Taubman Pharmacy Discharge Prescription Workflow Analysis

Final Report

Submitted To:

Dr. Lindsey Clark Ambulatory Pharmacy Initiatives and Transitions of Care Coordinator University of Michigan Health Systems Taubman Center Pharmacy

1500 E. Medical Center Dr. Ann Arbor, MI 48109

Marianne Pilat

Michigan Quality Systems Lean Coach University of Michigan Health Systems QI Michigan Quality System

2101 Commonwealth Blvd., Suite A Ann Arbor, MI 48105

Luca Capicchioni

Michigan Quality Systems Administrative Fellow University of Michigan Health Systems QI Michigan Quality System

2101 Commonwealth Blvd., Suite A Ann Arbor, MI 48105

Dr. Mark Van Oyen IOE 481 Professor

University of Michigan Industrial and Operations Engineering Department 1205 Beal Ave.

Ann Arbor, MI 48109

Submitted By: IOE 481 Team 7

Cassandra Cowhy Branden Mansour

Erin Shi Dylan Waldman

Date Submitted: April 23rd, 2015

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TABLE OF CONTENTS

EXECUTIVE SUMMARY  .............................................................................................................................  1  Background  ..........................................................................................................................................................................  1  Methods  .................................................................................................................................................................................  1  Findings  .................................................................................................................................................................................  2  Conclusions and Recommendations  ............................................................................................................................  3  

INTRODUCTION  .............................................................................................................................................  4  BACKGROUND  ...............................................................................................................................................  4  

Key Issues  .............................................................................................................................................................................  5  Goals and Objectives  ........................................................................................................................................................  5  Project Scope  .......................................................................................................................................................................  6  

METHODS  .........................................................................................................................................................  6  Literature Search  ................................................................................................................................................................  6  Observation and Interviews  ............................................................................................................................................  7  Time Studies  ........................................................................................................................................................................  8  Value Stream Mapping and Swim-Lane Diagram  ..................................................................................................  9  

FINDINGS AND CONCLUSIONS  ...............................................................................................................  9  RECOMMENDATIONS  ...............................................................................................................................  11  

Plan Ahead  ........................................................................................................................................................................  11  Use an E-Prescribe System  ..........................................................................................................................................  12  Implement and Maintain  ...............................................................................................................................................  12  

EXPECTED IMPACT  ...................................................................................................................................  13  LIST OF APPENDICES  ................................................................................................................................  15  

Appendix A: Time Data Collection Form  ..............................................................................................................  16  Appendix B: Swim-Lane  ..............................................................................................................................................  17  Appendix C: Current State Value Stream Map  .....................................................................................................  18  Appendix D: Future State Value Stream Map  .......................................................................................................  19  Appendix E: Inpatient Pharmacist Interview  .........................................................................................................  20  

LIST OF ATTACHMENTS  .........................................................................................................................  21  Attachment A: Difficult to Obtain Medications  ...................................................................................................  22  Attachment B: Common Prior Authorization Medications  ..............................................................................  26  Attachment C: TOC Technician Procedures  ..........................................................................................................  27  

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LIST OF TABLES

Table 1 Time Study Data………………………………………………………………………2 Table 2 Time Study Data………………………………………………………………………9

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EXECUTIVE SUMMARY The Taubman Pharmacy at the University of Michigan Health System (UMHS) fills prescriptions written by UMHS providers for patients to pick up after they are discharged. Currently, patients are dissatisfied with how long it takes for prescriptions to be filled once they are ready to be discharged. This patient dissatisfaction has resulted in the Ambulatory Pharmacy Initiatives and Transitions of Care Coordinator (APITC Coordinator) at UMHS Taubman Pharmacy to ask Team 7 from IOE 481 to investigate the causes of the delay when filling these discharge prescriptions. Ideally, prescriptions should be ready by time the discharged patients arrive at the pharmacy to pick them up. The team was asked to map out the entire current prescription filling process for patients being discharged in Unit 8C, which is the Urology Surgical Department for UMHS. The prescription filling process begins with a provider in Unit 8C writing a prescription, and ends with a patient picking the prescription up from Taubman. To collect information on this process, Team 7 conducted a time study and characterized the roles of key people involved in the prescription discharge process. This final report will present the methodology the team adopted to study the prescription filling process, the findings from the studies, and the team’s recommendations to fix the bottlenecks in the prescription filling process.

Background

Unit 8C is the surgical floor of Urology at the University of Michigan Hospital. According to the APITC Coordinator, Unit 8C treats 10-15 patients every day. The APITC coordinator reported that each patient typically picks up around three prescriptions after being discharged from the hospital. Patients usually choose whether they want to fill their prescriptions at Taubman Pharmacy or at an outside pharmacy. Some medications, such as compounds, must be filled at Taubman Pharmacy because the ingredients must be mixed together in a unique way to meet the individual needs of each patient. Prescriptions are written in MiChart and can be E-Prescribed, tubed through the pneumatic tube system, or faxed down to the pharmacy. The pharmacy prefers for all prescriptions to be E-Prescribed but providers use a variation of all methods. Medication providers include the Attending Physicians, Physician’s Assistants (PAs), Nurse Practitioners (NPs) and the hospitalists. According to the APTIC Coordinator, the results of a nationally standardized government issued survey showed that patients are overwhelmingly unhappy with their experience at Taubman Pharmacy. It is hard to speculate why this is because there is no baseline data available for any part of the prescription workflow process. The APTIC Coordinator deduces that patients are unhappy due to heavy delays in the pharmacy. When investigating the truth behind this claim, the team started from scratch to collect data.

