2
Do you know what your staff are doing?Performance improvement through tracers
Margarita Fedorova, CPhTCedars-Sinai Medical Center
Pharmacy Technician Supervisor
3
Disclosure
I have no relevant financial relationships with commercial interests pertaining to the content of this presentation.
4
Learning Objectives: Pharmacy Technicians
At the completion of this activity, the pharmacy technician will be able to:Describe the use of tracer methodology and the technician’s role in evaluating the medication use process (MUP)Discuss the development of a database collection tool for tracking compliance to medication use processesIdentify opportunities to improve quality and patient safetyDescribe feedback forums to staff to improve performance
5
Learning Objectives: Pharmacists
At the completion of this activity, the pharmacist will be able to:Describe the use of tracer methodology and the technician’s role in evaluating the medication use process (MUP)Discuss the development of a database collection tool for tracking compliance to medication use processesIdentify opportunities to improve quality and patient safetyDescribe feedback forums to staff to improve performance
6
Cedars Sinai Medical Center (CSMC)
Non-profit, acute, tertiary, teaching hospital
886 licensed beds120 intensive care unit beds
Level I trauma center, Comprehensive Stroke Center
Department of Pharmacy Services:Decentralized clinical pharmacy servicesEmergency department and operating room servicesSolid organ transplant servicesTransitions of care services Outpatient pharmacy services including ambulatory care clinicsOncology services
7
“Always Survey Ready”
On average, CMSC is subject to 15 regulatory surveys each year“Always Survey Ready” or “Ever-Ready” Compliance AT ALL TIMES to:
Federal and state regulatory requirements :The Joint Commission(TJC)Drug Enforcement Administration(DEA)California Department of Public Health(CDPH) Title 22California Board of PharmacyCenter for Medicare and Medicaid Services(CMS)Many others
8
“Always Survey Ready”, cont.
Compliance AT ALL TIMES to:National organizations best practices:Center for Disease Control and Prevention (CDC)US Pharmacopeia (USP)California Society of Health- System Pharmacists (CSHP)American Society of Health- System Pharmacists (ASHP)Institute for Safe Medication Practices (ISMP)Many others
Organization policies and procedures
Goal: CONSISTENT applications of established processes
9
Who’s Looking?
1
10
THEY are LookingThe Joint Commission (TJC) evaluates health care organizations to inspire them to excel in providing safe and effective care of the highest quality and value2
The California Department of Public Health (CDPH) is dedicated to optimizing the health and well-being of the people in California3
Centers for Medicare and Medicaid Services (CMS) Improve individual patient experiences of care along the Institute of Medicine’s six domains of quality: Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity4
CA Board of Pharmacy protects and promotes the health and safety of Californians by pursuing the highest quality of pharmacist’s care and the appropriate use of pharmaceuticals through education, communication, licensing, legislation, regulation, and enforcement5
11
THEY are LookingThe Joint Commission (TJC) evaluates health care organizations to inspire them to excel in providing safe and effective care of the highest quality and value2
The California Department of Public Health (CDPH) is dedicated to optimizing the health and well-being of the people in California3
Centers for Medicare and Medicaid Services (CMS) Improve individual patient experiences of care along the Institute of Medicine’s six domains of quality: Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity4
CA Board of Pharmacy protects and promotes the health and safety of Californians by pursuing the highest quality of pharmacist’s care and the appropriate use of pharmaceuticals through education, communication, licensing, legislation, regulation, and enforcement5
Patient Safety
12
Assessment Question #1
In which of the following steps of the Medication Use Process (MUP) are technicians involved in?
a) Administeringb) Dispensingc) Hiding medications from the nursesd) Storagee) B & D onlyf) All of the aboveg) I don’t know
13
Technician roles in the Medication Use Process:Safety is a Key Factor in All Aspects
Selection & Procurement Storage Ordering &
TranscriptionPreparation &
Dispensing Administration Monitoring &Evaluation
•Inventory•Floor Stock•Recalls•Automation
•Purchasing•Bar Coding •Drug Supply Chain Security Act (DSCSA)•Patient assistance
•Outpatient Order Entry (OE)
•Distribution•Order Pickup•First dose dispense•Phone Triage/Cust. Service•Cart fill & Check•Missing Med Invest.•Order Status requests•Compounding•Packaging/Bar Coding•IV preparation•Procedural services•Special Populations•Automation•IDS (Invest. Drug Serv.)•Patient assistance
•No current role •Cont. Regulatory Readiness•IV rounds•Unit Inspections•Quality audits•Error Investigation•Identify Quality Improvement (QI) opportunity•Identify Pts Omitted meds•Transitions Of Care (TOC)
14
Assessment Question #2
Which regulatory agencies have an oversight over the Medication Use Process that affect technician roles?
