3/28/2017

1

Valarie Hoffman, Lori Clark,

Roxie Shortt-Lewis, Vickie Elliott

Jeff Gray

Six Sigma Road Map

Improve/Design

Measure

Analyze

Define

Control/Verify

Explain how the DMAIC process was used to

discover reasons nurses spent an excessive

amount of time administering medications.

Explain how the DMAIC process was used to

capture baseline and current data.

Explain how the DMAIC process was used to

maintain the desired outcomes of adhering to

standardization of medication administration

process.

Define the project goals and deliverables for both

internal and external customers.

Project: Scheduled Medication Administration Times. Business Case Problem Statement

The nurse spends an average of 17.96 minutes during one medication

pass. There is an average of 0.86 unnecessary medication passes per

patient day. This equals 93 minutes of nursing time per nursing

assignment each day (6:1 patient to nurse ratio). At an average hourly

nurse pay rate of $25.00 and an average daily census of 200 patients on medical, surgical and ICU floors this equates to a daily waste of $1,290

and an annual waste of $470,850. The patient’s satisfaction also has the

potential to be poor because they are interrupted an average of 0.5 times

between 2200-0600 for medication administration.

The unnecessary medication pass times result in excessive use of nursing time. This has the potential to increase the cost of care, decrease patient satisfaction, result in medication errors and decrease employee satisfaction.

Scope Goals/Deliverables

All medication passes on 5E and 3W that are not scheduled

as STAT, Now, PRN or for time critical medications.

1. The number of medication pass times will decrease by 10% 2. The number of medication passes during 2200-0600 will decrease by 30%. This project has the potential to improve early and late medication administrations and HCAHPS scores.

Milestones (DMAIC,

LEAN)

Start Due Status Team Members

Define 9/9 9/16 Complete Lesley Weihs / Dennis Killian Executive Sponsor

Valarie Hoffman, Lori Clark, Roxie

Shortt-Lewis, Vickie Mobray

Project Leader (s) Measure 9/16 10/7 Complete

Valarie Hoffman Pharmacy

Supervisor

Process Owner (s)

Jeff Gray PI Facilitator Analyze 10/7 10/28 Complete

Sarah Wray RN Team Member

Improve 1/2016 2/2016 Complete Craig Scott Pharmacy IT Team Member

Josh Davis RN & Pamela Parks RN Team Member Control 2/2016 3/2016 Complete

Ashley Dennis Team Member

Team Member

Medication Administration Times - Pharmacy RPH Schedules: Current State Process Map 8-28-15

StartRPH chooses

product from list of options

RPH Schedules Predication

Charge?

No

Time ordered fits frequency

drug given

RPH opens order in HMM

RPH checks order for safety and

appropriateness

RPH checks to see if pt received dose in

pt charges

Check ED report for administration

Got in ED

Yes

No

Schedule dose @ next scheduled time

RPH schedules dose for current

scheduled timeNo

Schedule dose @ next scheduled time

Yes

RPH does not adjust times, med

scheduled @ standard times

RPH adjusts times to fit or gives

onetime dose then schedules med @

standard times

Pharamcist verifies order and releases

to nurse to give

1

No

Yes

Start

Schedule OT Now

Schedule Decision Path

Eligible for Standard Times

Yes Repeating Cycle Yes Time Critical No Daily QAM No BID No BIDDI No BIDAD No BIDWM

Senum Level, abx, Stat, Now, OT, Pre-

op, Invest, PRN Meds

No

Schedule as Orderd

Schedule ATC on the hour

Theraeutic AC, Insulin, Meds >

Q4H

No Yes

Daily ADNoTIDNoQIDNoQ8HNoQ8HANoQ6H

Yes

NO

0900

Yes

0900, 2100

Yes

0900, 1700

Yes

0800-1800

Yes

Floor Bx 5 times0800

NoQ64ANoQ4HNoQ24HNoDig or WorkinNoOrder tiime fits frequency given

No

RPN adjusts times to make exact fit

Yes

0800

Yes

0900, 1600, 2100

Yes

0900, 1300, 1700, 2100

Yes

0600, 1400, 2200

Yes

0200, 1000, 1800

Yes

0000, 0600, 1200, 1800

Yes

0400, 1000, 1600, 2200

Yes

0200, 0600, 1000, 1400, 1800, 2200

Yes

@ Next M

Yes

1800

Yes

Choose time specified under

frequencies

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Supplier Input Process Output Customer