Methods

To find the root causes for delay between unit 8C and Taubman Pharmacy, the team conducted a literature search, observed unit 8C as well as the Pharmacy, conducted a time study, interviewed employees of the University of Michigan Health System, and created a value stream map, a

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future state map and a swim-lane diagram for role characterization. The Literature Search was conducted to understand how hospitals and pharmacies operate and to get better acquainted with time studies and value stream maps. One of the articles found is about adding value to the time of employees working in the pharmacy. Another article discussed the methods in which a prescription could be sent to a pharmacy and how these methods impact processing time. The last article the team found focused on improving productivity in a one focus pharmacy. The team observed Unit 8C (the Urology Surgical Unit) for a full business day to understand what is involved in the prescription workflow process. After this initial observation, the team interviewed people involved in the prescription writing process over a three week period and got an idea for what type of data they wanted to collect and how. After observing, the team created a data collection sheet, which was used to conduct a time study. The sheet guided the team members in Unit 8C to document for each patient what time the prescription was written, what time the prescription was sent down to the pharmacy, what time the patient was ready for discharge, what time the prescription was filled and what time the prescription was picked up. The team used the results of this time study data to create a current state value stream map and a future state map. The maps include each individual's role in the prescription workflow process and the amount of time each individual activity takes on average.

Findings The team used time study data to understand how long each action within the prescription workflow process takes. As shown in Table 1, the team generated averages for the amount of time it takes from the moment a prescription is written to the time the prescription is sent down to Taubman Pharmacy, the patient discharge time, when the prescription is filled, and when the prescription is picked up by the patient. The sample size (number of prescriptions) used to generate the times is indicated as well.

Table 1. Time Study Data

Time it takes from writing a prescription to:

Mean Time (hours)

Standard Deviation (hours)

Number of Data Points

Sending a prescription down 1.12 1.25 33

When patient ready for discharge 2.65 2.46 22

Filling a prescription 4.15 1.90 29

Patient picking up a prescription 5.20 2.01 25

Through observation and interviews, the team was able to determine the most common method of sending prescriptions down to the pharmacy. The team was also able to determine what the reasons for delay are and what causes them.

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Conclusions and Recommendations

Based on the aforementioned findings, the team has determined a number of conclusions and recommendations to go along with them. First, a lack of standardization exists in Unit 8C and Taubman Pharmacy with regard to discharge prescriptions and how to deal with barriers. The team recommends that Unit 8C holds a meeting at the beginning of a patient’s stay that includes the provider; an inpatient pharmacist; and a designated pharmacy technician to remove access barriers to plan the patient’s discharge prescriptions ahead of time. Also, based on interviews with providers of Unit 8C, providers prefer to send prescriptions to Taubman Pharmacy using the pneumatic tube system. This is because the providers feel E-Prescribe is unreliable, and there is not a current way to prioritize prescriptions by patient discharge date. However, Taubman Pharmacy encourages providers to utilize the E-Prescribe method, and the team recommends that providers use E-Prescribing to send down prescriptions. Ideally, E-Prescribe would include the ability to prioritize prescriptions by day of discharge, and would provide real time feedback to confirm when prescriptions are successfully sent to Taubman Pharmacy’s queue and when they are filled and ready for pickup. Taubman Pharmacy currently has no standard way of informing the providers of Unit 8C if an access barrier for a patient’s discharge prescriptions are discovered. To help standardize this process, the team recommends that Taubman Pharmacy hire a technician who is designated to maintain contact with insurance companies and is responsible for taking care of insurance related delays. To be sure that all of these recommendations are working, the team recommends that Taubman Pharmacy implement and maintain a data collection dashboard that continues collecting data on the current state of the system. This way Unit 8C and Taubman Pharmacy can compare the current state to the future state, and have a baseline for future projects to compare against.

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INTRODUCTION The Taubman Pharmacy at the University of Michigan Health System (UMHS) fills prescriptions written by UMHS providers for patients to pick up after they are discharged. Every month, senior members of the pharmacy receive monthly results of nationally standardized Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys to understand patient satisfaction levels. The HCAHPS survey provides responses from a mixed sampling of recently discharged patients on their experience. Based on recent survey results, patients are dissatisfied with the amount of time it takes to receive their prescribed medications at Taubman Pharmacy at time of discharge. The Ambulatory Pharmacy Initiatives and Transitions of Care Coordinator (APITC Coordinator) at UMHS Taubman Pharmacy has asked Team 7 from IOE 481 to investigate the causes of these delays. Specifically, the APITC Coordinator wants the team to observe and map out the entire current prescription filling process for patients being discharged in Unit 8C, which is the Urology Surgical Department for UMHS. The prescription filling process begins with a provider in Unit 8C writing a prescription. The provider sends it to the pharmacy where a pharmacist fills the prescription. The process ends with the receipt of prescription by patient. To collect information on this process, Team 7 has conducted a time study and characterized the roles of everyone involved in the prescription discharge process, from the providers (physicians, physician assistants, surgical residents and interns, and nurse practitioners), to the pharmacists. The purpose of this final report is to present the methodology the team used to study the prescription filling process, the findings and conclusions from the studies, and the team’s recommendations to reduce delays in the prescription filling process.

