designing best practice for the pharmacy
TRANSCRIPT
Designing Best Practice for the Pharmacy
Meleah MonroeLean Sigma Black BeltBloomington Hospital
May 14, 2010
Bloomington Hospital
• 355 licensed beds
• 13,102 annual admissions, excluding newborns
• 2,139 full-time equivalent employees
• 51,834 Emergency Department visits
• More than 300 physicians trained in more than 40 medical specialties
• 2,012 births
• 11,821 outpatient and 5,921 inpatient surgery visits
Process Improvement Team
• Michael Melby, Director of Pharmacy
• Steve Speth, Manager of Pharmacy Operations• Derek Fields, Pharmacy Clinical Coordinator
• Deborah Curtis, Clinical Staff Pharmacist• Marcy Grupenhoff, Clinical Staff Pharmacist
• Charity McGannon, Clinical Pharmacy Educator• Dan Workman, Informatics Pharmacist
• Meleah Monroe, Lean Sigma Black Belt
Striving for Perfection
• Is 99% good enough?– Two short or long landings at major airports each day – Unsafe drinking water for almost 15 minutes each day– No electricity for almost 7 hours each month – At least 200,000 wrong drug prescriptions each year– 5,000 incorrect surgical procedures per week– 50 dropped newborn babies each day
• Clearly, 99% is not good enough!We want perfection …
Bloomington Hospital’s Process Improvement Methodology
Plan
ACT Do
Check
The “Cycle”
FOCUS
Steps F Find a process to improve
O Organize a team that KNOWS the process
C Clarify the current knowledge of the process
U Uncover the root cause of variation or poor outcome; understand variation (data)
S Start the “Plan-Do-Check-Act” Cycle
Plan Plan the process to improve
Do Do the improvement; data collection and analysis
Check Check the results and lessons learned
Act Act by adopting, adjusting, or abandoning the change
Lean Sigma Toolkit Steps
Define
Initiate the Project Define the Process
Determine Customer Requirements Define Key Process Output Variables
Measure
Understand the Process Evaluate Risk on Process Inputs
Develop and Evaluate Measurement Systems Measure Current Performance
Analyze Analyze Data to Prioritize Key Input Variables Identify Waste
Improve Verify Critical Inputs
Design Improvements Pilot New Process
Control Finalize the Control System Verify Long Term Capability
FOCUS PDCA and Lean Sigma
Plan
ACT Do
Check
FOCUS
Lean Sigma Tools and Knowledge
Failure Modes and Effects Analysis (FMEA)• FMEA is a structured approach to
– Indentifying the ways in which a product, service, or process can fail
– Estimate risk associated with specific failure causes
– Prioritize the actions to reduce risk of failure
FMEA Goals
• Facilitate system changes to the order entry process that will reduce the likelihood that we will make preventable order entry errors
• Provide pharmacy staff experience with a quality improvement method that can be utilized to examine other high-risk, problem-prone areas within the department
Define
• Series of weekly team meetings (March – June 2009)– Develop a detailed map of the current process– Conduct a value analysis of the current process– Complete risk analysis of the current process– Complete actions necessary to implement process
changes• Subsequent monthly team meetings(July – December 2009)
– Discuss status of the process improvement implementation
– Review and discuss process control chart
Exit patient profile
Read the order
Attach order to patient
Select the correct patient
admission
Order communicated to Pharmacy (Verbal/Fax)
Determine medication
order priority
Review patient profile
Verify order entry per
medication
Acknowledge medication warnings
Enter medication
orders
Define
Define
Suppliers Inputs Process Outputs Customers(Who?) (What?) (How?) (What?) (Who?)