Medical Record Patient Information

Physician orders med

IS

Physician

IS

Order for med

Order for med

Pharmacy verifies, profiles and schedules

Computer for order/ HEO

HMM

Pharmacy

Scheduled Med

Nurse confirms order

HC Alert

Nurse

Medication SchedulePharmacy

IS

Nurse administers med

Medication Administration Times SIPOC

Nurse obtains med

Confirmed Order Medication Admin Nurse

Delivered Medication

Floor Stock MedicationAcudose

Pharmacy Patient

PharmacyDown in med Inventory

Correct Medication

IS Computer

Central Supply

Nurse Medication

Supplies

Patient Treated Physician

Documentation

Administered Med Patient

Medical Record

Measure the process to determine current

performance

Nurse flow

Equipment Available

Meds Available

Time to administer meds

Type of med

# of meds

How many meds pass

Short wait if coming from

pharmacy

On unit

Time of med pass

Computer Works

Computer Available

{

{

Actual Time of med pass{

{

Record time from order to

available{

{

# of times computer

doesn’t work{

# med pas per shift

{

# of times looking for computer

# of meds per pass

Type of med

# of times med

Requested

Audit

Who -Vickie, Lori, Roxie

What -Med profile on 4 pts 5E and

3W ptsFrequency -M-F

daily

Run Report?

Who -What -

Frequency -

AuditWho -What -

Frequency -

AuditWho -What -

Frequency -

Patient

Less Interruptions

Right Med

Med on time

# of Med Pass Times

{

Early Meds

{

Late Meds

Report run

Who -Dennis KillianWhat -

spreadsheet on all late meds

Frequency -TBD

Right dosage

Given the right way

Right time

Don’t wake up

All meds one time

{ Late Meds

{# Med pass 2200 - 0600

{# of meds

given wrongReport

run

Who -Risk Management

What -Medication incident reportsFrequency -TBD

Audit

Who -Vickie, Lori, Roxie

What -Med profile on 4 pts 5E and

3W ptsFrequency -M-F

daily

Audited 4 patients on 3W & 5E daily

Monday- Friday, 8/29/2015 –

10/2/2015

Average: 4.2

Median: 4 Mode: 3

Range: 1-12

Standard Deviation:

2.48

Average: 2.1

Median: 2 Mode: 1

Range: 0-6

Standard deviation:

1.4

0

2

4

6

8

10

12

14

1

16

31

46

61

76

91

106

121

136

151

166

A.M. Med Passes per Shift

Number ofPasses in Shift

ucl

lcl

0

2

4

6

8

10

12

14

1

16

31

46

61

76

91

106

121

136

151

166

PM Med pass times per shift

Number ofPasses in Shift

ucl

lcl

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3

Analyze and determine the root cause(s) of the

defects

0

2

4

6

8

10

12

14

0:0

00:0

03:0

06:0

06:0

06:0

07:3

07:3

08:0

08:0

08:3

09:0

09:0

09:0

09:0

09:0

09:0

09:0

010:0

011:3

012:0

012:0

0

12:0

012:3

014:0

014:0

014:0

015:0

016:0

016:0

016:3

017:0

017:0

017:3

018:0

018:0

018:0

020:0

021:0

021:0

021:0

021:0

021:0

021:0

0

22:0

022:0

0

Series1

Total Potential savings of time at 15% is 62 Passes or 18

hours and 34 minutes of nursing time.

60%40%20%-0%-20%

Median

Mean

20%15%10%5%0%

1st Q uartile 0.00000

Median 0.14286

3rd Q uartile 0.27679

Maximum 0.60000

0.10442 0.19751

0.00000 0.19599

0.17019 0.23702

A -Squared 2.60

P-V alue < 0.005

Mean 0.15096

StDev 0.19809

V ariance 0.03924

Skewness 0.402239

Kurtosis 0.354675

N 72

Minimum -0.33333

A nderson-Darling Normality Test

95% C onfidence Interv al for Mean

95% C onfidence Interv al for Median

95% C onfidence Interv al for StDev95% Confidence Intervals

Summary for Total Potential Benefit %

2200-0600 potential savings of time at 38% is 15 Passes

or 4 hours and 30 minutes of nursing and patient time.