BACKGROUND The APITC Coordinator initially estimated that on a typical day, Unit 8C sees roughly 10 to 15 patients. On average, each surgical patient needs to pick up three prescriptions after his or her surgery. The three medications that are prescribed most frequently are an antibiotic, a pain medication, and a stool softener.. The APITC Coordinator estimates that approximately 85% of these patients are prescribed at least one of these medications. Patients can have their prescriptions filled at Taubman Pharmacy, or they can have their prescription sent to an outside pharmacy to be filled. Instead of determining ahead of time through a standardized way where a patient will be filling discharge prescriptions, the Nurse Practitioner currently asks for this information on the day of the patient’s discharge. Ideally, prescriptions would be ready by time the patients arrive at the pharmacy to pick them up. Typically for the Urology Surgical Unit, a provider writes the prescription in the morning and sends it to the pharmacy to be filled by the time the patient is discharged later that day. The provider types the prescriptions into MiChart. In Unit 8C, the providers are the Attending Physicians, Physician’s Assistants (PA), Nurse Practitioners (NP) and the hospitalists. After writing the prescription, there are three methods to send the prescription to the Taubman

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Pharmacy: it can be printed from MiChart and sent to the pharmacy using a pneumatic tube system, printed out and faxed to the pharmacy, or electronically sent through E-Prescribing. The APITC Coordinator stated that the hospital encourages all providers to send their prescriptions electronically to standardize the current process, but many providers prefer to use the pneumatic tube system or fax machines. E-Prescribing is not an option for compound medications because they are not included in the software’s database. Another problem in standardization is that timestamps are not always provided on prescriptions. When a prescription is E-Prescribed, a timestamp is recorded while it is in the electronic queue, but it disappears when the prescription is taken out of the queue. When a prescription is sent to Taubman Pharmacy using a pneumatic tube system, the time it is received by the pharmacy is manually documented by a pharmacy technician. However, there are no time stamps for prescriptions that are faxed down to the pharmacy. This is a problem because it does not allow for the pharmacists to fill prescriptions in the order that they were sent and it makes it difficult to collect data. The team was also informed by the APITC Coordinator that there has not been any data analysis done on the current discharge prescription process since UMHS implemented MiChart in June of 2015. Therefore, little data is available concerning wait times for prescriptions and patients at the pharmacy. The APITC Coordinator does not know how many patients are currently experiencing delays in discharge due to their prescriptions not being available on time at the pharmacy. Therefore, a critical component of this project is data collection on time and percentages of patients who have to wait for their prescriptions after discharge. The team has also be asked to collect data regarding the staff roles in each step of the patient pharmacy discharge process in Unit 8C. In particular, the APITC Coordinator asked the team to analyze the Urology Surgical Unit’s Inpatient Pharmacist’s role in the outpatient prescription process.

Key Issues

Relating to the prescription discharge process, Unit 8C and Taubman Pharmacy are currently facing the following key issues:

• Prescriptions are not ready on time, causing delays in patient discharges • There is not a lot of data available that defines a baseline time for how long it takes to fill

a prescription at Taubman • Current process to fill a discharge prescription has not been mapped out

Goals and Objectives

The primary goal of this project is to determine causes of delay by identifying bottlenecks in the current workflow process of writing and servicing prescriptions at the UMHS Taubman Pharmacy for patients discharged from Unit 8C. Determining these bottlenecks will allow the

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Taubman Pharmacy and Unit 8C to adjust their current prescription process to maximize discharged patient satisfaction. To achieve this goal, the following objectives were addressed:

• Characterize each role in the workflow process for outpatient prescriptions in the Urology Surgical Unit (Unit 8C)

• Analyze the role of the Surgical Unit’s inpatient pharmacist • Determine the average time it takes for a prescription to be filled after it is written • Determine the average time a patient will wait for a prescription after the patient is ready

to be discharged

Project Scope

The scope of this project is contained to UMHS Unit 8C, which is the Urology Surgical Unit. Specifically, the team only focused on patients who are discharged on the day of the team’s observation. The process being observed starts with a provider in Unit 8C writing a prescription, and ends with the Taubman pharmacy filling that prescription for the patient to pick up. This process includes any movement of the prescription, as well as any person who is involved in moving it. The scope of this project did not include any other units besides Unit 8C; nor does it consider patients who are not discharged on the day of the team’s observation. Also outside of the scope is anything in Unit 8C that does not impact the prescription directly. Results are limited to identification of bottlenecks (delays) and associated countermeasures.

METHODS To identify causes of delay and suggest improvements, the team observed the existing prescription process in Unit 8C and collected data to analyze the current process. The team conducted a literature search to examine relevant literary articles on related projects prior to develop an observation and data collection plan. Based on the literature research and conversations with the APITC Coordinator, the team developed a plan to observe all the personnels involved in the prescription process and interview them, collect time study data, develop a current state value stream map of Unit 8C’s prescription process, develop a swim-lane diagram for role characterization and a future state value stream map based on the team’s recommendation.

