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HomeMy WebLinkAbout2122-5 Management of Case Investigation and Contact TracingManagement of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Management of Pandemic Case Investigation and Contact Tracing To request this information in an alternate format, please call (541) 330-4674 or send email to David.Givans@Deschutes.org Deschutes County, Oregon David Givans, CPA, CIA Deschutes County Internal Auditor 1300 NW Wall St Bend, OR 97703 541-330-4674 David.Givans@deschutes.org Audit committee members: Daryl Parrish, Chair - Public member Jodi Burch – Public Member Tom Linhares - Public member Scott Reich - Public member Summer Sears – Public member Stan Turel - Public member Patti Adair, County Commissioner Charles Fadeley, Justice of the Peace Lee Randall, Facilities Director Take survey by clicking HERE Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 TABLE OF CONTENTS: HIGHLIGHTS 1. INTRODUCTION 1.1. Background on the Audit …………..…………….………………………………………. 1 1.2. Objectives and Scope ……………….……..…………….…………….……..………… 1-2 1.3. Methodology ………………………………….………….…………………………..……… 2-4 1.4. Background on Case Investigation and Contact Tracing …….…………. 4-9 1.5. Benchmarking information – County comparisons ……………………... 9-11 2. FINDINGS and OBSERVATIONS 2.1. Temporary worker costs – Pandemic (CI/CT) ……………….………….… 11-17 2.2. Performance metrics (CI/CT) ………………………………………………….….. 18-27 2.3. Survey of CI/CT temporary staff …………….…………..……………………... 28-36 3. MANAGEMENT RESPONSES 3.1. Health Services ……………………………..……………..……….…………....... 37-39 3.2. Human Resources …………………………………………………………………. 39-41 Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 HIGHLIGHTS Why this audit was performed: The County has been providing resources for pandemic case investigation and contact tracing. What was recommended: Recommendations include: • developing a new invitation to bid for temporary labor; • establishing more effective leadership and management of the temporary labor contracts and how they are used • considering what practices should be employed to provide feedback to contracted temporary staff; and • using more metrics to manage temporary and remote staffing workloads. Management of Pandemic Case Investigation and Contact Tracing The focus of the audit is management of staffing for case investigation (CI) and contact tracing (CT). Important tools for fighting the current COVID-19 pandemic. Most of the staffing is with temporary staff hired through a staffing company. What was found The audit report presented some valuable information on benchmarking of cases. Deschutes County during surges appears to sustain a higher level of cases than their peers. Deschutes has done a much better job of addressing their workload in a timely manner as evidenced in trends in percent of Covid-19 cases with follow-up initiated within 24 hours. Trends in CI/CT costs and pandemic cases tend to move together indicating that utilization moving with the influx of cases. It was observed that additional management of temporary labor vendor contract was needed. It was also noted that additional job performance input could be provided to longer duration contracted temporary staff. A number of metrics for case investigation and contact tracing were calculated and presented over a period of time in comparison to case activity to show how these metrics might provide insights into performance and outcomes of the work. These metrics when developed at the staff level (and compared across staff over time) can be useful for oversight and training purposes. A survey of the 29 CI/CT temporary contract staff was overall very positive towards the process of working with Health Services. Deschutes County Internal Audit Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 1 1. Introduction 1.1 BACKGROUND ON THE AUDIT Audit Authority: The Deschutes County Audit Committee authorized the review of management of the pandemic case investigation and contact tracing with the FY 22 FY 23 internal audit workplan. Case investigation (CI) and contact tracing (CT) are important tools for fighting the current COVID-19 pandemic. The County has limited resources and has been working towards making sure staffing is appropriate for the case investigation and contact tracing needs. Most of the staffing is with temporary staff hired through a staffing company. The focus of the audit is management of staffing for this vital function. 1.2 OBJECTIVES and SCOPE “Audit objectives” define the goals of the audit. The audit work occurred during the COVID-19 pandemic. Objectives included: 1) Review CI/CT activities through surges. a) Assess performance measures regarding workload of case investigation and contact tracing (CICT) efforts and how they are impacted with recent surges. Consider comparing some measures with comparable counties. b) Assess and review CI/CT staffing management and costs. 2) Inquire of CI/CT staff satisfaction with onboarding, training, communications, supervision, and technology support as well as dealing with HIPAA and privacy concerns. 3) Be aware of any issues with compliance with federal and state regulations and requirements, as may be applicable. 4) Be aware for areas for improvement. Scope and timing: The overall audit commenced in November 2021. Work was commenced during the downturn in Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 2 Delta variant cases and as Omicron variant cases were starting to rise. The scope was limited to temporary staffing services used for case investigation and contact tracing (identified as temporary staff through a contracting service provider for communicable diseases area). Contact tracing activities were limited significantly during periods of surge. The audit tried to use data that reflected activity levels back to December 1, 2020 through November 2021 for Deschutes County. Oregon Health Authority (OHA) published data was used for some comparisons between comparable sized counties. The eight counties used included (in descending population): Clackamas, Lane, Marion, Jackson, Linn, Douglas, Yamhill, and Benton counties. The scope of the audit did not include internal controls employed. Some of the audit observations on performance measures relied significantly on Deschutes data obtained from OHA. Data gathered by Deschutes County for case investigation and contact tracing goes into a state system (OPERA and ARIAS) and OHA controls access. While grateful to have some indirect access to Deschutes data, the access was not typical of the level of access for most County audits. This indirect access came with significant delays to the audit. The indirect access did not appear to significantly impair the analyses and associated observations, though when dealing with data provided by another agency, there is no certainty as to its completeness. Based on the analyses applied, it is believed the data is sufficient and appropriate as used. This audit report does not contain any protected personal information nor was any protected information necessary in compiling the information for this audit. Internal audits respect HIPPA, Privacy laws, and the confidentiality of personal health information. 