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PHARMACY AUTOMATION DO’S AND DON’TS

When Its Good, Its Very, Very Good, And When Its Bad… Marian Daum

Christopher LambertDelbert SiegmundGay WallSESSION 139

OJBECTIVES• Evaluating your needs:• Choosing the right equipment for

your operation• Other factors to consider -

– Maximum Output– Minimum Requirements– Reliability – Service Contracts

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OBJECTIVES• Develop a Business Case for the

Purchase of the Equipment

– Funding– Benefits to the pharmacy– Benefits to the facility

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OJBECTIVES• Pre-implementation – who needs to

be at the table– Within your department– Within your facility– Within your medical center– Are your timelines realistic?– Are there any other issues?– What does a good installation look like?

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OBJECTIVES• Doesn’t the machine do the

work for you?

• Setting up a Training Program• Assessing Competence• Common Training Pitfalls

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OBJECTIVESCan the system generate the reports

you need?Do you have the right medication in

the machine?Are your par levels set too high or too

low?What else is the system telling you?

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Automating a ProcessChoosing the Right Equipment for

your Program

Why can’t I get a replicator and a transporter unit ????

Marian Daum

AUTOMATING A PROCESS• What to you want to get out of

automating your process?• Lower inventory, better turn around

time• The same amount of medication

stored using less space• Tight control of a process with

accountability at each step

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AUTOMATING A PROCESS

MANUAL PROCUREMENT PROCESS

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AUTOMATING A PROCESS• What are your options?

– McKesson MedCarousel– SwissLog Box Picker– Omnicell WorkflowRx– Talyst AutoCarousel– Automed FastFind

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AUTOMATING A PROCESSEQUIPMENT CONTROL MANAGEMENT SPACE TOTAL

McKesson MedCarousel 2 2 3 7 (13)

Swisslog Box Picker 3 2 3 8 (17)

Omnicell WorkFlow Rx 1 2 2 5 (8)

Talyst AutoCarousel 1 2 2 5 (8)

Automed FastFind 3 3 2 8 (17)

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AUTOMATING A PROCESSEQUIPMENT INTEGRATE RELIABLE SERVICE

CONTRACTINTERFACE TOTAL

McKesson Med Carousel

2 3 3 2 10 (12)

Swisslog Box Picker

2 3 2 3 10 (12)

Omnicell Workflow Rx

4 4 3 3 14 (18)

Talyst AutoCarousel

2 3 2 2 9 (11)

Automed FastFind

3 4 4 2 13 (16)

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AUTOMATING A PROCESSEQUIPMENT OBJECTIVES OTHER

FEATURESGRAND TOTAL

McKesson Med Carousel 13 12 25Swisslog Box Picker 17 12 29

Omnicell WorkFlow Rx 8 18 26Talyst AutoCarousel 8 11 19Automed FastFind 17 16 33

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CHANGING EXISTING AUTOMATION

Why do you want to change your process?Process time starts out okay in the morning,

but have a processing time of over an hour by 2PM.

Problem prescriptions go into an exception file and you find this out when the patient comes up to the pickup window to complain.

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CHANGING EXISTING AUTOMATION• Is it reliable?• Do you get adequate support from

the vendor’s help desk?• Is there newer, more efficient

technology out there?

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CHANGING EXISTING AUTOMATIONIs this machine still able to handle your

current workload?

- Look at hourly processing time in VistA Bingo Board Manager Program

- Is your staff waiting for the machine to finish processing prescriptions?

- Is there work that you can shift to another time?

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CHANGING EXISTING AUTOMATION• Upgrade vs. Replacement

– Cheaper and Less Disruptive• Newer Version or Higher Capacity

Version of Same Vendor’s Equipment– Same interface, staff familiarity,

disruptive• Change to another vendor’s

equipment– Most disruptive, staff retraining, patient

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CHANGING EXISTING AUTOMATION• Why are you making the change?