Literature Search

The team found three articles on related topics for this project, and used them to support methods used throughout the project. Analyzing methods for improved management of workflow in an outpatient pharmacy setting [1] In this article written about the University of North Carolina Hospitals and Clinics Department of Pharmacy, lean health-care concepts were used during direct observation to do a workflow

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analysis of the outpatient pharmacy. Opportunities to add value to pharmacists’ time in the original process were found. Effects of Computerized Prescriber Order Entry on Pharmacy Order-Processing Time [2] A study was conducted to evaluate the time it takes to order medication when using a computerized prescriber. The study was done at a Tertiary Care Hospital. They conducted a time study to analyze the time the prescriber ordered the medication, the time the pharmacy received the order, and the time the order was completed by a pharmacist. Using Lean Methodology to Improve Productivity in a Hospital Oncology Pharmacy [3] The outpatient oncology pharmacy at Yale-New Haven Hospital conducted an analysis to improve quality of their services and implement workflow changes to aid in expansion. Lean concepts, including elimination of non-value-added steps, were used to create a map for a streamlined workflow.

Observation and Interviews

Before starting data collection, the team spent one full business day, from 6am - 5pm, observing processes in Unit 8C and how it interacted with Taubman Pharmacy. The observations happened in four shifts throughout the day, one for each team member. During this time, the team noted the steps in the prescription process, the people involved, and their roles. The team also shadowed and interviewed the nurse practitioner in Unit 8C to determine what she saw as areas of improvement in the current prescription process. Other staff members of Unit 8C were interviewed throughout the day as well, including two RN Case Managers, the Clinical Nursing Supervisor, a Social Worker, and two Physicians Assistants. This gave the team information on what the staff in Unit 8C identified as problems and what can be improved in the process for writing and filling prescriptions. The APITC Coordinator requested that the team interview an inpatient pharmacist. The results of the interview are outlined in Appendix E. In addition to the inpatient pharmacist, the team interviewed the Transitions of Care (TOC) Technician, who works for the medicine faculty hospitalist services and removes access barriers for patient prescriptions. As other hospital units hear about her job, she is extending her services, as she is the only one who currently is in this position. She reports that units that utilize her services are seemingly proactive at looking ahead to patient discharge plans, and difficult prescriptions are sent down in advance to reduce stress on day of discharge to get a prescription filled on time. When an access barrier, such as missing insurance information or medication needs prior authorization, exists for a prescription, the patient’s provider will let the TOC know, and she will work with the insurance company to get approval. Access barriers for prescriptions can include prior authorization, exceptions for non-formulary prescriptions, high copays, or the patient has no insurance/insurance is not on file. On a busy day, she stated she can remove access barriers for up to 15-20 patients, with prior authorization barriers taking up to an hour each to resolve.

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When asked how the TOC’s role could be improved, she said her services could be more localized to only working with certain units. She commented that additional TOCs would be beneficial, as they would become familiar with typical prescriptions for their units and how to negotiate them with different insurance companies. She also said that making this service known to physicians in the hospital would improve the effectiveness of the role, as many units do not know the role exists and, therefore, do not utilize it. Another area she sees for improvement is eliminating redundancy in the number of people who contact her about an access barrier. She said for anyone prescription she could be contacted by multiple people, such as the inpatient pharmacist or the case manager, about the issue. This demonstrates a lack of communication. See Attachment C for the document outlining TOC procedures. The team also spent one afternoon observing at Taubman Pharmacy. Based on the observation, the technicians in the pharmacy spend a significant amount of time transferring E-Prescription information from MiChart into the pharmacy system, while the prescriptions sent down via the pneumatic tube would take an even longer time to be transferred according to a technician in the pharmacy, since more information needs to be manually entered into the system. Please refer to Appendix B for a swim-lane diagram that further characterizes what each of these key player’s roles is in the discharge prescription filling process.

Time Studies

The APITC Coordinator has noted that insufficient data exists on how long it takes for a prescription to be filled once a provider submits it. Therefore, Team 7 has collected time data for prescriptions sent from Unit 8C to be filled at Taubman Pharmacy. The team observed by following a prescription from when a provider writes it to when the patient picks the filled prescription up at the pharmacy. When a team member was present in Unit 8C, the provider told the team member when prescriptions are given to a clerk or sent down, if and when the pharmacy calls needing pre-approval, if and when any other delays occur, and when the patient is set to be discharged. The team developed a time chart (see Appendix A) to record corresponding times for each step in the prescription process. When the team was not present in Unit 8C, the providers agreed to fill out the time chart for each prescription and give the filled out forms to the team on the next observation day. The steps listed on the time chart include the time each prescription was written, time each sent to Taubman, time the patient was ready to be discharged, the time each prescription was filled, and whether the prescription needed prior authorization. Unit 8C providers filled out all the information on the chart, except the time the prescription was filled by Taubman Pharmacy. To get fill times, the team gave the APITC Coordinator the patient MRNs associated to the prescriptions recorded on the time charts and she looked up the time Taubman Pharmacy filled that patient’s prescription from the pharmacy’s system.

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Value Stream Mapping and Swim-Lane Diagram

The team analyzed the time study data and used it to create a current state value stream map of the prescription process (see Appendix C). The current state map includes the process from start to finish as well as the reasons for delays in each step. The times collected during the time study are included along the bottom of the map, corresponding to the process steps. The map highlights redundant activities and bottleneck steps within the prescription discharge process. A swim-lane diagram is also included in the current state map, where the team characterized the roles of the personnel involved in the prescription filling process and summarized their tasks. The swim-lane diagram can provide the client, as well as Unit 8C, a detailed description of everyone’s responsibility and identify any gaps or overlaps that might exist between the roles. Based on the swim-lane diagram and the current state map, the team then created a future state map (see Appendix D) with the team’s recommended changes to streamline the process. These recommended changes will be further discussed in the Recommendations section of this report.