1.3 METHODOLOGY Audit procedures relevant to the reported topics in this report include: • Interviews of selected departmental management and staff and OHA. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 3 “Audit procedures are created to address the audit objectives” • Reviewed pandemic information on case investigation and contact tracing from WHO, CDD, OHA and others. • Consider best practices and benchmarking measures against other counties (if data is available). Consider calculating other performance measures (if sufficient time and data) • Analyze data on pandemic for Deschutes County and comparable counties. • Assess and determine staffing costs and staffing headcount (hours) for case investigation and contact tracing during the audit period (contracted temporary staff). • Assess workload (case reports) and staffing (hours) for Case investigation and Contact tracing. • Review and assess management efforts over CI/CT staffing, including tools management is using to manage workforce and supervision being performed. Analyze information from OPERA (Case investigation) and contact tracing (ARIAS) and develop identified measures by month and by staff. • Surveying contact tracers and case investigators to establish practices they are performing, feedback on supervision and oversight, as well as how the system is working (and how it might be improved). Criteria Utilized best practices and guidelines published by the OHA and CDC guidance. Identified similar sized counties to be used for benchmarking based on similar caseloads per capita. We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives, however noting the limited access to data described in the scope. (2018 Revision of Government Auditing Standards, issued by the Comptroller General of the United States.) Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 4 The County Internal Auditor was created by the Deschutes County Code as an independent office conducting performance audits to provide information and recommendations for improvement. 1.4 BACKGROUND FOR CASE INVESTIGATION AND CONTACT TRACING (CICT) Chart I – Oregon trend in cases by week since inception COVID-19 Pandemic States and counties have, since the pandemic started, mounted large-scale case investigation and contact tracing efforts to identify and isolate those who have contracted COVID-19. Source: Oregon COVID-19 Case and Testing Counts Statewide Deschutes County’s case activity has a very similar trend profile, and represents 6% of the cumulative state cases at the end of the fifth wave (Deschutes County represents about 5% of the state’s population). The most recent sixth wave was from the Omicron variant and appears to be tailing off but at levels still higher than prior surges. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 5 Diagram I – Word cloud depiction of frequency of other wrap around services. Deschutes County response to pandemic Deschutes County provides case investigation and contact tracing in coordination with the Oregon Health Authority (OHA) and under their direction. Case investigation and contact tracing was required to be implemented very quickly and with great uncertainty as to what the needs would be. A temporary labor force was developed for case investigation and contact tracing by Health Services and was premised on limited capacity available in the department to provide oversight and training. The County, in addition to case investigation and contact tracing, provides hotline and additional services to people adversely impacted by the pandemic. These services are primarily provided by the Public Health Division of Health Services. Most of the case investigation and contact tracing staffing are comprised of temporary workers. Tool: EdWordle http://www.edwordle.net Case Investigations and Contact Tracing (CICT) Case investigation and contact tracing are disease control strategies that involve identifying persons diagnosed with a disease and their contacts, then working with these individuals to interrupt further transmission. Local and state health departments have employed this strategy for decades. • Case investigation reaches out to a person recently diagnosed with the disease. The investigator inquires about the person’s symptoms, and asks where they have spent time and Wrap around services are provided in about 11% of cases. As indicated to the left, food and rent are among the most frequently requested support. Case investigators will refer these cases to other Health Services staff in charge of supporting these services. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 6 Diagram II – Case Investigation workflow (CDC) may have exposed others to COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/investigating-covid-19-case.html • Contact tracing then reaches out to people who have been near the positively diagnosed person to notify them of their exposure and ask them to quarantine. Contact tracing is key to slowing the spread of disease by letting people know that they may have been exposed and providing them with information on how to monitor their health for symptoms. It also helps these individuals get tested and connects them to resources and support during their time of self-isolation (if they have the disease) or self-quarantine (if they had close contact with someone who has been infected). Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 7 Diagram III – Contact Tracing workflow (CDC) https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/contact-tracing.html OHA pandemic systems (OPERA/ARIAS) These computerized systems available to all counties in coordination with OHA are a tool to house case and contact information and are critical to tracking, tracing, isolating, and quarantining new cases and mitigating spread of COVID-19. • OPERA (Oregon Pandemic Emergency Response Application) is a person-centric database where a person record is associated with a case record of a disease. These are generally created on identification of a positive test for Covid-19. This system is primarily for case investigation. Potential exposed contacts are noted and shared with the ARIAS system. The OPERA data then informs the work of epidemiologists and policy makers at Local Public Health Authorities, OHA, and the Centers for Disease Control and Prevention (CDC). This includes reporting disease statistics so that the general public is aware of the spread of the Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 8 disease locally and nationally. • ARIAS (At Risk Identification Alerting System) is used for contact tracing individuals reported in OPERA investigations. The system supports automated symptom monitoring assessments. Surge protocols When cases reach beyond normal capacity, the department puts in place surge protocols. These protocols prioritize case investigation as well as certain populations. For instance the following populations are prioritized a) Cases ages 0-18 years old, b) Cases ages 55+ years old, and c) High interest cases (daycare teacher, K-12 teacher, long term care worker, etc.) Surge protocols go into place at Deschutes County when weekly cases go