Physician Order
Order Communicated to Pharmacy (Verbal/Faxed) Medication Patient
Nurse
Patient Demographics (Weight, Age, Allergies, Diagnosis, Disease State)
Select the correct patient admission Education Nurse
HLAB Lab results Attach order to patient
Information (medication reconciliation information available for discharge) Physician
STAR System ADT Read the order
Administration information Nurse needs to provide medication Patient Families
HED Last DoseDetermine medication order priority Medication labels
Other ancilary departments (RT, Dietary)
Patient
Enter medication orders (dose, route, frequency, etc.) (to be broken down later) Clinical Information Tech
Patient FamilyAcknowledge medication warnings Clinical Pharmacists
ED Pharmacy TechVerify order entry per medication Physician Portal
Review patient profileExit patient profile
Define/Measure
• Medication Process
Order EntryError
OrderReviewError
Physician writes order In patient’s chart
Order faxedto pharmacy
Pharmacist reviewsorder for appropriateness(patient, drug, dose, route,
frequency, time)
Pharmacist entersorder into pharmacy
computer system
Nurse confirms orderIn barcode scanning
system
Nurse removes medicationfrom dispensing cabinet
Nurse scans medicationbarcode and administers
to patientNurse alerts pharmacyof order discrepancy
Order EntryError
OrderReviewError
Physician writes order In patient’s chart
Order faxedto pharmacy
Pharmacist reviewsorder for appropriateness(patient, drug, dose, route,
frequency, time)
Pharmacist entersorder into pharmacy
computer system
Nurse confirms orderIn barcode scanning
system
Nurse removes medicationfrom dispensing cabinet
Nurse scans medicationbarcode and administers
to patientNurse alerts pharmacyof order discrepancy
Physician writes order In patient’s chart
Order faxedto pharmacy
Pharmacist reviewsorder for appropriateness(patient, drug, dose, route,
frequency, time)
Pharmacist entersorder into pharmacy
computer system
Nurse confirms orderIn barcode scanning
system
Nurse removes medicationfrom dispensing cabinet
Nurse scans medicationbarcode and administers
to patientNurse alerts pharmacyof order discrepancy
Measure
• Detailed process map excerpt
Wait fo
r patient to
be in the system
Measure
• Detailed process map excerpt
Measure
• Key Process Input Variables Identified Through Detailed Process Mapping
• Focus on the “BAM – Everything Complete”– “Front End” Order Entry Practices
– “Back End” Order Verification Practices• Lack of consistent processes
Analyze
Process Name:Pharmacy Order Entry Process
Prepared by: Meleah Monroe
Responsible: Michael Melby FMEA Date (Orig) 4/8/09 (Rev) _____________
Process Step Input Potential Failure Mode Potential Fa ilure EffectsSEV
Potential CausesOCC
Current Controls
DET
RPN
Step of the process under investigation
Input under investigation?
In what ways does the Key Input go wrong?
What is the impact on the Key Output Variables (Customer Requirements) or
internal requirements?
How
Sev
ere
is th
e ef
fect
to th
e cu
sotm
er?
What causes the Key Input to go wrong?
How
ofte
n do
es
caus
e or
FM
occ
ur? What are the
existing controls and procedures
(inspection and test) that
prevent eith the cause or the H
ow w
ell c
an y
ou
dete
ct c
ause
or
FM
?
Order Communicated (Fax or Verbal)
Nurse Inaccurate/Infrequent processing of verbal orders
Wrong therapy entered10
Lack of standardized forcing function mandating correct information
8None we know about 8 640
Order Communicated (Fax or Verbal)
Unit Coordinator Delay in faxing orders from unit
Delayed therapy; omitted therapy; wrong therapy administered; wrong dose
10Lack of standardization of process; UC training + competency assessment
6None we know about 10 600
Order Communicated (Fax or Verbal)
Order Order not received Delayed therapy; omitted therapy
10
Bad fax machine; Lack of standardization of process; UC training + competency assessment
5
None we know about
10 500
Order Communicated (Fax or Verbal)
Caller (Nurse or physician)
Incorrect interpretation of verbal order
Wrong therapy entered
10
Can't hear well enough; no verbal cues; lack of knowledge by caller; lack of clarification by receiver; information loss during repition of transmitted information
7
None we know about
7 490
Failure Modes and Effects Analysis(FMEA)
• Failure Modes and Effects Analysis excerpt
Analyze• Six categories of action steps to reduce order entry errors were
identified
– Design and implement best practice for order entry and order review(completed and in control)
– Optimize pre-built protocols in the pharmacy computer system(completed and in control)
– Reduce the number of nuisance alerts in the pharmacy computer system (completed and in control)
– Filter pharmacist work assignments in the pharmacy computer system(completed and in control)
– Incorporating a double check to verify accuracy of order entry (to be developed)
– Reduce distractions and interruptions during order entry (to be developed)
Improve
Issue #
Date Raised
Action Item Actions Taken Issue
Owner Date Due
Status
1 6/24/2009 Second person perform verification of all order entry
• 7/15/09 Update: Need to develop high-level work plan
Deb End of Q1 2010
2 6/24/2009 Decrease distractions (including telephones and layout)
• Steve End of Q1 2010 Using back entrance to pharmacy seemed to have little effect on distractions since we are unable to remodel to accommodate deliveries. Relocating order entry will be discussed at next PIT meeting. Non-work related conversations remain an issue and will be addressed at staff meeting (again).
