative, and taking appropriate action.
The responsibility of pulling all of the report data
together, reviewing each contract area for local work with
promising outcomes that support families and child care
providers, and identifying areas where support to
surveyors was required was assigned to a specific staff
person.
A summary is now presented at each District Specialists
meeting. A plan for follow up is being developed with the
field supervisor.

Project: Complaint Review Process
Team Members: Lisa Walker, Debi Nelson
Summary: Completed complaints, both substantiated and
unsubstantiated, were routed to the program consultant for
review. This procedure was not consistent with previous
procedures when complaints were received on paper.
Additionally, the procedure prevented timely review of
substantiated compliance and program enforcement.
Admin procedures were updated to include closing
complaints that are unsubstantiated and do not have other
significant noncompliance identified. Levels of
noncompliance were reviewed with staff. The supervisor and
program consultant met with administrative staff on
11/12/2019 to review updated procedures and train as
needed.
The revised procedures were implemented on 11/13/2019.

Project: Business Concern Disclosure
Statement (BCDS) Revision
Team Leader: Mandy Patek (DOE-BWM)
Team Members: Julie Coleman, Mindy Bowman, Nancy Ulrich,
John Truong
Summary: There were two different BCDS forms Form I and Form II).
If a company had 100 or more employees then they completed Form
I and if they had less than 100 employees then Form II was
completed. If the applicant had a parent company then the applicant
completed BCDS Form I and the parent company completed BCDS
Form II. The BCDS Form I was 16 pages long and the BCDS Form II
was 8 pages long. Both forms included PII data that served no
purpose and was not of any benefit to conducting our background
investigation. A lot of the information requested was very repetitive
and cumbersome for the applicant to complete.
We met as a group to review the requirements of the statutes and to
determine the information we were required to collect for review. A
new form was drafted based on our discussions and then sent to the
group for review and approval. The outcome was there is only one
form instead of two different forms, the new form is not as
cumbersome, and is only 5 pages.

Project: Personal QI: Inbox Tasks and
Communication Timeliness
Team Leader: Ren Morton (DOPH-BCHS)
Team Members: N/A
Summary: Lagging response to customer emails.
Implemented a new inbox organization system to:
- decrease response time - certain categories are
down to same-day response or within a week.
- decrease missed emails/documentation - no missed
applications or documentation in the past 6 months
(down from an average of 2 missed applications a
month prior).
- increase reliability and efficiency - reflected in
customer feedback
- increase timely notification of opportunities to
general membership- reflected in increased emails
asking me to include something on the calendar or in
the newsletter.

Project: Trauma QI: Reliable
Communication
Team Members: N/A
Summary: Needed structure for our program to
predictably deliver certain types of
communication to our general membership.
Revised how the trauma calendar was used and
made it functional, implemented a bi-weekly
email newsletter that general membership
could anticipate. General membership began
requested the newsletter, self-selecting to
update their emails and staff's emails to receive
the newsletter, send an average of 16 events a
month to post on the trauma calendar, trauma
program membership will reference the trauma
calendar at site surveys and in meetings.

Project: Kansas Grant Management
System (KGMS) Budget Process mapping
Team Leader: Karen Kelley (DOPH-BCHS)
Team Members: Cristi Cain, Scott Strobel, Michael Roush,
Carrie Akin, Greg Hockenberger, Kevin Shaughnessy,
Annie Gile (BCHS, BDCP, BFH, DMB, OITS)
Summary: The problem was that aid to local budgets
could not be edited and the functionality needed to be
there for the locals to be able to completed
edits/changes to their current budget.
We convened a team and discussed an ideal process
(process mapping) for updating budgets and met to
discuss business rules.
The end result was a brand new process for editing
budgets and it was a communication tool for OITS to
better understand how the process needed to work.

Project: Updating Regional Management
to Access (part 1)
Team Members: N/A
Summary: The funding application process for each of the six
trauma regions were managed through six excel spreadsheets,
which required hand calculation when our advisory board wanted
to know such things as how much of funding when to a certain
course or how a specific region delineated their funding. It was also
administratively burdensome to upkeep six different workbooks. I
migrated all six workbooks to access. We reached our goal of
streamlining the management of the regional funding process. The
ability to sort, search, and query one table with all the funding
requests have expedited the processing of applications, led to a
simplification of the funding application, increased the timeliness
of invoicing, have allowed for additional processes to be structured
- such as following up on documentation which allows us to close
budgets, allows us to pull a variety of reports for the advisory
board, and have improved budget discussions at the regional
councils meetings.

Project: Trauma Regional Management
Reboot
Team Members: Wendy O'Hare, Danielle Sass
Summary: The Regional Trauma Councils were
providing feedback that they were disengaged and
felt siloed from the other regions. Implements a
reboot plan that included creating a new model
for the program, new agenda format for the
meetings, facilitated the choosing of fiscal
priorities, rescheduled all of their meetings with
intention, updated applications and policies, and
designed a new regional report. Improved
communication between the regions, increased
attendance at meetings and trauma events,
council members are assuming more work,
regional priorities are being discussed and worked
on. Used the 5 Why's.

Project: Trauma Website Remodel (Part 1)
Team Members: Wendy O'Hare, Danielle Sass, Jill Cavender,
Brittney Nochols
Summary: The Trauma website was outdated on several
levels. Each staff member claimed a certain number of pages
to remove outdated documents and program links, we
reordered the left side-bar for easier navigation, we
research other websites to find a look and impression to
strive for, we work with communication to update our
graphics, we restructured pages to follow the process they
were dedicated to to provide our membership with
additional visiual and structural understanding of the
processes (i.e. designation and performance improvement),
updated logos, and have begun rewriting pages for the web.
Membership were excited about the new look of the pages
and have emailed resources to be posted. We have received
less outdated documents which has decreased requesting
duplicate work on new forms. We have been able to link
directly to our website resources when providing technical
assistance via email.

Project: ACES Compliance Test Review
Team Leader: Allyson Prue (DOE-BOA)
Team Members: Connie Ellis, Jayson Prentice, Amy
Seeds, Vivien Smith, Charles Marx, Chris Appier, Philip
Schlaman, Logan Jones
Summary: Purpose of project was to restructure ACES testing
section to fix compliance testing report review backlog and address
issues that arose. Two primary problems that became apparent
included lack of equipment for field personnel, and a lack of
personnel properly cross-trained for compliance test observations.
Actions taken included personnel receiving tablets, cameras, and
additional safety equipment (including H2S monitors to be worn at
all times while on-site), and adjustment of position descriptions
and cross-training for all three field positions. Personnel now have
the ability to complete simple reviews of PT reports/protocols
during downtime in the field but also have access to test
method/regulation materials and permitting information.
Following the implementation of KEIMS, all documentation will be
cloud based and accessible in the field. Cameras allow for better
documentation of potential issues observed while on-site.

Project: Division of Environment
Team Leader: Ann D'Alfonso and Jayson Prentice
(DOE-BOW/BOA)
Team Members: N/A
Summary: A process needed to be developed for staff
regarding the development and approval of any IT
project in the Division of Environment at the bureau
and division level. This step-by-step process could be
used by any staff within DOE who has an idea to full
implementation of an IT project. This process is simple
and straight forwards and allows for sharing of ideas
across bureau lines to decrease duplication and
increase efficiency. Deliverable from this process can
also be used to fulfill requirements for the next phase
of IT approval which also increases efficiency.

KDHE 2019 Reported QI Projects

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KDHE 2019 Reported QI Projects