a) CMS
b) TJC
c) CDPH
d) CA Board of Pharmacy
e) All of the above
f) Your local cable company
g) I don’t know
15
Core Technician Roles in Medication Use Process
Focus Areas for Regulatory Agencies and
Safety OrganizationsTJC CMS CDPH ISMP
Storage x x x x
Dispensing x x x x
Evaluation x x x x
16
Technician Role in Medication Use Process: Storage
Checking Beyond Use Dating (BUD)/expiration dates:Dating of open multidose vials IV Fluids outside of overwrapCompounded Sterile Products (CSPs)
Monitoring refrigerator/freezer temperaturesEnsuring medications are protected from light, when applicableStoring medications in the right location (refrigerator vs. warmer vs. room temperature)Removal of outdated medicationsEnsuring cleanliness of medication storage areas
17
Technician Role in Medication Use Process: Dispensing
Ensuring dispensing accuracyRight patient: use of 2 patient identifiersRight drugRight doseRight timeRight route
Ensuring safe use of Patient’s Own Medications (POM)*Alert pharmacist when POM are available to be verified right medication administered
to patientAlert nursing leadership when POM are left behind at discharge minimal disruption to
patient’s regimen and patient’s and organizational financial impact
*CSMC Process
18
Technician Role in Medication Use Process: Evaluation
Assess for dispensing and stocking errors
HIPAA : safeguarding Protected Health Information (PHI) on and off the clock
Discharge medications not provided to patient upon discharge
Duplicate medications dispensed
19
Technician Role in the Medication Use Process: Summary
Safe Medication Storage
Safe Dispensing
Evaluation
Identification of opportunities to reduce waste and improve quality/performance
Overall Medication Safety
20
Assessment Question #3
Tracer is a process to analyze an organization's systems, with particular attention to identified priority focus areas, by following an individual patient, resident, or individual served through the organization's care process in the sequence experienced by each individual.
a) True
b) False
21
What is Tracer Methodology?
A process to analyze an organization's systems, with particular attention to identified priority focus areas, by following an individual patient, resident, or individual served through the organization's care process in the sequence experienced by each individual6
TJC uses tracer methodology to assess organization’s compliance to its standardsTracer methodology is utilized to follow technicians through the medication use process and ensure:Compliance to organization’s policies and procedures and regulatory requirements,
and national standardsConsistent application of established processes
22
Why are Technician Tracers Needed?
General points: Increasing number of staffIncreasing roles of techniciansIncreasing regulatory requirementsMore complicated medication regimensIncreasing use of automationImplementation of CPOE
23
Why are technician tracers needed?, cont
Recent 26% increase in number of technicians to supervise.New Comprehensive Stroke Center designationGrowing transplant programChange in technician practice model:
Before After
• Technician order entry
• Decentralized distribution model
Dispensing from the satellites Delivery from the satellites Floor stock from the satellite
• Computerized Physician Order Entry (CPOE) implementation
• Centralized distribution model(with responsibilities on the floor) Dispensing from the central location Deliveries from the central location Floor stock from the central location
24
Tracer Criteria
Tracer criteria are developed and evolve based on:
Regulatory requirements
Organization policies and procedures
Previously identified gaps, deficiencies or problematic areas
25
Focus Areas
Current CSMC tracer focus categories:
1. Temperature Logs 2. Outdates3. Patient Own Medications4. Discontinued Medications5. Deliveries To The Wrong Location6. Transfer of medications 7. Dispensing Error 8. Stock Error 9. HIPAA 10. Meds In The Tube station
11. Technician Name Posted12. Cleaning Medication Carts13. Signing Delivery Log 14. Dating Of The Insulin Vials 15. Answering Assigned Phone16. Unnecessary Refill 17. Medication Cart Labeling 18. Nothing Found 19. Discharge meds left behind 20. Other
26
Development of a Tracer Database
Several methods exist to track tracer findings:
Paper logs, notes in the file
Email notes to yourself and store in a dedicated Outlook® folder
Use Excel® spreadsheets
27
Development of a Tracer Database
Several methods exist to track tracer findings:
Paper logs, notes in the file
Email to yourself and store in a dedicated Outlook® folder
Use Excel® spreadsheets
Manual or Semi-Manual Processes
28
Assessment Question #4
What are the advantages of an Access® database in tracking tracer results when compared to other traditional methods?
a) Data structure & Normalization
b) Scalability
c) Data and Referential Integrity
d) Queries and Reports
e) All of the above
f) Helps to Win the Lottery
g) I don’t know
29
Access® Database
What is an Access® database?7
Microsoft Access®, often abbreviated "MS Access," is a popular database application for
Windows
Access allows users to create custom databases that store information (collection of
records) in an organized structure
The program also provides a visual interface for creating custom forms, tables and reports,
and easy manipulate the data using queries
30
Access® Database, cont.