3a 6/24/2009 Best practice for verification • 7/15/09 Update: Best practice draft is located on R:/drive. Develop competency to test individual on best practice. Random competency assessment approximately 4 weeks post education. As part of the best practiced education tell people it’s okay to slow down on the order entry process to ensure that we are following best practice.
• Are there any mnemonics that would make this process easier? Need to post instruction/guideline inside cubicles.
Charity Implementation by End of Q3;
results recognized by
End of Q4
Group to review draft best practice and provide comments to Charity by 7/29/09. Group will conduct pilot of best practice process and provide feedback as necessary. Charity will provide education to staff. Post-education competency will be conducted and then annual competency.
• Action Log excerpt
Improve
That’s That’s That’s That’s Mr. Mr. Mr. Mr. PACWAD PACWAD PACWAD PACWAD to you!to you!to you!to you!
Patient Verification Allergies Creatinine Clearance Weight Age Drug Profile
Improve
Mr. PACWAD is here to remind you:Mr. PACWAD is here to remind you:Mr. PACWAD is here to remind you:Mr. PACWAD is here to remind you:
Use Best Practice—Every Patient, Every Order, Every Time!
Don’t forget your “Z Review”
Don’t DRiFT! See?
DDDDrug, DDDDose, RRRRoute, FFFFrequency, TTTTime, CCCComments
Improve
% self-reported before
training
% observed
after training
patient verification 78 100allergies 56 50crcl 28 71weight 11 64age 22 64drug profile 61 71
allergy override reason entered 6 100
Z review prior to finalizing order 39 79click description 67 79
Best Practice for Order Entry
Improve
Feb 2010
Jan 2010
Dec 2009
Nov 2009
Oct 2009
Sep 2009
Aug 2009
Jul 2009
Jun 2009
May 2009
Apr 2009
Mar 2009
Feb 2009
7
6
5
4
3
2
1
0
Month
Mean of OE ERRORS
2.25
2.709682.93548
2.366672.58065
3.26667
4.35484
3.80645
4.5
5.06452
3.63333
4.83871
6.82143
Chart of Mean( OE ERRORS )
Improve
Baseline: Mean = 6.82
FMEA: Mean = 4.37
Results: Mean = 2.69
39135231327423519615711879401
20
15
10
5
0
-5
Observation
Individual Value
1
1
1
1
1
1
1
1
1
1
1
1
I Chart of OE ERRORS by Time Period
Baseline
FMEA
Results
Improve
39135231327423519615711879401
20
15
10
5
0
-5
Observation
Individual Value
1
1
1
1
1
1
1
1
1
1
1
1
I Chart of OE ERRORS by Time Period
Baseline
FMEA
Results
99.89% Accurate4.5696 sigma61%
Improvement
Improve
39135231327423519615711879401
20
15
10
5
0
-5
Observation
Individual Value
1
1
1
1
1
1
1
1
1
1
1
1
I Chart of OE ERRORS by Time Period
Baseline
FMEA
Results
Potential savings Of approximately $19,400 per day($4,700 per medication error from
American Society of Health Systems Pharmacists)
99.89% Accurate4.5696 sigma
Control
Process: Pharmacy Order Entry Date: (original) 12/15/2009Key Contact: Michael Melby (9199)
Meleah Monroe (5399) Date: (revised)
Process Control Element Metric Measurement Technique Goal Process Spec Sample Size &
FrequencyOwner Reaction Plan
Statistical Process Control (SPC)
# of order entry errors per day
Rx Comm error reporting < 2 per day 0 per day All orders/monthly Steve Speth
Conduct thorough analysis of each instance of special
cause variation to determine cause
Second person to perform verification of all
order entry (to be implemented by end of
Q1 2010)
# of order entry errors per day
Rx Comm error reporting < 2 per day 0 per dayEach medication before it
is administeredSteve Speth
Conduct thorough analysis of each instance of special
cause variation to determine cause
Order Entry Policy and Procedure
NAAnnual staff competency; annual
policy reviewNA NA NA Charity McGannon
Update policy and procedure if and when there is a fundamental
change in the order entry process
Order Verification Policy and Procedure
NAAnnual staff competency; annual
policy reviewNA NA NA Charity McGannon
Update policy and procedure if and when there is a fundamental
change in the order verification process
Order Alerts # of order alertsManual review of order alerts in
systemAll order alerts/quarterly Dan Workman
Control Plan
Order Entry Pharmacist
Order communicated
Select patient using 2 patient identifiers
(Name and Account Number)
Order Entry (utilizing PACWAD)
Order Verification (utilizing DDRFCT)
Confirm all orders entered
Hit escape to return to queue
Questions?
Thank you for your time!
Meleah MonroeLean Sigma Black Belt
Bloomington [email protected]