Designing Best Practice for the Pharmacy

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




frequency, time)


computer system


system







frequency, time)


computer system


system




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


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 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


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


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


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]

Designing Best Practice for the Pharmacy

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