To make certain that it can identify and address existing work backlogs and comply with all of its federal and state obligations, the department should develop a staffing plan for the branch based on current, reliable data. The plan should involve a reevaluation of the branch's assumptions about workload factors, such as how many inspections an inspector can perform annually. The plan should also include the following components:
• An assessment of all backlogged work and the human resources necessary to eliminate that backlog within a reasonable amount of time.
• An assessment of all currently required work and the human resources necessary to accomplish it.
The Radiologic Health Branch (RHB) has contracted with a professional organization to perform a workload quantitative analysis (QA) on all of the programs operations. The scope of work for this project includes reasonable time expectancies for each program task including inspections, application processing and other vital program workloads. Estimated completion time and issuance of the report is October 2017.
In 2015, the X-Ray Inspection, Compliance, and Enforcement program completed a staffing review. This review shows that by July 1, 2016, assuming that no current staff are lost through retirement or transfer, inspection staffing levels will be sufficient to meet workload demands. In addition, the Radioactive Health Branch will perform a branch workload and staffing quantitative analysis.
The status of this recommendation is unchanged.
The Radiologic Health Branch (RHB) continues to measure backlogs and ensure compliance with federal and state inspection frequency and quality requirements.
In September 2009, RHB completed a data backlog correction plan. Managers and staff conduct data quality checks using independent and computerized data edit checks. Management evaluates error rates and the need for new procedures to ensure we maintain an error rate of less than 5%.
The Radiation & Certification Section (RCS) found the registration workload was beyond the skills of the staff assigned and upgraded two positions to complete complex registrations. RCS uses a registration procedure known as "Making the Facility Whole." Staff addresses all outstanding requests associated with a facility. This reduces error and rework. RCS tracked all unprocessed registration forms to create an accurate registration inventory. RCS tracked expedites separately from the backlogged work and reduced portions of the backlog that could be addressed quickly.
The X-Ray Inspection, Compliance, and Enforcement (ICE) program crosschecks federal Mammography Quality Standards Act inspection due dates with the US FDA database. The analyst who does all data entry for ICE Inspection performs the cross check, minimizing the opportunity for error. The two inspection reports are checked by the Senior Health Physicist. X-Ray ICE tracks non-mammographic state inspection workload independently from the Health Applications Licensing (HAL) database and cross checks the X-Ray inspection database with HAL. RHB will digitize inspection files to increase reliability and save time. In 2012, RHB hired 3 new X-ray inspection staff. Funding for the new staff resulted from an analysis of the X-ray inspection workload. The X-ray inspection section also implemented a remote inspection program called CARRD that allows an individual facility to perform its own test and return the test kit via mail.
The department's response claims that it developed a data backlog correction plan in September 2009. However, the department did not include this plan with its response.
The California Department of Public Health (CDPH) disagrees with the auditor's determination that this recommendation is not fully implemented. CDPH believes it has fully implemented this recommendation and resubmits its response from last year.
CDPH Radiologic Health Branch (RHB) implemented and continues to use a plan that identifies existing backlogs. The plan ensures that CDPH measures and validates compliance with federal and state inspection frequency and quality requirements. Furthermore, the implementation of an on-line licensing system will provide a timelier, more accurate, and more complete data analysis. CDPH is currently able to review production and staffing information that reflects monthly management program inspection activities.
In September 2009, CDPH completed its data backlog correction plan and continues to resolve backlog associated with the Health Applications Licensing (HAL) system. Both managers and staff continue to conduct data quality checks using independent and computerized data edit checks. Management routinely evaluates error rates and the need for new procedures or quality assurance checks to ensure an error rate of less than five percent. Using information technology tools and procedures, this error rate reduction has been achieved.
In addition, CDPH-RHB has completed a reevaluation of the X-Ray Inspection, Compliance, and Enforcement (ICE) program. As part of this reevaluation, the existing inspection database was modified to allow real time tracking of each inspector's inspection history (HAL does not track inspector workload).
CDPH-RHB has implemented procedures that routinely evaluate workload and staff resources.
Agency responses received after June 2013 are posted verbatim.