– Table of requirements and desires ranked from most to least important

• Map out the process• What are the holes in your system?

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CHANGING EXISTING AUTOMATION

Biggest requirement- Prescription filling capacity during peak hours of operation

ScriptPro SP200 is the existing equipment- Upgrade with RCM model

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Developing a Business Case

If you try sometimes….You just might find….You get what

you need.

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Marian Daum

DEVELOPING A BUSINESS CASE• Funding your equipment

– Local Funding can be used for a purchase most smaller items and upgrades to existing equipment

– An equipment purchase of over $250,000 may have to be submitted to the VISN’s high cost/high tech equipment fund

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LOCAL EQUIPMENT REQUEST 

• Robotic Cell Multiplexor with Field Conversion of SP200•  • This is an add-on to our SP200 robot that is used to fill outpatient prescriptions. Currently the

machine can only fill one prescription at a time and our technicians are frequently waiting for the machine to finish. This will allow the machine to fill faster decreasing our wait time for prescriptions at the Outpatient Pick-up window

•  •  • Lionville 800 Series Medication Cart with Computer & Scanner • (6 Carts) – do not have price quote yet.•  • These are small medication carts that will be used to bring the domiciliary units into compliance

with new medication standards requiring nursing administration of controlled substance and for nursing administration of medication to those veterans who are unable to manage their own medication regimen. This model is currently used in the medical center and the drawer in the unit is able to accommodate the punch cards being manufactured by the Pharmacy.

•  • Omnicell Auxiliary Cabinet•  • This is an add-on to the existing unit on 59B. The Omnicell cabinet there is full and the additional

cabinet will allow for the storage of stock that does not currently fit in the existing unit.•  

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DEVELOPING A BUSINESS CASE• Added Value

– Acquisition Cost Savings– Better Use of FTEE– Better Service for the Veteran

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LOCAL EQUIPMENT REQUEST• ScriptPro Upgrade Request• The service was able to save $9,572.00 in one month of

operation. Annualized, this savings could be up to $114,864.00. The upgrade to the unit, purchase of the multiplexor and installation cost 19,179. The service would like to expand this process to other identified medications that we are able to purchase locally at a significant savings over CMOP. If the service experienced a similar rate of savings through the use of the requested 5 multiplexor canisters, the Medical Center would realize an annual savings of $300,000.00 on the $20,160.00 investment without an erosion in the quality of service provided at the outpatient pharmacy pickup window or the requirement for additional FTEE to service the machine.

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HIGH COST/HIGH TECH REQUEST• This funding is used for equipment

that costs over $250,000. (VHA Directive 2009-17)

– The funding comes directly from the VISN and not the local facility

– Your request must compete with other high cost/high tech requests throughout the VISN

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HIGH COST/HIGH TECH REQUEST•

Identify equipment to be replaced (EE#, Mfg, Model, Serial#, etc) and explain reason for replacement (if applicable) Omnicell unit in 1B, AMCU, 138A, 138B, 138H are currently inadequate to store all the items necessary to provide effective patient care on these units. CVAMC needs to purchase upgraded storage capacity for these areas to allow CVAMC to make stock readily available to staff while being stored in a secured manner. Additional items are needed to meet the directive of the Undersecretary; this directive requires all facilities with Domicilaries to begin to have staff administer controlled substances to patients in the DOMS on an around-the-clock basis. CVAMC plans to use the omnicell equipment currently used in the acute medical areas, noted above, to meet the need in the DOMS. The existing units will need to be upgraded to be repurposed for use.      

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HIGH COST/HIGH TECH REQUEST

• We were also required to submit a return on investment (ROI) analysis.

– How long will it take the equipment to

“pay for itself”– How much of a cost savings will be

realized in 10 years.