Advantages of an Access® database8
Data structure and normalization through multiple tablesDatabases make it easy to store information in one place and reference it in multiple
placesScalability, Data and Referential IntegrityDatabases provide many tools to maintain data quality and eliminate redundancies
Queries and ReportsMS Access queries and reports let you slice and dice your data and present it in detail or
summary form
31
Access® Database, cont.
Advantages of an Access® database8
Data structure and normalization through multiple tablesDatabases make it easy to store information in one place and reference it in multiple
placesScalability, Data and Referential IntegrityDatabases provide many tools to maintain data quality and eliminate redundancies
Queries and ReportsMS Access queries and reports let you slice and dice your data and present it in detail or
summary form
Fully Automated
Process
Access® Database Field Relationships
32
33
Database Input Form
34
Database Results Findings by Location Findings by Employee
35
How is data evaluated?Periodic evaluations (monthly, quarterly, annually) to:Identify trend directionAssess overall compliance to standards
36
Top Issues Identified 2013 – 2015*
* Through August 2015
37
Overall Issues Identified 2013 – 2015*
* Through August 2015Year 2013 Year 2014 Year 20150
50
100
150
200
250
Overall Issues Identified 2013-2015*
Problems Found Exponential (Problems Found)Nothing Found Exponential (Nothing Found)
38
Assessment Question #5
How can tracer results be used to improve the Medication Use Process?
a) Identify Performance Improvement Opportunities
b) Staff Recognition
c) Performance Appraisal
d) A & B only
e) All of the above
f) I don’t know
39
How is Data Used?
Staff engagement & recognitionStaff meetings/huddlesOpen forum meetings
Performance improvement initiativesDownward trends focus for performance improvement initiatives
Individual Follow-upStaff is notified immediately about findings
Periodic performance appraisal/discussions with the supervisor
40
Performance Improvement (PI) Initiatives
Based on tracer results we:Identify areas requiring process re-designing and implement changes utilizing the Plan, Do, Study, Act (PDSA) methodologyMonitor successful test of change implementationInitiate PI projects:Compliance to temperature recordingCompliance with removal of medications for discharged patientsMissing medication studyChange in insulin dispense methodology
41
SummaryTechnicians play an integral role in ensuring a safe medication use process.
Increased regulatory oversight warrants the need for an “Always Survey Ready” state.
Tracers provide an objective method to assess technician’s compliance to established processes and standards
Access® databases have many advantages to:Record, track, and report tracer findings to various forums.Identify performance improvement/process redesign initiativesCompile objective data for staff recognition and individual feedback
42
Acknowledgements
CSMC Pharmacy Technicians and Administrative Staff
Karen Youmbi, PharmD, BCPS
Kimberly Snodgrass, PharmD, BCPS
Bruce Vinson, PharmD, FASHP
Rita Shane, PharmD, FASHP, FCSHP
Roman Fedorov, MCSD
43
References1. Hardcore Investigations[Internet] Available from: www.hardcoreinvestigations.net
2. The Joint Commission[Internet] Available from: http://www.jointcommission.org/the_joint_commission_mission_statement/
3. CDPH[Internet] Available from: http://www.cdph.ca.gov/pages/AboutUs.aspx
4. CMS[Internet] Available from: http://innovation.cms.gov/about/Our-Mission/index.html
5. CA Board of Pharmacy[Internet] Available from: http://pharmacy.ca.gov/about/mission_statement.shtml
6. The Joint Commission E- dition[Internet] Available from : https://e-dition.jcrinc.com/MainContent.aspx
7. Access Definition[Internet] Available from: http://techterms.com/definition/access
8. FMS World Class Software Solutions[Internet] Available from: http://fmsinc.com/microsoftaccess/dataanalysis/versus-excel.html
44
Thank you for attending!
Please write down your CE secret code.
All ACPE credit must be claimed online no later than November 20, 2015.
See Seminar Program Book for details.
Top Related