Making state government in Ohio simpler, faster, better, and less costly. .

Faster licensing will allow new nurses to work for their employers up to 19 weeks sooner -- while allowing nurses who are already licensed to renew in one-tenth the time

IN BRIEF: In Ohio, all nurses have to be licensed in order to practice, and they have to renew their licenses every two years. The Ohio Board of Nursing manages and staffs the licensing process, and it's a big job, with 265,832 licenses and certificates active in FY 2013. Board leadership wanted to make the process simpler, faster, and easier for everyone. They chartered a Kaizen team that fulfilled its mission and then some.

FASTER PROCESSING: For initial license exam and endorsement applications, process time will be reduced from a maximum of 100 days to just 12 days. For renewal applications, process time will be reduced even more -- from a max of 194 days to 8 days.

DOING AWAY WITH DELAYS: The current process for initial exam and endorsements had 29 delay points -- while the new process has only 8, all of which are necessary. The current renewal process had 12 delay points -- while the redesigned process for renewal applications has just 1 delay.

SAVINGS: Once all the improvements are implemented, the new approach will generate annual cost savings of $86,000 due to a reduction in imaging, scanning, paper, printing, and postage.

WISE USE OF RESOURCES: With the new process requiring fewer work hours, staff time that will become available for other work activities with a yearly wage equivalent of $190,760 once all the improvements are implemented.

The number of people served by the Ohio Board of Nursing has increased 34% over the past 11 years.

When it comes to ensuring quality nursing, the licensing process serves a vital purpose. All nurses must be licensed in order to practice in Ohio, and they must renew their licenses every two years.

The Ohio Board of Nursing is the regulatory agency that manages this process. It's a key function of the Board's mission "to actively safeguard the health of the public through the effective regulation of nursing care."

It's a complicated function as well. The Board handles an enormous volume of applications for newly issued licenses, renewals, reactivations, and reinstatements. Nurses can renew their licenses online (for the 2013 renewal period, 97% of registered nurses renewed online), but all other applications are submitted in paper form, and they often include multiple supporting documents. The inflow of paper is big and never-ending.

In addition, some applicants have compliance or discipline issues that must be thoroughly addressed. Most applications arrive by mail, but in some cases, applicants arrive in person with their paperwork. Calls and emails are routinely received by licensing staff from nurses, nursing students, and other healthcare staff -- with questions about various aspects of the licensing process.

A subgroup talks about possibilities for a redesigned process. Right before, the whole team discussed improvement ideas, so this subgroup and two others are working with a big set of high-potential options. (Left to right: Karen Unroe, Eric Mays, Norm Heading (DAS/IT), Betsy Houchen, Brenda Murphy)

Determined to simplify and streamline the entire undertaking, Board leadership organized a Kaizen event. The five-day improvement blitz involved a cross-section of staff and tackled the entire process -- from receipt of a completed application all the way to the issuing of a license or renewal, reactivation, or reinstatement.

The team started by mapping out the process in detail. Right away, the light bulbs began going on as staff saw their current approach in a revealing light. For instance, incoming applications were being handled by different people performing different functions in the process -- which was causing time-consuming handoffs, loopbacks, rework, and delays.

Team members scrutinized their process map to uncover every instance of inefficiency. They brainstormed specific improvement actions, coming up with 70 unique ideas. Then they worked in three subgroups, each creating a draft redesign of the process.

From these three perspectives, the team developed a final redesign that represents true transformation. The "future state" process for renewals will take an estimated 2-8 days -- compared to 68-194 days with the "current state." For licenses involving initial examination and endorsements, the process is expected to move from start to finish in 5-12 days -- compared to 19-100 days before.

Driving these impressive numbers is a series of major improvements developed by the team. One of these has to do with how applications that have compliance issues are dealt with from the moment they arrive. Going forward, each of these incoming applications will be assigned to a designated liaison who handles all the attachments and interfaces with compliance. This will free up the other licensure staff to work with applicants who don't have any compliance issues -- preventing those time-consuming loopbacks and handoffs that affected the previous process.

Renewal and initial applications are being reviewed, simplified, and clarified to ensure that all needed information is provided the first time around at the very start of the process. Also, applications will no longer need to be notarized. This will eliminate the delay and frustration that are caused when an applicant leaves certain items blank -- then has to have the full application re-notarized after filling in the needed information.

Other improvements take good advantage of technology. For one, renewal applicants will be able to retrieve their passwords and user IDs online -- putting a welcome end to those frequent calls from people who can't locate their login information. Licensure applicants will also benefit from an online checklist that shows them exactly what they still need to submit in order to complete their applications. A full electronic application for initial licenses will eventually be available, which will dramatically decrease the inflow of mail-in paperwork.

According to team calculations, the switch to an electronic application will save $86,000 annually in reduced paper, envelopes, printing, mailing, and imaging expense.

In addition, with the new process requiring fewer labor hours overall, staff time will be freed up for other mission-critical activities. The team estimates that this redirected time will have a yearly wage equivalent of $190,760 once all the improvements are implemented.

All of these changes are being communicated internally (through meetings, emails, handouts, presentations, and more), and external communication is getting under way (through social media, Board meetings, FAQs, the website, and so on). Also, a dashboard is being developed to monitor the ongoing health of the process, with measures including process time, the percentage of applicants using the online versus paper application, cost savings, and customer satisfaction.


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Download the team report-out
All downloads are in PDF format

This report was published November 12, 2013. Projected and actual results may have changed since then. For the latest info, contact the Ohio Board of Nursing or LeanOhio.

    Board of Nursing contact:
    Betsy J. Houchen, Exec. Director

Ohio Board of Nursing
Licensure and Renewal Process
November 2013

Team members
Team members 
Front row, left to right: Brenda Murphy, Karen Unroe, Jodi Crowe, Eric Mays, Ruchi Grewal, Elisha Ehnes (Ohio Department of Natural Resources). Back row, left to right: Angela White, Betsy Houchen (Team Sponsor), Lesleigh Robinson (Team Leader), Kathy King, Melody Gullion, Karen Scott. Not pictured: Debbie Fulk.