or educators.

"The CAO chose our nurses because, in part, there are great community demands for this classification of workers and a national crisis in nurse recruitment. This presented a perfect choice to improve our productivity without more staffing."

In specific terms, the HHSA was expected to produce a 25 percent increase in the numbers of clients served and a 25 percent reduction in time needed to serve clients. These initial goals seemed unrealistic to Macchione and "knocked us off our chairs," he said.

To address wasted travel and office time issues, the county invested in wireless, electronic tablets for the public-health nurses. The tablets contain each nurse's client database, which provides patients' vital statistics and medical histories. The tablets' portability allows nurses to schedule appointments, fill out forms, record pertinent follow-up information for later retrieval, and perform other administrative tasks remotely. This convenience not only saves time, but also promotes enhanced care to appropriate individuals.

Project participants said the pilot succeeded because line employees were involved from the outset. In the first operational phase, the agency asked the public-health nurses how the county could improve and streamline their administrative tasks.

"The thing that was really positive from the very beginning was the line nurses were in on the design and implementation," said Kitty Roche, public-health nursing supervisor in the North Inland Region. "The people who were using it in the field had as much input as those overseeing it, and we felt very much a part of it. We were all asked to express what we thought the barriers and problems were in the process. I have an incredible team of nurses, who from the very start were very positive about the project."

The second phase of process enhancement started in July 2005 and lasted three months.

"This is where we did our workflow redesign," said Macchione. "We looked at all the steps, identified the 18 paper steps, and discovered it was a cumbersome, highly frustrating system for the referral agencies, staff and clients. We then began to enact organizational change. Although nurses were concerned this would mean losing jobs, we made it clear we were looking to gain efficiencies to gain more clients. Less paper, more clients served."

Macchione and his colleagues gathered a core design team of nurses and clients. A process engineer consultant guided them through the process of eliminating steps and reducing time. Macchione said that during the process of shortening travel and administrative time, the idea developed for a Web-based referral system.

"We did not start out with the idea, but through the process, we discovered it," he said. "We then realized we also needed a database to manage cases. This led us to the next step of dispatching referrals to the nurses in the field, and we thought it would be great to have a desktop in the hands of the nurses, along with clinical information to educate clients, do notation, client input, time recording and mileage tracking."

Use of tablets at the point of service was the logical next step, he said.

The Results

San Diego County public-health nurses will get to see 2,400 more clients each year thanks to the new referral system and electronic tablets. Without this new technology, it would require 23 additional staff members to achieve such an increase, according to Macchione.

Now the average amount of time it takes to make contact with clients is around 13 days.

"We are still not satisfied with that number," said Macchione, adding that this is a reduction of 75 percent, and 11 percent of the time, clients are seen on the same day.

Over the long term, more clients will see public-health nurses, so fewer San Diego residents will need to rely on the health-care system, generating