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BUSINESS CASE• Other factors to strengthen your

request

– Network with other services

– Work with your service’s business manager and/or quadrad to smooth the way

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Implementation & Installation: Avoiding the Pitfalls

Christopher Lambert

YOU BOUGHT IT: NOW WHAT?How to Build an Implementation

Team• Identify the Pharmacy Project

Manager• Identify the Departments Involved /

Departments Impacted• Identify Responsible / Key Staff within

Each Department• Schedule Implementation Meetings• Distribute the Timeline

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Identify the Pharmacy Project Manager (That’s you, sucker)

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IDENTIFYING THE DEPARTMENTS INVOLVED

• Manufacturer Implementation Manager • Information Resource Management (IRM)

– Data Drops / Telephone Lines / Server Housing

• Information Security Officer (ISO)– If equipment is on the VA network

• Engineering / Interior Design / Biomed– Prepare space for equipment– Infrastructure upgrades (electricity –

compressed air)

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IDENTIFYING IMPACTED DEPARTMENTS

• Nursing• Procedure Changes• Medication Packaging Changes

• Pharmacy Staff• Assignment/Responsibility Changes

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IDENTIFY RESPONSIBLE / KEY STAFF WITHIN EACH DEPARTMENT

Request that each involved department assign a staff member and a back-up contact for the project.

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IMPLEMENTATION MEETINGSGood Communication is Key to a

Successful Project• All involved departments and

Manufacturer Implementation manager

• Clarify each departments responsibility

• Review Manufacturer Timeline• Schedule follow-up meetings • Keep and distribute minutes 35

TIMELINE-DELEGATE BUT VERIFY-Each assignment is assigned to a

specific Implementation Team Member.

-Completed assignments Verified by Pharmacy Project Manager.

-Verify Manufacturer is staying on schedule

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PHARMACY IMPLEMENTATIONPREPARATION

• How will the work get done during implementation?

• Plan contingencies• Schedule for off peak periods• Limit annual leave• Prepare for implementation to take

much longer than planned

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What Can Go Wrong: Don’t Let this Happen to You

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Automation Training and Competency

Does anybody know how to work this thing????

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Delbert Siegmund

FALLACY: AUTOMATION EQUIPMENT DOES THE WORK

Truth is real live human beings do the

work, and the automation equipment is just a tool they use to do the work, either:

FasterIn greater volume

More accurately etc.

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TYPICAL ENTHUSIASM STORYLINE• Vendor states equipment can fix all problems = High enthusiasm• Getting $$ appropriated to buy gizmo = Less enthusiasm• Coordinating delivery and installation = Significant dent in

enthusiasm• Fixing and solving all interface issues, populating databases,

assigning privileges = BIG drain in enthusiasm• Discovery that the installed equipment didn’t solve all problems as

promised = Last drops of enthusiasm drained• Desire to train staff on equipment use = ENTHUSIASM TANK

EMPTY

DON’T FORGET TO TAKE A BREATH, REGAIN YOUR COMPOSURE AND FUEL UP FOR TRAINING!

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STAFF TRAINING: THE PENULTIMATE INSTALLATION STEP

Frequently used and high value pieces

of equipment all have the same thing in common:

• Competent staff who really know how to use the equipment

• Confident staff who know what they are doing with the equipment

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THE MOST EFFECTIVE STAFF HAVE OFTEN BEEN….

• Trained by the vendor at the time of installation at least once

• Trained yet again shortly after by the local super user (someone they know and trust)

• Trained yet again by themselves where they can practice using the machine and answer their own questions by trial and error in private

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THE WORST TRAINING POSSIBLEWhatever staff in attendance that Friday are gathered during lunch break for an un-announced training session on new equipment. The installer runs through the equipment use, point to an operating manual and a CD that also contains the manual. The 1-800 number on the machine is referenced. The installer smiles at the group, asks if there are any questions on what they just demonstrated and when there are no questions has the group sign the training sheet……….

