Reissues galore…

1. Reissues galore… An effort to find missing scheduled doses – before they are missing. Amanda Johnson and Kim Miller Wednesday, December 1, 2010PHARM 5812: Implementing Healthcare Innovations

2. Current Condition Analysis • Hospital Pharmacy • One manager and several current staff members were interviewed • Individually • Different times • Process observation was also completed at this time • Observing work flow

3. Leadership Positive Negative Formal vision* Provide tools/resources Staff perception that leaders are transparent* • Stable formal leadership* • Innovation implementation* • Blame* • Available for help? • Leader-leader relationships • Clear staff expectations • Informal leadership • Consistent leadership styles *given score of highest or lowest

4. “If you keep throwing your department under the bus all of the time, you just get fired.” - Formal leader

5. Organizational Culture Positive Negative Conflict* • Decision Making • Power • Relationships • Learning *given score of highest or lowest

6. “Everyday’s like Christmas, you never know what you are going to get.” - Staff member, on relationships

7. “Relationships have power.” - Staff member, regarding power

8. “If you’re working after someone who is mad at you, watch out…they will give it to you good.” - Staff member, regarding conflict

9. Performance Measurement Positive Negative Transparency* • Adaptive to changes in envrionment • Collection of data during course of work* • Meaningful measures • Systematic internal learning system • All staff know about and use system to improve work *given score of highest or lowest

10. Performance Measurement

11. Performance Measurement

12. Internal Learning Positive Negative Follows 4 Rules of Use Established “ideal” • Established internal learning system in all of its work and improvements

13. Internal Learning

14. External Learning Positive Negative System to identify when additional training is needed • Established plan for ongoing staff development • Comprehensive training • Differentiate knowledge from skill • Staff finds training relevant and effective

15. Scientific Model Positive Negative Applies interventions that are scientific and provided with fidelity • System has a method for identifying new science for application

16. Overall Scores

17. Overall Score Justification Positive Negative No overall vision Conflict Non-transparency Short staffing Physical layout (no common med room, poor medication storage containers) Management open to trying new things Poor staff training/ongoing learning opportunities • Positive relationships • External learning (especially for pharmacists) • Internal learning for quality improvement • High potential for adaptive environment • Use of power (not coercive, expert used often)

18. The Problem: Missing Scheduled Doses • Missing schedule doses on units with several possible sources of system flaws • Churchill WW et al. study (1988) • Reason identified: 170/227 of missed doses • 13.3% were pharmacy generated • 45.8% were nursing generated • Grabowski B. (1987) • Dispense doses needed using a medication request form • Allows problems to be quantified and resolved • Adelman DN. (1982) • Used computer system with simple data entry and uninterrupted processing. • Found that number of missing medication doses reduced by 36.8% • NOTE: All resources found date back at least 22 years ago.

19. Potential Obstacles to Successful and Consistent Drug Delivery • Physical layout • Lack of physical space to implement new delivery and storage processes • Poor delivery process • Inconsistently delivering medication to proper location where the nurses expect to find it • Pharmacy inconsistencies • Medication orders not being filled • Drug not in stock • Drug was not ordered • Did not communicate that drug could not be obtained • Poor communication with nursing staff • Nurses “borrowing” medications from other patients

21. Vision • No formal vision for entire health care structure OR pharmacy department • No way define success • No way to work towards common goals • New proposed vision: Increase the quality of patient care by having no scheduled missing doses. • Ideal: If the medication is ordered, it should be always available to the patient on time.

22. Implementing an Innovation • Update current reissue process • Current process: • Nurses can send “request” to pharmacy • Request initiates label reprinting • Order filled and delivered with next scheduled delivery • Nurse may also phone requests into pharmacy • New process: • Nurses must send hard copy reissue (no phone calls!) • All reissues sent to one printer located in the pharmacy • Follow current process of generating label and filling medication

23. Implementing an Innovation • Designated “Service Recovery Technician” (SRT) responsible for delivering missed dose • Must give medication directly to nurse taking care of patient • SRT investigates source of missing dose • Look on unit, review history on patient’s profile, search medications waiting to be delivered • Fill out service recovery form, timestamp it, and staple it to the initial reissue request • Forms will be collected in a central location in the pharmacy

24. Sample Service Recovery Documentation Form

25. How to follow up… • Collect service recovery forms daily • Look for common obstacles in the medication filling, delivery • Implement new processes to avoid common process errors • Re-evaluate new process regularly • Run pilot on one unit • Collect perceptions and feedback from staff in “real time”

26. Additional Measures to Prevent Missing Doses • Medication storage on unit • Central location for all medications • Two envelopes per patient • (1) Daily medications • (2) New medications, delivered by technicians throughout the day • Continue to collect meaningful feedback in real time • Better communication with nurses • Speak with nursing directors, charge nurses on best ways to prevent missing doses • Collect staff feedback • Pharmacists, technicians

27. What we have learned.. • Hard to understand both leadership and staff perspectives • Difficult to get facts on current condition without personal bias • Hard to get to true root of problem, especially in short amount of time • Difficult to envision ideal when so many confounding problems (i.e. staff shortage)

28. References • Churchill WW, Gavin TJ, et al. Source of missing doses in a decentralized unit dose system: a quality assurance review. HospPharm. 1988 May;23(5):453-6. • Grabowski B. Missing medications in a unit-dose system: quality assurance. Hosp Pharm. 1987 Jul;22(7):679-80. • Adelman DN. Reducing the number of missing doses with the aid of a computer system. Hosp Pharm. 1982 Apr;17(4):195-6, 199.