FINDINGS AND CONCLUSIONS This section will present the team’s findings through time study data collection, observations and interviews, as well as outline the team’s conclusions based on the findings. Discharge Prescription Baseline Time On average, from the moment the prescription is written, it takes 4.15 hours for the prescription to be filled and ready for pick up, which is 1.50 hours after the patient is ready for discharge. All five providers interviewed told the team that due to these delays, they only send prescriptions to Taubman if absolutely necessary, such as for compound medications or pain medications a patient may need for a long drive home. A detailed breakdown for times and corresponding number of data points used to calculate the time averages can be found in Table 2.

Table 2. Time Study Data

Time it takes from writing a prescription to:

Mean Time (hours)

Standard Deviation (hours)

Number of Data Points

Sending a prescription down 1.12 1.25 33

When patient ready for discharge 2.65 2.46 22

Filling a prescription 4.15 1.90 29

Patient picking up a prescription 5.20 2.01 25

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The team attributes these delays to a lack of communication between Unit 8C and Taubman Pharmacy when it comes to discharge prescriptions. As a result, providers are sometimes unaware of the status of the discharge prescriptions they have written. Delay Modes With the help of the providers on Unit 8C, as well as the APITC Coordinator, six kinds of reason for delay were identified in filling prescriptions for discharge patients. Of the six, three of them are related to the patient’s insurance information, and according to the providers these are the most time consuming. These delays can be that the patient needs prior authorization, the copay is too high and he/she needs GAP funding, or that the insurance information is not on file. Attachment A lists difficult to obtain medications, which are medications that commonly require prior authorization. According to the APITC coordinator, about 500 prescriptions are sent to Taubman Pharmacy in a day. About 60% of these prescriptions are discharges, and about 90% of the discharge prescriptions are for patients who are filling at Taubman for the first time and therefore have a higher chance of not having insurance information on file. No system is in place to deal with these kinds of delays. As a result, these problems become the responsibility of the providers, who are busy with other patient care activities and may not have the time to mitigate insurance barriers. Currently, no one standard way exists to inform the providers of Unit 8C if Taubman Pharmacy encounters an access barrier that delays the filling of a prescription, which can delay the prescription filling process. The delays are often caused by providers unaware that they need to address an access barrier until they contact the Taubman to check the status of the prescription. The most time-consuming access barriers are related to the patient’s insurance coverage. Since patients sometimes wait a long time for their prescriptions to be filled when using Taubman Pharmacy, providers avoid sending their discharge prescription orders to Taubman if they can. Options for Sending Prescriptions to Taubman Pharmacy The options providers have for sending prescriptions to Taubman pharmacy are to send them down via a tube system, fax them down or E-Prescribe them through MiChart. Through surveys, the team has discovered flaws in the E-Prescribe system. It is not possible to E-Prescribe certain types of medications such as compounds. These types of medications are needed for many of the patients that use Taubman Pharmacy. If some parts of a patient's’ medications cannot be E-Prescribed, all of their prescriptions will not be sent through the E-Prescribing system. According to all of the providers of Unit 8C, E-Prescribing is avoided because it is considered unreliable. Though collecting quantitative data reflecting problems with E-Prescribing was out of the project scope, the team found reasons for avoidance through interviews with five providers on Unit 8C. Two of the providers reported seeing different prescription information on their E-Prescribing screen than the pharmacy, while another provider reported sending a list of prescriptions and only a fraction were received by Taubman. All five providers reported being

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frustrated with the perceived inability of the system to prioritize prescriptions by discharge time. Therefore, they prefer to use the pneumatic tube system to send prescriptions to Taubman. However, some prescriptions cannot be sent via E-Prescribing, such as compounds, which need to be printed and sent via the tube system. Lack of Data Collection Based on a small sample of data (about 30 patients’ prescription), only 50% of patients have their prescriptions sent to Taubman every day from floor 8C. It has also been found that Unit 8C does not currently collect any data on its processes regarding discharge prescription process.

RECOMMENDATIONS

Based on conclusions, the team has formed recommendations for UMHS to improve their prescription filling process. The recommendation section will discuss suggested actions to be taken and possible future implementation plans. See Appendix D for the future state map that reflects changes made to the current state from the recommendations from this section.

Plan Ahead During observation and interviews, the team found that a leading cause of delays in filling prescriptions is waiting until the day of patient discharge to send difficult to obtain prescriptions down to the pharmacy. To improve this, the team recommends that the pharmacy provide a list of difficult to obtain medications, such as the one found in Attachment A, to Unit 8C providers. Educating providers on which prescriptions often result in barriers or long delays in filling can encourage providers to send prescriptions down ahead of the patient’s discharge day. To facilitate planning ahead, the team recommends Unit 8C holds a meeting at the beginning of a patient’s stay that includes the provider; an inpatient pharmacist; and a designated person to remove access barriers. These meetings will decide the medications the patient will likely take during the hospital stay, the medications the patient will likely be prescribed at time of discharge, and if the prescription will be filled at Taubman or the patient’s home pharmacy. These meetings are a proactive approach to determine what needs to be done to have the prescriptions ready at the time of a patient’s discharge. From there, the provider should send the prescription down as soon as possible, rather than waiting until day of discharge, especially if known to be a difficult to obtain medication. Designate Person to Remove Access Barriers A designated technician should be assigned to act as a bridge between Taubman Pharmacy and Unit 8C to remove access barriers for prescriptions. Ideally, the technician would have access to Taubman Pharmacy’s software, as well as MiChart, to determine insurance and prescription information for patients. This technician would attend the meeting at the beginning of the patient’s stay to hear what prescriptions the patient will take home. If the prescription is a known