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BETTER TRAINING• All staff (including nights/weekends/part time) are included• Training time is after breakfast, but well before lunch• Groups for training are smaller and more intimate when possible• Extra staff coverage is provided during trainings sessions, so staff

do not feel they are falling behind with their regular work• Staff know what equipment is, what it does and have questions

prepared in advance• HANDS ON, HANDS ON, HANDS ON!! Staff should be using

equipment during training, and each member should repeat the same training, not just one brave volunteer.

• Vendor trainer is available after training sessions are complete for one-on-one questions and mini demonstration during the rest of the day

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THE INSTALLER IS GONE…NOW WHAT?• Somebody at your site needs to be a designated

Super User. It can be ANYBODY and you would be surprised at who that might be. Consider EVERYBODY in your staff as a potential super-user

• For physical use of the machine, vendor provided video can be a very good reference

• For equipment with a computer interface, strongly consider SCREEN SHOTS of the interface as an aid for navigation through screens and menus.

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PROVE YOUR GOOD TRAINING WITH A COMPETENCY ASSESSMENT!

When boiled down, most assessments are the same

• Employee can start up and shut down the equipment

• Employee can calibrate/prepare the equipment• Employee can load and replace “consumables” in

the equipment• Employee can demonstrate use of the equipment• Employee can clean and maintain the equipment• Employee knows both local support and technical

support contacts in the event of a malfunction.

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SIMPLE IS BETTERRemember the following points about competency assessment forms and documentation:

• Most regulatory/internal reviews focus on “missing” competency assessments - not their content. Make them simple and executable.

• Manufacturer provided “competency” forms have gotten much better (though many stink ). Don’t overlook them as a source (vs. making your own from scratch.)

• Keep the competency assessment separate from Policy and Procedures. Competency assessment shows staff can operate the equipment, and that is it.

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AVOID THE FOLLOWING AT ALL COST OR YOUR EQUIPMENT WILL

SURELY DIE• Nobody knows what equipment is going in, or why they

are getting it, or what it is supposed to do when they get it

• Everyone is scared of the equipment due to cost, or damage risk, or complexity

• Only one person in the pharmacy knows how to run the equipment and there is no staff rotation on operating the equipment.

• There is no reference material or “how to use” sheets available for individuals to look at

• Harsh or punitive measures when the equipment breaks or an “accident” happens (well, at least the first time )

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Maximizing UseUsing Reports to Increase Efficiency

Its all in the report…Marian Daum

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MAXIMIZING USE• Automation will expose any

weakness in your processes

• Gaps in the database– Stock out/stock not moving

• Too many manual processes– Not looking at usage data

• Operator Error– Don’t forget to push the green button….

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MAXIMIZING USE• Reviewing the Use of Narcotics

• Setting up a Surveillance Program

Poor Practice vs. DiversionInvolve key staff

Follow through to reinforce goodPractice and stop poor practice

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MAXIMIZING USE• Misadventures in Narcotic Use

– You found What above the false ceiling?

– 15 minutes of fame that you can do without

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MAXIMIZING USE• Other Narcotic Surveillance Reports

– Usage Compared to Other Personnel

– Witness Pairs

– Number of Discrepancies

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MAXIMIZING USE• What about that installation?

– What did you get out of the change in process?

• Better Inventory Management• Better Turn Around Time

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MAXIMIZING USE• Unexpected Benefits

– The law of unintended consequences can sometimes be a good thing.

– Are you able to demonstrate additional benefits to your recent upgrade?

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MAXIMIZING USE• What if I want to kick it up a notch?

• Advanced Report Writing• Custom Reports• Combining VistA and the automation reports

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MAXIMIZING USE• Please share with the entire class

• http://vaww.national.cmop.va.gov/pre/default2

• Please post your best practices on the automation Sharepoint discussion board

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AUTOMATION• Choosing the best equipment for

your service• Developing an implementation plan

for a smooth installation• Developing a comprehensive training

and competency assessment program

• Evaluating the performance of the equipment on an on-going basis

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Questions??

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