100%80%60%40%20%0%

Median

Mean

60%50%40%30%20%10%0%

1st Q uartile 0.00000

Median 0.41667

3rd Q uartile 0.62500

Maximum 1.00000

0.21380 0.54261

0.00000 0.50000

0.31923 0.56189

A -Squared 2.29

P-V alue < 0.005

Mean 0.37821

StDev 0.40704

V ariance 0.16568

Skewness 0.51776

Kurtosis -1.27687

N 26

Minimum 0.00000

A nderson-Darling Normality Test

95% C onfidence Interv al for Mean

95% C onfidence Interv al for Median

95% C onfidence Interv al for StDev95% Confidence Intervals

Summary for 2200-0600 Potential Benefit %

Mean 17.95706

Median 16

Mode 20

Standard Deviation 10.83867

Min 2

Max 56

0

10

20

30

40

50

60

1 8

15

22

29

36

43

50

57

64

71

78

85

92

99

106

113

120

127

134

141

148

155

162

Total time pass meds

ucl

lcl

Improve the process by eliminating defects

Control future process performance

3/28/2017

4

Lost pt.

access

Excessive time

spent on Med

Passes by

Nurses External

Facility

Equipment/Supplies

Process People Material

Location of

Accudose Communication

with nursing

Pt. off

floor

Patient

preference

Supply Room

Layout

RN

interruptions

Computer Systems

Pharmacy uses

Pt.

acuity

Computers

available

Multiple systems

Vitals machines

Critical timed

meds on profile

Communication

with nursing

Unreliable

charting

Pt not

on floor

Pt. preference

of med

administration

Labs/vitals

available

Procedure

being done

Vitals/labs

Nurse call to

adjust times

Number

of meds

Available

meds

Available

supplies

Available

computers

Rooms not

prepared

water/cups

IV Pump

available

Accudose

Interruptions

Nurse

interruptions

Communication

barriers with

nursing

Provider &

Pharmacy not

using

standard

times

Computer systems

pharmacy uses

Combination

meds cannot be

given together

Standard

times not

used

Unsure if given

in ED, home ,

or floor

C.N.A. not preparing

room

Medications can no be

given together

Communication

with nursing

Frequency of

medication

Phone

calls

Nurse calls

to adjust

times

Drop meds

Meds

stocked

only on

A/B

Accudose

PRN

meds

Missing

Medications

Admission,

discharge, MDR, RR,

codes

Providers place

orders to give

“now”

Why are patients

interrupted?

Medication pass times

Why are pass times

varied?

Why does Pharmacy time which

such variety?

Why doesn’t Pharmacy use

standard administration

times?

Why are

medication

pass times

interrupting?

Varied

times of

passes

They are varied

because of how

Pharmacy times

Pharmacy uses

exact times

instead of

standard

timed.

Easier to use

exact time.

Does enhancements of current standard

medication administration times policy

decrease number of medication passes.

Start process February 1, 2016

Pod audit on 3W and 5E (8 patients) weekly

until controlled, then monthly

All nurses and patients will benefit. (The nurse

will have more time to give medications on time and provide

non-medication related nursing tasks. The patient will benefit

from increased nursing time and decreased interruptions

during sleeping hours.)

What Reduce the amount of time that nursing staff spends doing meds passes.

Why We want to free up time for nurses to do assessments and education while, at the same

time, increasing the amount of quiet healing time for patients through fewer interruptions.

Where All patients at PRMC.

How Through strict adherence of standard med administration times by pharmacy and

nursing, we can reduce the number of med passes on a patient each day. Standard medication administration times are also designed to minimize the times a patient has

to be interrupted between 10 p.m. and 6 a.m. for medication administration. We will

implement this after pharmacist and nursing education about the importance of

standard medication administration times.

Standard Medication Administration Times policy will be revised.

Inform CP&S, PNT, and all Directors

Education:

All Nurses – staff meeting, core team meetings email/news letter updates, huddles, posters, & Read & sign.