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difficult to obtain prescription, the provider would send the prescription down as soon as possible, while the technician would gather the patient’s prescription insurance information and anticipate any barriers that may arise in trying to get the prescription filled. These barriers could be that the patient’s insurance company requires prior authorizations for the prescription, and the technician will need to call the insurance company to receive the authorization to fill it. Once the insurance company approves, the technician would inform Taubman Pharmacy to proceed with filling. If a patient does not have insurance, or after a negotiations phone call the patient’s insurance company will not cover enough of the prescription cost, the technician would need to get the social worker to involve GAP funding. This technician would alleviate the responsibility of the providers to find time to call insurance companies, as well as facilitate communication between Taubman Pharmacy and Unit 8C on prescription status. This reduces the number of calls from Unit 8C to Taubman Pharmacy, which in turn reduces interruptions for pharmacy employees that slow down the filling process. To expand this technician role on a larger scale in the hospital, the team recommends that each unit have a designated technician to remove access barriers. This will allow technicians to become familiar with the medications typically prescribed in their units, making it easier to negotiate with insurance companies for prior authorizations on a regular basis. Once successfully implemented, these technicians can quickly and efficiently anticipate and remove access barriers that create delays in discharging patients with filled prescriptions.

Use an E-Prescribe System When sending a prescription to Taubman Pharmacy, providers should use an E-Prescribing system. It is the preferred method for the pharmacy and eliminates wasted time waiting for the tube system to be clear to send printed prescriptions. Based on feedback from two providers on Unit 8C about problems in the current system, an ideal E-Prescribing system would include the following:

• Real time feedback to provide confirmation that the prescription was successfully sent to the Taubman Pharmacy queue

• A way to prioritize prescriptions, particularly in relation to discharge times o A prescription for a patient who is being discharged at 2:00pm that day should be

higher priority than a prescription for a patient being discharged in two days • A way for provider to see when the prescription is being filled and when it is ready for

pickup

Implement and Maintain A main problem encountered during this project was a lack of available data for the team to analyze. The team worked to collect enough data to establish a baseline to define the current state of the process. Going forward, the team recommends Unit 8C and Taubman Pharmacy implement a dashboard system by regularly collecting data to know the state of the system. For one additional week, data should be collected for every prescription in Unit 8C on all of the

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times the team collected throughout this project, in order to get a robust data set to establish the baseline. These data points include the time prescriptions are written, sent to the pharmacy, checked in by the Taubman, filled by Taubman, and picked up by a patient. Any barriers encountered during the process should also be recorded. Barriers can be recorded into categories, in order to quantify the data and identify which barriers are causing the most significant delays. After the week of additional data collection, the recommendations discussed earlier in this section should be implemented for Unit 8C. The process should be standardized so each person’s role is clearly defined and follows the procedure for filling prescriptions. It will be necessary to train Unit 8C, as well as Taubman pharmacists and technicians, on what the roles will be in the new standard process. Once the recommended changes are implemented roles are standardized and defined, the team recommends that data be again collected for another week for all prescriptions in Unit 8C to evaluate the effectiveness of implemented changes. The system can be adjusted accordingly to make it more efficient, and then implemented into other units of UMHS. To ensure the system does not slip back into its previous state, data collection can then be cut back to periodically collecting data for one week on all prescriptions every six months to maintain.

EXPECTED IMPACT The team has studied the performances in Unit 8C regarding the discharge prescription filling process. However, the recommended changes could also be easily implemented to other Units upon test run in Unit 8C. The team expects the following impacts on UMHS if the recommendations are adopted. By having a designated person to remove potential access barriers for prescribing certain medications, more prescriptions will be filled before Unit 8C patients are discharged. This designated person will also help improve communication between the unit and the Taubman Pharmacy, which will help reduce the distraction of both the pharmacists and the providers, which will in turn reduce delays in filling. The baseline data regarding prescription filling time can help Taubman Pharmacy as well as UMHS Units to understand the timeline of a prescription and how long it normally takes for a prescription to be filled after providers send out the prescriptions. This initial data collection provides a baseline to compare against to measure effectiveness of changes. The current state value stream map will provide Unit 8C and Taubman Pharmacy a clearly defined current discharge prescription process. The future state value stream map, along with the team’s other recommendations, will provide an ideal state of the process and actions to achieve the future state. Implementing a dashboard system for data collection will help with further data collection regarding prescription filling times. Future projects will be able to use this data as an initial baseline for comparison. The dashboard will serve as a tool to monitor performance of the current prescription filling process and help continuous improvement.