beyond 350 cases a week. This can also reduce the efforts to contact as well as the extent and nature of the contact with cases. Omicron variant surge update (late 2021 and early 2022): Case levels in December started rising precipitously from the Omicron variant. The current and rapidly growing surge of COVID-19 cases has outpaced the capacity of the public health system to effectively conduct active case investigation and contact tracing. Given the burdens to the entire public health infrastructure and the need to pivot resources to higher priority public health measures, the County and OHA are moving away from individual investigation and contact tracing calls to focus on investigating outbreaks in high-risk settings (congregate care living, food chain, healthcare, childcare, and K-12 settings). OHA (and the County) will adopt an “opt-in” approach to case investigation, with a focus on ensuring people who test positive for COVID-19 or who are exposed to COVID-19 can quickly access information and resources to safely isolate and quarantine. Staffing previously focused on case investigations and contact tracing is being pivoted to a COVID-19 Case Support Hotline focused Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 9 on providing health education, survey assistance, referrals and resources to people who test positive for or have been exposed to COVID-19. OHA measures addressing case investigation are no longer being published. 1.5 BENCHMARKING INFORMATION –County comparisons Chart II – Weekly trend pf per capita cases between Deschutes and 8 similar counties on population. Overall case trends (per capita): In addition to just trending case information, comparisons are more readily discernable when developed per capita. Source: OHA Oregon Covid-19 Public Health indicators Observation: Deschutes County during surges appears to sustain a higher level of cases than their peers. The eight counties used included (in descending population): Clackamas, Lane, Marion, Jackson, Linn, Douglas, Yamhill, and Benton counties. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 10 Chart III – Weekly trend in measure of following up within 24 hours and comparison to other 8 county average. Deschutes county appears to perform better in this measure than their peers. The counties represented seem to struggle more during peak surges. Percent of Covid-19 cases with follow-up initiated within 24 hours. This is a workload measure which calculates the ability of the case investigators to reach out to their case load within 24 hours. Measure performance goals would generally be to have this metric at 90-95%. Source: OHA Oregon Covid-19 Public Health indicators More discussion of this and other performance metrics will be discussed below. Deschutes County’s average during this period is 84%. Compared to the 8 county average, Deschutes has done a much better job of addressing their workload in a timely manner. This is especially the case during the Delta variant wave which started in August 2021. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 11 Note for Omicron surge: OHA during the Omicron surge (starting around 12/12/2021) has discontinued presenting this measure as the case numbers have gone up considerably and case investigators are no longer trying to address all cases coming in. 2. Findings and Observations The audit included limited procedures to understand the systems of internal control. No significant deficiencies were found in this audit. A significant deficiency is defined as an internal control deficiency that could adversely affect the entity’s ability to initiate, record, process, and report financial data consistent with the assertions of management in the financial statements. The findings noted were primarily compliance and efficiency matters. Audit findings result from incidents of non-compliance with stated procedures and/or departures from prudent operation. The findings are, by nature, subjective. The audit disclosed certain policies, procedures and practices that could be improved. The audit was neither designed nor intended to be a detailed study of every relevant system, procedure or transaction. Accordingly, the opportunities for improvement presented in the report may not be all-inclusive of areas where improvement may be needed and does not replace efforts needed to design an effective system of internal control. 2.1 TEMPORARY WORKER COSTS – PANDEMIC (Case investigation / Contact tracing) Trends in costs Overall temporary worker costs being spent through Public Health – Communicable diseases (and the primary temp worker vendor) have moved with the surges of the pandemic. Of the $2.5 million spent in the 12 months, 74% (or $1.85 million) was utilized for case investigation and contact tracing (CICT) staffing, 22% (or nearly $562k) was spent on the call center and hotline staffing. Four percent went to other programs. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 12 Chart IV – Monthly trend in temporary worker costs compared to case levels Source: Temporary worker costs from vendor invoice export Most of the costs for case investigation and contact tracing are being paid through federal and state pandemic funding. Trend in staffing Average weekly hours of temporary staff are pretty consistent and average around 31 hours. The most recent wave was staffed through adding additional staff. A majority of the temporary staff are paid at ranges from $34/hour to $37/hour. Rates may include lead pay premium as well as a premium for bilingual skills. Though relatively infrequent, sometimes overtime is paid. Some Deschutes County staff working on cases are paid less of an hourly rate and are exempt from overtime. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 13 Chart V – Monthly trend in CICT staff hours, average weekly count and average weekly hours. Source: Temporary worker costs from vendor invoice export Comparison between case volumes and CICT hours The CICT hours do not move or react as quickly or as much as the cases. This is seen as partly due to the constraints when needing to add additional staffing. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 14 Chart VI – Monthly trend in CICT hours to cases (Deschutes) Source: Temporary worker costs from vendor invoice export Additional management of temporary labor vendor contract needed. There are a number of areas identified with the primary vendor relationship for temporary labor (CICT) with the County that could be improved. • The primary vendor charged their highest margin (29.5%) on new Health Service labor (all CICT staffing). It is not clear there was any negotiation for a lower rate. This job type is not a higher risk category such as road crews. • The contract with primary vendor is technically expired and the County has not reached out for new bids. County Counsel thinks that an interim contract is needed until new bids can be obtained. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 15 Internal Audit completed an audit on Temporary Services in July 2011 (#10/11-2). Within that audit, there was a recommendation for the County to “consider coordinating a County-wide invitation to bid to minimize cost to County for temporary staffing services”. County Administration agreed with the recommendation and issued the invitation to bid in May 2011. The contract with the primary vendor commenced in August 2011 and was a two year contract. The contract provided for a set margin for different job classes. The margin applied to most of these jobs were at 25.5% and one class (road crew) was at 29.5%. Additional jobs were to be negotiated as they were added. County administrative staff originally responsible for the primary vendor contract for temporary labor moved out of administration and the contract did not receive additional attention. The primary vendor with the increased margin (29.5% vs 25.5%) has been able to charge an additional $78 thousand on the $2.5 million in temporary labor used by Health Services communicable disease program (from December 2020-November 2021). Health Services also has been the primary recruiter for these staff and the vendor has not recruited many staff to meet the needs of the department. Human Resources performs the pre-service screenings for new contracted staff. With the County taking over some screening activities should the County be paying this high of a margin? Are there ways to get credit with a lower margin for the additional work that happens by the County? The County has significant needs for bilingual staff and the vendor has not shown a strength in this area. The primary vendor has not been responsive to requests for reports and data from the department. These are among the questions that should be addressed as the RFP and contracts are updated. The County is able to create its own on call labor pool and has the potential to save some monies. In the internal audit above another recommendation was “for County departments to consider utilizing the County’s personnel/payroll system for handling some hourly and on-call workers”. What has changed since issuing that recommendation is that the County may have to pick-up health insurance and pay into retirement (PERS) for some temporary staff meeting certain hour thresholds or if they are Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 16 already part of PERS. This could erase any potential savings and even cost the County more. With the base level fringe benefits (Social Security, Medicare, and unemployment insurance) there is 8.8% in costs. For the temporary labor used in communicable diseases that leaves nearly 20.7% (or $400 thousand) to cover other fringe benefits or for savings. It is very much dependent on the labor pool in force and how much they are used. It is not clear we have a good understanding as to the pros and cons of developing labor through temporary labor vendor versus handling through a County developed oncall pool. Especially with the surges and changes from the pandemic, the use of temporary services through a vendor has allowed greater flexibility. It is recommended for the County to develop a new invitation to bid to cover the newer needs of the County for temporary labor and address the handling of margin and concerns noted above. It is recommended the current contract with the primary vendor for temporary labor be extended out 12-18 months until an invitation to bid can be developed and issued. It is recommended for the County to establish more effective leadership and management of the temporary labor contracts and how they are used by County departments. They may want to consider a policy or procedures to address the variety of human resource issues that come with using a temporary workforce. This would include whether an in-house labor pool could be developed and when departments should consider contracted labor. {Human Resources has indicated they will be taking over efforts to work on the temporary labor RFP/contracts.} How much job performance input should the County provide to longer duration contracted temporary staff? The contracted temporary staff for case investigation and contact tracing are not receiving formal Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 17 evaluations. A number of survey respondents indicated they were looking for more input on their work. The County has some guidance to departments for on call staff on evaluations. These are most similar to the temporary staff. On call staff are hired by the County and generally are unbenefited, not full time, and their hours can vary. Generally, on call staff are supposed to receive evaluations when they have reached a thousand hours and have worked at least 12 months. A number of our temporary staff would have reached these levels. However, there are no practices in place to provide formal feedback and there does not appear enough informal feedback. Given the nearly $2.5 million in temporary staffing for the CI/CT, this is definitely a significant investment in resources. These staff should be provided a certain level of feedback and guidance as they work for the County. The County generally reserves formal evaluations for probationary, annual job step increases, or annual reviews. Whereas these don’t necessarily apply to the temporary staff, the County should consider how best to manage and improve this kind of workforce. Just because these staff are contracted, the County still controls what they work on and how they perform the job. Without sufficient input and oversight, the County may not be addressing issues until they are a problem. Health Services indicates they have performed data quality reviews and periodically identify workers needing additional training, however with the numerous pandemic surges these efforts tend to not occur routinely. It is recommended for the County (and Health Services) consider what practices should be employed to provide feedback (formal, informal, and to what extent) to contracted temporary staff working for the County. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 18 2.2 PERFORMANCE METRICS – Case investigation and contact tracing Health Services in their work with OHA have access to one particular metric for their performance on case investigation and contact tracing. It was the percent of Covid-19 cases with follow-up initiated within 24 hours (See Chart III). This measure is available for the weekly periods but County staff did not obtain and did not look at the performance down to a staff level to see how particular staff were performing. Oversight staff do periodically review data quality reports which can identify staff needing additional data entry training. Granted this is a pandemic and resources and time are limited for staff, but the use of metrics is a great way to monitor and manage performance. It also can give information on whether staffing levels are at the right level. The CDC published guidance on their website (in early 2020) for Evaluating Case Investigation and Contact Tracing Success. In their introduction they explained their reason for providing this information. “Routine review of both process and outcome metrics will also be crucial for case investigation and contact tracing success. By examining these data regularly, issues can be identified and rapidly addressed, changes to internal case investigation and