Clinical Supervisors, CQS’s & Clinical Educator– In depth training

Pharmacists-training during pharmacist meetings

Go-live date: February 2016

Standard Medication Administration Times

Designed for pharmacist and nursing education

Includes a review of PRMC’s standard medication

administration times

Provides instruction for scheduling new

medication orders and re-establishing a

medication schedule after a missed dose

Lists medications exempt from standard

administration times

Educates nursing staff on how to approve

medication orders

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Key education points

Strict adherence to standard administration

times

Proper scheduling of around-the-clock

medications

Utilization of “alternate hours” administration

times

Development of standard administration times

for Q24H medications

Control Item Average # of unnecessary med passes over 24 hours and overnight (2200-0600)

Goal 90% overall decrease and 75% overnight decrease

Source and Measurement Auditing of HED MAR sheets

Frequency of Observation Weekly until controlled, then monthly

Sample Size Pod audit on 3W and 5E (8 patients)

Criteria for Taking Action Less than 80% overall decrease and 65% overnight decrease from baseline data

What Action to Take Investigate non-standard administration time outliers and provide re-education

Who Acts Process Owner- Pharmacy Supervisor

Control Item Percent of medications not on a standard administration time

Goal Less than 5% of medication orders

Source and Measurement Auditing of HED MAR sheets

Frequency of Observation Weekly until controlled, then monthly

Sample Size Pod audit on 3W and 5E (8 patients)

Criteria for Taking Action Greater than 7.5% of medication orders

What Action to Take Investigate non-standard administration time outliers and provide re-

education

Who Acts Process Owner- Pharmacy Supervisor

EPIC Willow Software

Provides decision making support to schedule

medications according to the new standard

administration time policy

Medication Administration Time project

prepares pharmacy and nursing for future

medication schedules

Reduce the number of scheduling overrides in

EPIC

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1. The number of medication pass times will decrease by 10%

2. The number of medication passes during 2200-0600 will decrease by 30%

After auditing control phase patients, it was determined that a more accurate measurement of success was a percent reduction of unnecessary medication passes.

Why? The control phase patient population had an overall increase in medication passes due to a higher prevalence in more frequently administered medications (e.g. sliding scale insulin, Q6H antibiotics).

Even though there was an overall increase in medication passes, regimens were more standardized and medication passes were avoided.

As a bonus, medication passes during 2200-0600 were reduced by 28%, despite the overall increase in medication passes.

Baseline of Unnecessary Med Passes / patient= 0.86

Daily Census= 200

Total Unnecessary Med Passes= 172

Average Time per med Pass in minutes= 17.96

Total Hours of Unnecessary Med Passes = 51.5

Daily Potential Savings= $ 1,610.46

Annual Potential Savings = $ 587,818.35

% of Unnecessary Med Passes Removed From Process= 90%

% of Unnecessary Med Passes Removed from 2200-0600= 83%

Actual Savings from Removing Unnecessary Med Passes= $ 1,454.41

$ 530,859.43

2W: 2507, 2510, 2501

3L: 3006, 3019, 3022

3W: 3504, 3540, 3528

5E: 5108, 5103, 5127

5L: 5026, 5006, 5014

5W: 5533, 5503, 5527

The results of the audit are all Patient’s

scheduled medications are on the Standard

Medication Administration Times!!

How first two component, Define & Measure

helped identify inconsistencies with

adherence to current standard medication

administration guidelines.

How Analyze & Improve processes were

implemented in the standardization of

medication administration process.

How the last component, Control is needed

to maintain the desired outcomes of

adhering to standardization of medication

administration process

3/28/2017

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Institute for Safe medication Practices. (January 13, 2011). Guidelines for timely medication administration Response to the CMS "30-minute rule”. Retrieved from

www.ismp.org/newsletters/acutecare/articles/20110113.asp

National Patient Safety Agency (NPSA). Rapid response report NPSA/2010/RRR009: reducing harm from omitted and delayed medicines in hospital. Retrieved from www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=66720

Patient Safety & Quality healthcare. (December 9, 2015). Overcoming Barriers on the Way to Evidence-Based Practice. Retrieved from

http://www.psqh.com/analysis/overcoming-barriers-on-the-way-to-evidence-based-practice/

Business Performance. The DMAIC Method in Six Sigma. Retrieved from http://www.businessperform.com/articles/process-improvement/dmaic_method.html