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REFERENCES [1] A. Jenkins & S.F. Eckel, “Analyzing Methods for Improved Management of Workflow in

an Outpatient Pharmacy Setting,” American Journal of Health-System Pharmacy, June 2012

[2] J. Wietholter, S. Sitterson & S. Allison, “Effects of Computerized Prescriber Order Entry on Pharmacy Order-Processing Time,” American Journal of Health-System Pharmacy, August 2009

[3] P. Sullivan, S. Soefje, D. Reinhart, C, McGeary & E.D. Cable, “Using Lean Methodology to

Improve Productivity in a Hospital Oncology Pharmacy,” American Journal of Health System Pharmacy, September 2014

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LIST OF APPENDICES Appendix A: Time Data Collection Form Appendix B: Swim-Lane Appendix C: Current State Value Stream Map Appendix D: Future State Value Stream Map Appendix E: Inpatient Pharmacist Interview

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Appendix A: Time Data Collection Form Date: ________ # Patients Filling RXs: _______ # Patients Filling at Taubman: _____

MRN Time RX Written

Time RX Sent to Pharm

Time of Patient

Discharge

Time RX filled

Pre-Approval Needed?

Reasons for

Delays

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Appendix B: Swim-Lane

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Appendix C: Current State Value Stream Map

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Appendix D: Future State Value Stream Map

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Appendix E: Inpatient Pharmacist Interview The APITC Coordinator requested that the team informally interview an inpatient pharmacist to characterize her role and whether it has any overlap with the process for filling patient discharge prescriptions. During the interview, the pharmacist explained that her daily responsibilities included medical recommendation at patient admittance, along with morning rounds to check on inpatients and provide directions for meds when necessary. Other responsibilities were outlined such as verifying inpatient prescription orders/dose adjustments, antibiotic dosing and anticoagulant management. The inpatient pharmacist mentioned that she will occasionally help with discharge prescription orders, but that it is not her responsibility. The inpatient pharmacist’s role characterization aided the team in forming recommendations on how to improve the current discharge prescription process.

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LIST OF ATTACHMENTS

Attachment A: Difficult to Obtain Medications Attachment B: Common Prior Authorization Medications Attachment C: TOC Technician Procedures

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Attachment A: Difficult to Obtain Medications

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24

25

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Attachment B: Common Prior Authorization Medications Enoxaparin Xarelto Eliquis Pradaxa Vancomycin (capsules and compound) Xifaxan Dipyridamole Sildenafil Noxafil (tablets and suspension) Neupogen Neulasta Voriconazole Ondansetron ODT Brilinta Zyvox Lidocaine 5% patches Octreotide injections

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Attachment C: TOC Technician Procedures Drug information for prior auths: Cardiac medications: Dipyridamole (Brand-Persantine): Used in combination with blood thinners to keep clots from forming after heart valve replacements. (Class: Platelet Inhibitors) Pentoxifylline (Brand- Trental): Decreased the “stickiness” of blood to improve flow to arteries-treats symptoms of intermittent pain/cramping in lower leg due to inadequate blood flow to muscle caused by peripheral arterial disease. Revatio (Generic- Sildenafil): For Pulmonary Arterial Hypertension- Ask what other medications have been tried and failed for this diagnosis. Effient (Generic- Prasugrel): For patients with stents- Prevents platelets from sticking together and forming clots inside stent and the arteries of the heart. Brilinta (Generic- Ticagrelor): BID dosing Antiplatelet medication for recent heart attacks or unstable angina Alternative medication: Plavix (ask if patient has tried and failed this medication first or if there is a reason this medication would not work for the patient) Oral Atrial Fibrillation medications: These are not approved for A fib patients with heart valve replacements or artificial heart valves. If the ordered medication is not covered or requires a prior auth automatically check the other two medications for coverage. Xarelto (Generic- Rivalroxaban): Once daily dosing Pradaxa (Generic- Dabigatran): Twice daily dosing Eliquis (Generic- Apixaban): Twice daily dosing

Heme/Onc Medications: Neupogen/Neulasta: For Neutropenia (288.00) or Pancytopenia (284.19) due to chemotherapy Give Cancer Diagnosis first when trying to obtain a prior authorization Acute Lymphoblastic Leukemia (204.00) Will probably be asked by insurance to give chemotherapy regimen

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• Try to find out how long the patient will need this medication • Find out chemo schedule if possible (ie every 3 or 4 weeks)

Noxafil (Generic- Posaconazole): Tablet dosing- 300mg once daily; Suspension dosing- (usually) 200mg BID For treatment of or prophylaxis for fungal Aspergillus infection Insurance preferred alternative medication is Fluconazole- We have a study that shows the increased benefits of posaconazole use vs fluconazole, you can send that with the prior auth or appeal if you feel that will help. Other medications: Lovenox (enoxaparin):

• MFH patients usually bridge to warfarin after discharge (5 to 14 days) unless they have a cancer diagnosis then it could be long term use.

Vancomycin:

• Treatment of Clostridium Difficile diarrhea (008.45) • Much have previously tried and failed Flagyl (Metronidazole) • Meridian medicaid does not cover capsules, they will approve for compound liquid but the

pharmacy much call them for an override (30 day max, call 866-984-6462) Zyvox (Linezolid):

• Zyvox sensitive MRSA (Methicillin-Resistant Staphylococcus aureus) • cSSSI- Complicated skin and skin structure infection (Osteomyelitis)

Xifaxan (Rifaximin):

• Covered for Hepatic Encephalopathy (572.2) and Traveler’s Diarrhea (009.2) • Must have tried Lactulose

Aranesp:

• First- see if patient is on Dialysis, if NO- check for Anemia, mostly due to renal failure or chronic kidney disease (CKD)- Look for Hgb and HCT levels (they should be listed in progress note or look in CBC labs)

Lidoderm: • FDA approved diagnosis- post herpetic neuralgia (nerve pain associated with shingles) • most insurances will require patients to try and fail Gabapentin first • 5% ointment or 2% jelly is usually covered without prior auth • Meridian Medicaid will only cover 2% jelly • Before contacting MD about prior auth for patches check to see if 5% ointment is covered so

you can let them know if there is a covered alternative to the patches and what the copay is.