contact tracing processes can be made, and the local health authority can more easily pivot when new high-risk populations are identified.” There are numerous metrics identified by the CDC, however with the limited availability of data from the OPERA and ARIAS systems (collected and provided by OHA) only a select number of the metrics identified by the CDC could be explored. SELECTED METRIC ANALYSES: To support supervision of case investigation and contact tracing staff, developed reports showing metrics at the level of the individual case investigator and contact tracer will help ensure that staff are meeting expectations and identify areas for additional training. Programmatic metrics help leadership with insights on program successes and possible opportunities for additional training, Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 19 resources, or focus areas. Some metrics touch on both. Case investigation measures • Number of case investigations assigned during review period (individual and programmatic) • Number of clients interviewed during review period (individual and programmatic) • Number of clients interviewed/Number of case investigations (programmatic) • Number and percentage of clients interviewed <24 hours from report to health authority during review period (individual and programmatic) Contact tracing measures • Number and percent of case investigations in which at least one close contact was elicited during review period (individual and programmatic) • Total number of contacts interviewed/total number of contacts named by cases during review period (Individual and programmatic) Case investigation measures 1) Number of case investigations assigned during review period (monthly) This metric provides an indication of how many case investigations were assigned out to staff and measures the capacity needed to be covered. These numbers compare closely with cases reported above. Deschutes County staff contributed during surges. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 20 Chart VII – Monthly trend in number of case investigations assigned. Chart VIII – Monthly trend in case investigations assigned per billed hour compared to number of case investigations assigned. (for temporary staff) When looked at the staff level it can identify with other metrics whether staff are being over- burdened. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 21 Chart IX – Monthly trend in case investigations assigned per billed hour (indicating lead and non-lead staff) compared to number of case investigations assigned. (for temporary staff) With an average of .4 cases per billed hour, the average 8 hour shift is able to take on 3.2 cases. It is probably higher as some of the temporary staff are not handling cases. Staff indicated that 6-8 are normal case assignment levels. More cases per hour are assigned during surges, but we can look at other metrics to see how well these were addressed. Cases assigned per billed hours for lead-temporary staff are fairly consistent and average at .26 cases per hour as they have additional responsibilities and are assigned more difficult cases. Other staffing cases per hour vary from .14 to .93 cases per hour. The increased capacity during surges is likely to do with spending less time on cases. 2) Number of clients interviewed during review period (monthly) This metric provides an indication of how many cases assigned had interviews completed during the period. Differentiated form the previous measure on cases assigned, this metric indicates Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 22 Chart X – Monthly trend in number of case interviews completed vs. cases assigned (for temporary staff) how many of the cases assigned had interviews completed. This measure shows very strong correlation between case interviews completed and cases assigned with the only deviations occurring during surges. More notable is doing this analysis at the staff level to assure that staff are getting to the work assigned. 3) Number of clients interviewed/Number of case investigations (monthly) What is perhaps most interesting from this measure is comparing the cases where interviews have been completed to cases assigned. What the analysis will call percentage (%) complete, this calculation distils down to the actual performance on workload. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 23 Chart XI – Monthly trend in percentage (%) cases interviewed vs. number of case interviews completed and cases assigned (for temporary staff) The percentage % complete is nearly 100% in most months except for the peak surges. In September it was its lowest point during the pandemic at 95%. More notable is doing this analysis at the staff level to assure that staff are getting to the work assigned. At the staff level, it does show where some staff are struggling with completing interviews. This are situations where management should try to make sure they are following up with staff. 4) Number and percentage of clients interviewed <24 hours from report to health authority during review period As noted previously in Chart III, this parallels the workload measure (published by the OHA) which calculates the ability of the case investigators to reach out to their case load within 24 hours. Measure performance goals would generally be to have this metric at 90-95%. The following analysis is just for the temporary staff efforts. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 24 Chart XII – Monthly trend in number and % of clients interviewed within 24 hours compared to number of cases assigned (for temporary staff) Chart XIII – Distribution of number of days for first interview call (for temporary staff) (Dec 2020-Nov 2021) The % interview call date within 24 hours is relatively flat and averages around 79% though it is lower during surges. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 25 Chart XIV – Monthly trend in number and percentage (%) of cases resulting in at least 1 contact (for temporary staff) This provides a better understanding of how many days it sometimes takes. Contact Tracing measures 5) Number and percent of case investigations in which at least one close contact was elicited during review period This metric anticipates that most case investigations should or would prompt at least one contact. As one might suspect, the most recent surge with higher case levels resulted in a lessor priority to develop contacts. The average percentage of cases that developed at least 1 contact was 51%. Not all case investigations will result in one or more contacts. Some but not all contacts identified get transferred over to the separate ARIAS system for contact follow-ups. This will impact this measure. Health Services staff have developed teams to provide additional outreach and sometimes instead of creating individual contacts these teams can provide outreach to Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 26 Chart XV – Monthly trend in percentage (%) of contacts identified that had interviews completed (for temporary staff) group settings (employers, retirement homes, schools, etc… ) and have those groups perform the outreach to the potential contacts. One other reason this approach is useful is that some individuals are less willing to provide individual contacts or may not have the information to identify those contacts. Health Services indicates this outreach approach has been much better received and is far more effective and efficient use of staff time. 6) Total number of contacts interviewed/total number of contacts named by cases during review period This particular metric shows whether the contacts identified with cases are interviewed. As indicated in the prior metric, not all cases results in a contact being identified. Of those contacts that are identified only about 5% (on average) are having interviews completed. Since the County is using surge protocols. These are a low priority during surges and you can see improvement in the lulls between surges. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 27 Additional metrics provide better insights into use of temporary labor. The County currently has had access to limited metrics on the usage and outcomes from their use of temporary staffing for case investigation and contact tracing. OHA did publish the metric for calls within 24 hours of the case reporting. As noted in the above metrics, there are numerous metrics that can help managers and supervisors understand whether additional training or support is needed for staff. Since this staffing is remote and temporary, it is not always easy to have good transparency on the work being performed. The County has been working hard to manage this process amidst wave after wave of the pandemic. In addition, the data for this particular program is controlled by the state and was not as easily accessible by County staff. There are also no reports available in the OPERA/ARIAS system to report on these other metrics. With this additional information. The County does have ability to see how better to use staff and manage associated workloads. Drilling down to metrics available by staff person, it is possible to develop a response to make the programs more effective and efficient. The County has expended significant resources to provide case investigation and contact tracing with outside temporary staffing. It is recommended for Health Services and the County to consider using more metrics as they manage temporary and remote staffing workloads (for case investigation and contact tracing). Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 28 2.3 SURVEY OF CASE INVESTIGATION AND CONTACT TRACING TEMPORARY STAFF Chart XVI – Survey responses for onboarding / training process preparing you for this job It was the intent of the anonymous survey to assess practices Health Services is performing, feedback on supervision and oversight, as well as how the system is working (and how it might be improved). The survey was developed with Health Services staff. The survey went out to 29 CI/CT staff and all responded. The lead responses are broken out in the analyses as they are a slightly different perspective (more experienced and longer term) and represents a small portion of the total responses (at 14%). SURVEY QUESTION 1: The Deschutes County onboarding/training process prepared you for this job. Overall, the staff indicated at a level of 4.3 out of 5 (86%) that they were prepared for the job. Lead staff, who have additional oversight and training burdens, had a lower perception of this readiness. SURVEY QUESTION 2: I was setup for success. Overall, the staff indicated at a level of 4.4 out of 5 (88%) that they were setup to succeed. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 29 Chart XVII – Survey responses for setup for success Chart XVIII – Survey responses manageable workload Lead staff, who have additional oversight and training burdens, had only slightly lower perception of this readiness. SURVEY QUESTION 3: The workload I receive from the COVID-19 leadership team is manageable within the hours worked. Overall, the staff indicated at a level of 4 out of 5 (80%) that their workload was manageable. Regular staff seemed to have a slightly lower response given the distribution of responses. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 30 Chart XIX – Survey responses on keeping up with work assigned with hours provided There a number of comments provided, highlights include the following: • “… During surges, it is at difficult to keep up with the work if it requires more attention and several emails to various groups, and still maintain the number of calls necessary, along with the data entry within a certain timeframe.” • “… Everyone is so helpful and always available to answer questions. I really do love this team!” • “…Surges have been challenging, but leadership has done a good job of balancing our workload by (1)prioritizing populations at risk, and (2)farming out cases to OHA and to county volunteers.” SURVEY QUESTION 4: During pandemic surges, I have been able to keep up with work assigned in the hours provided. Overall, the staff indicated at a level of 3.7 out of 5 (74%) that they are able to keep up with the work assigned with the hours provided. Lead staff, who have additional oversight and training burdens, had a lower perception of being able to keep up with work assigned. SURVEY QUESTION 5: The COVID-19 leadership team has reasonable expectations for my workload. Overall, the staff indicated at a level of 4.2 out of 5 (83%) that leadership had reasonable expectations Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 31 Chart XX – Survey responses on whether leadership has reasonable expectations on workload Chart XXI – Survey responses on receiving timely communications on workload. SURVEY QUESTION 6: I have received timely communications from the COVID-19 leadership team (or County supervisors) on state and local process changes, operational decisions, and other aspects of the COVID response. Overall, the staff indicated at a level of 4.6 out of 5 (91%) that leadership provides timely communications. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 32 Chart XXII – Survey responses on leadership team being approachable Chart XXIII – Survey responses on awareness of how to escalate matters. SURVEY QUESTION 7: My COVID-19 leadership team supervisors are approachable. Overall, the staff indicated at a level of 4.7 out of 5 (94%) that the leadership team was very approachable. SURVEY QUESTION 8: I understand how to escalate matters. Overall, the staff indicated at a level of 4.6 out of 5 (92%) that they were aware of how to escalate matters. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 33 Chart XXIV – Survey responses on receiving adequate supervision Chart XXV – Survey responses on adequate remote workplace tools. SURVEY QUESTION 9: I receive adequate supervision from the COVID-19 leadership team (or County supervisors). Overall, the staff indicated at a level of 4.6 out of 5 (91%) that they receive adequate supervision. Lead staff, who have additional oversight and training burdens, had only slightly lower perception of adequate supervision. SURVEY QUESTION 10: The remote workplace tools (phone, computer, etc...) provided to me are adequate for the job. Overall, the staff indicated at a level of 4.4 out of 5 (89%) that they have adequate remote workplace tools. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 34 Chart XXVI – Survey responses on prioritizing HIPAA and privacy Of the nine comments received, most of the comments for this were around having the need for newer laptops and with larger screens. One person indicated the County should streamline the process of onboarding new staff to OPERA. One person indicated voice enabled features for phone and computer would be useful. SURVEY QUESTION 11: We prioritize HIPAA and privacy concerns while providing a valuable service. Overall, the staff indicated at a level of 4.8 out of 5 (95%) that they are able to prioritize HIPAA and privacy concerns. SURVEY - OPEN COMMENTS and SUGGESTIONS AREA: The following are some of the unedited comments and that are pretty representative of the comments provided: • “… The "Neither agree or disagree" answers that I gave pertaining to leadership were because there are many levels of leadership. Some have great timely responses and support while others do not. It would certainly help if we could establish a hierarchy that is sustainable and not one that changes every couple of months. That makes it virtually impossible for continuity in training and implementation. That said, the revolving door of change happens because DCPH employees are getting moved around, promoting, etc. leaving all of the temp workers with new supervisors trying Survey averages = Overall 95% (4.8/5) CICT Leads 100% (5/5) CICT Staff 94% (4.7/5) Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 35 to figure out what we've all been doing for 2 years! Ironically the "temp" workers are the ones staying in Covid Response and managing the pandemic in DC. The Employees are the ones accepting positions else wear and creating the constant change that makes management of this situation very difficult.” • “…Due to excellent leadership and the dedication of team members, the DCHS CI/CT team provides informed, timely, and accessible service to local COVID cases. Leadership updates us every morning, keeping us informed about current scientific and demographic information to help us understand and perform our work. … We are a cohesive unit, a well-oiled machine, and everything runs smoothly even during surges because of each and every teammate. Everyone on the team, and on related teams, is professional, intelligent, and kind. Being associated with these people is the biggest honor of my professional life. “ • “… I would like to see someone reach out and either ask me how it's going or look at my cases and let me know if I am doing anything wrong. I'm going with no news is good news right now.” • “… I think that the processes and guidelines are amazing and our leads make sure that the job gets done with satisfactory results.” • “… The impact we are making on branching out and building trust in the community is wonderful and rare. People are impressed and thankful when I get done talking to them. They feel heard, supported and important. That is worth its weight in gold. People start to heal the moment they feel heard.” • “… Consider performance reviews for team members.” {INTERNAL AUDITOR: County on call staff receive performance reviews once they have reached 1,000 hours and 12 months. With contracted temporary staff there are no requirements for any reviews nor have any received formal evaluations. Some of these contracted temporary staff have had more than 1,000 hours and 12 months. See earlier provided recommendation. } • “… DCHS should be very proud of the people who initially set up CIs and CTs for success, and proud of those who have since taken the ball and run with it. They are resilient, compassionate, and effective warriors in the fight against COVID.” Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 36 Chart XXVII – Survey responses sufficiency of background Chart XXVIII – Respondents time working with the County (Ci/CT) SURVEY – DEMOGRAPHICS Background Overall, the staff indicated at a level of 4.7 out of 5 (94%) think their background is sufficient for the CI/CT work. Time working with County As one would expect, the lead staff have had the longest tenure with this work. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 37 3. Management responses Health Services Department Nahad Sadr- Azodi Public Health Director March 3, 2022 First and foremost, as Health Services Public Health Division, we extend our gratitude to you (David Givans) for undertaking a massive and complicated auditing exercise with our COVID-19 Case Investigation and Contact Tracing (CICT) process/ unit. We acknowledge that it was at times very difficult to access good data and information in a timely manner, particularly from the State, and David’s patience and persistence was highly appreciated. As a Division, we welcomed the audit both to reinforce the great work that we were confident that we had done, and to learn from and correct any potential shortcomings and inefficiencies. Second, we would like to extend our gratitude to the Board of Commission and the County Administration (including Finance, Human Resources, previous and current Administrators) for their unwavering support throughout the pandemic, and in particular for ensuring adequate resources and capacity to deliver an incredibly high quality CICT service to the community. This audit shows that despite ‘building the plane while flying it”, we generally met or exceeded expectations and metrics. As evident in the findings, “Deschutes County during surges appears to sustain a higher level of cases than their peers.” This is a tremendous recognition of a dedicated and relentless CICT team, led by Carissa Heinige and Emily Freeland, who are (collectively), in my view, our Pandemic Heroes. Moreover, the staff survey shows that our supervisors and leads balanced the intended outcomes with a dignified process and provided great support for our temporary CICT staff. In other words (and although I acknowledge the tremendous stress and pressures), our temporary staff and their wellbeing were not sacrificed to achieve or meet a target. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 38 Health Services Department (continued) Third, please see our direct responses to the recommendation: It is recommended for the County to develop a new invitation to bid to cover the newer needs of the County for temporary labor and address the handling of margin and concerns noted above. We support this recommendation. It is recommended the current contract with the primary vendor for temporary labor be extended out 12-18 months until an invitation to bid can be developed and issued. We support this recommendation. It is recommended for the County to establish more effective leadership and management of the temporary labor contracts and how they are used by County departments. They may want to consider a policy or procedures to address the variety of human resource (HR) issues that come with using a temporary workforce. This would include whether an in-house labor pool could be developed and when departments should consider contracted labor. We support this recommendation. We would appreciate clear guidance and technical assistance from HR on the management of temporary labor contracts and how temporary labor can best be managed and utilized. It is recommended for the County (and Health Services) consider what practices should be employed to provide feedback (formal and informal and to what extent) to contracted temporary staff working for the County. We support this recommendation and this is partially in process. We are creating procedures for evaluation of temporary staff (for the COVID response) and would appreciate further guidance and technical assistance from HR. It is recommended for Health Services and the County to consider using more metrics as they manage temporary and remote staffing workloads (for case investigation and contact tracing. We agree with this recommendation and started implementing metric tracking procedures prior to the release of this report, however due to the change in requirements from OHA of no longer requiring comprehensive case investigation for all cases, we are reassessing what workload quality assurance and control metrics and assessments are necessary for temporary and limited duration staff. We would appreciate further HR guidance Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 39 Health Services Department (continued) and technical assistance on this matter, as we continue to implement mechanisms to track output and quality assurances for COVID-19 response staff. Human Resources Kathleen Hinman, HR Director Interoffice memorandum Delivered via email. Date: March 6, 2022 To: David Givans, Deschutes County Internal Auditor From: Kathleen Hinman, HR Director Re: HR Response - Management of Pandemic Case Investigation and Contract Tracing Audit Thank you to the Deschutes County Internal Auditor for your thorough work on this audit, and to the Audit Committee members for supporting this topic be included in the internal audit work plan. Human Resources is glad to see in this audit report that, generally, the Case Investigation and Contact Tracing (CICT) team members reported a positive work environment and work load; this is an improvement from the very first few months of the pandemic where staff struggled with the ever evolving workload. Adding the use of temporary staffing allowed for the highest level of flexibility in meeting the dynamic staffing needs and required response to the pandemic by Health Services. HR is proud of the work Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 40 Human Resources (continued) completed by the CICT and the Deschutes County Public Health management team. This work has been a great support to our community, for individuals and employers, as we all navigate the impacts of the pandemic. Audit Recommendations: It is recommended for the County to develop a new invitation to bid to cover the newer needs of the County for temporary labor and address the handling of margin and concerns noted above. HR agrees with this recommendation and we have made note of the recommendations raised in this audit to be included in the bid and selection process. It is recommended the current contract with the primary vendor for temporary labor be extended out 12-18 months until an invitation to bid can be developed and issued. HR agrees with this recommendation and will partner with Deschutes County Legal Services staff to engage with the primary vendor on a temporary extension of the contract for services. It is recommended for the County to establish more effective leadership and management of the temporary labor contracts and how they are used by County departments. They may want to consider a policy or procedures to address the variety of human resource issues that come with using a temporary workforce. This would include whether an in-house labor pool could be developed and when departments should consider contracted labor. {Human Resources has indicated they will be taking over efforts to work on the temporary labor RFP/contracts.} HR agrees with this recommendation. HR will consider drafting guidelines for the use of a temporary workforce to meet department staffing needs. Current practice for HR is to discuss with departments the pros and cons of using an in-house labor pool vs. a temporary staffing agency to help departments determine their preferred staffing solution. HR did discuss with Health Services an in-house labor pool option for staffing the CICT and it was determined that a staffing agency was preferred. It is common for DC HR to actively recruit for temporary staff alongside the staffing agency to increase the pool of Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 41 Human Resources (continued) qualified candidates. It is recommended for the County (and Health Services) consider what practices should be employed to provide feedback (formal and informal and to what extent) to contracted temporary staff working for the County. HR agrees with this recommendation. The County has established guidelines for providing performance evaluation and wage increases for on-call and hourly employees. These same guidelines should be applied to contracted temporary staff working in a capacity greater than temporary fill-in and seasonal support. HR will consider drafting guidelines for departments on the performance management for temporary staffing. HR – Personnel Rules 7.030.B. Wage and Salary Adjustments. “…For an employee to receive a merit step increase, the employee’s department head must complete a written performance evaluation of the employee with a recommendation for the increase…Supervisors shall complete a scheduled performance evaluation for on-call and hourly employees after the employee has been employed for at least 12-months and worked at least 1,000 hours…On-call and hourly employees are eligible for a merit step increase when receiving a scheduled performance evaluation. A department head may authorize a performance evaluation for an on- call or hourly employee before the required hours have been worked, if in the department head’s discretion such an evaluation is necessary or prudent.” It is recommended for Health Services and the County to consider using more metrics as they manage temporary and remote staffing workloads (for case investigation and contact tracing). HR agrees with this recommendation. HR has seen that many managers are effectively managing productivity and performance for their staff, both on-site and remote. However, there are some instances where documentation of productivity standards is seen as extra effort or managers are lacking the experience in establishing metrics for monitoring productivity. HR has been able to provide support to managers in this area and will consider establishing formal guidelines to support management and staff. Management of Pandemic Case Investigation and Contact tracing report #2122-5 March 2022 Page 42 {End of Report} Please take a survey on this report by clicking on the attached link: https://www.surveymonkey.com/r/HS-CaseInvestigation If you would like to receive future reports and information from Internal Audit or know someone else who might like to receive our updates, sign up at http://bit.ly/DCInternalAudit.