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INSURANCE CONTACT INFORMATION: MIDWEST MEDICAID: (paper form only)

• 888-274-2031 WASHTENAW HEALTH PLAN: (over the phone only)

• (Liz) 734-544-3034 • No PA’s allowed but might be able to get an override or recduced price for certain

medications. • Check for active M-Support with patient has Wash Health Plan

MERIDIAN MEDICAID: (paper form only)

• 866-984-6462 (pharmacy technicians) • 313-324-3800 (pharmacists)

PART D WHP (Wellcare): (paper form only)

• 866-800-6111 MEDCO (commercial and part D coverage): (over the phone or by paper form)

• 800-753-2851 EXPRESS SCRIPTS (commerical and part D coverage): (over the phone or by paper form)

• 800-417-8164 PART D CATAMARAN (retired teachers): (over the phone or by paper form)

• (eligibility line) 800-880-1188 BCN COMPLETE: (paper form only)

• (phone) 888-989-0057 • (fax) 855-811-9326

HAP: (over the phone or by paper form)

• 313-664-8940 OPTUM RX (AARP PART D): (over the phone or by paper form)

• 800-711-4555 CVS CAREMARK: (over the phone or by paper form)

• 877-433-7643 PART D CVS CAREMARK: (over the phone or by paper form)

• 855-344-0930 EHIM (Employee Health Insurance Management): (paper form only)

• (phone) 248-948-9900 • (fax) 248-948-9904

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UNITED HEALTHCARE COMMUNITY MEDICAID (Prescription solutions): (paper form only)

• 800-310-6826 PHYSICIANS HEALTH PLAN (PHP): (paper form only)

• (phone) 877-883-5689 • (fax) 877-391-7298

MICHIGAN MEDICAID (Magellan Medicaid Administration): (paper form only)

• (phone) 877-864-9014 • (fax) 888-603-7696

Where to find important patient information:

Patient summary tab > patient overview > IP Facesheet • patient demographics • PCP • patient contact information • insurance coverage

Patient summary tab > Patient overview > Treatment team

• first contacts and medical team • Diagnosis codes

Patient summary tab > Patient overview > ADT Events

• Services (past and current during admission) Patient summary tab > After Visit summary

• Height, weight, BMI Patient summary tab > IP Labs

• Lab results since admission (not sure how to print this yet) MAR tab:

• Will show you when medications were given or if past due Chart Review: Notes tab:

• Progress notes (most notes include labs) • social work notes • case management notes • Admit H&P • Discharge Summaries

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Radiology tab: • CT’s and other scan results

Media tab: • Outside records • Filters for insurance card

Reports and Contacts for services and medication orders

(Highlight new patients and medications)

4C (STC service): Print report from Medication Search daily • Page pharmacist covering the service pager (36529) with high copays • Page first contact on medical team for PA’s/meds not covered

MFH: Print reports from Medication Search lists daily: Antibiotics, Pain meds, Misc.

• page attending (first contact pager) with PA’s/meds not covered/high copays • Use med lists created in medication search but can be contacted to look into any medication

patients are going to be discharged on MHP: Print report from patient lists when contacted for specific patients

• respond to original request contact • Will be contacted to look into any possible discharge medication • If PA is required for specialty medications:

o Ask if medication is required to be filled at a specialty pharmacy o find out specialty pharmacy information (phone and fax numbers) o ask if plan allows for override to fill at retail pharmacy for patient’s discharge o find out what the patient’s copay is going to be (at retail and/or mail order) o find out if the patient has to still meet a deductible or in their coverage gap

• If script is sent down to pharmacy and is require to be filled at a specialty pharmacy call insurance to verify medication does not require a prior authorization still and ask coverage questions from above.

A-fib/Enoxaparin medications: Print report from medication search daily

• page first contact listed with medical team or respond directly to pages or emails MHE/MON: Print report from patient lists daily

• Email pharmacist who is covering the service based pager (MON: 36708 MHE: 34837 • Look through entire inpatient medication list for medications that are high cost or usually

require prior auths (neupogen, neulasta, voriconazole,noxafil, ect) GYO: Print emails for post-operative enoxaparin screening

• Respond directly to email (will usually be Catherine Christen unless she tells you to contact someone else via email)

• If copays are high look to see if the patient has to meet their deductible still or if they are in a coverage gap (social work might be contacting you otherwise to check on that if you don’t automatically look into it)

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BCN Advantage patients: Discharge Medication lists

Open patient chart > Chart Review > Encounters tab > Look for admission (Discharge) for the date the patient was here (double click) > scroll to Discharge Summary Note (click on summary note)

- Highlight and copy the following information to a word document for all discharged patients

• Patient name, MRN#, age, sex, admit date, service • Discharge date • Attending Physician • Problem list box • Medication list • Allergies

- Save document under BCN DC (patients with the date) - Log into BCN email

https://securedmail.bcbsm.com/s/welcome.jsp?b=bcbsm - Attach document to email and send to med rec team at:

bcnadvantagemedrec@bcbsm.com

- Contact: Lance Rrokaj: FRrokaj@bcbsm.com o Cell phone: 248-258-0135