Transcript Concepts in Measurement for Hospital Based Pharmacies

Concepts in Measurement for
Hospital Based Pharmacies
• Michael R McDaniel, R.Ph., MBA, FASHP
• Director of Pharmacy Services
• Huntsville Hospital, Huntsville, Alabama
About Us
• Huntsville Hospital
o
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o
o
941 beds
40,000 discharges
80,000 adjusted discharges
525 ADC
180,000 outpatient visits
• The Pharmacy
o Inpatient pharmacy – 142 ftes
• Oncology satellite off campus
• Main pharmacy
• Women’s and Children’s pharmacy
o Outpatient pharmacy, retail based – 3 sites, 8,000 monthly Rx’s, 20 fte’s
o Automation
• Pyxis 4000 – 160 locations (includes OR)
• PhACTS carousels – 2 vertical and 2 horizontal
• Health Robotics (Aesynt) IV Station and IV Soft Assist
What are we going to
cover?
• Measurement
o Financial
o Operational
o Productivity
• Tools
o Use of spreadsheets
o Use of MS Access
• Data
o How to collect
o How to manage
• Concepts
o Analyzing
o Sharing
Why Measure?
• Measurement is a vital management necessity
• Without measurement
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You don’t know where you are
You don’t know where you are going
You don’t know if you’ve arrived at a goal
You can’t set realistic goals
• Without measurement you can’t respond to perceptions
from others accurately
• Without accurate measurement you can’t hold others
accountable
• Measurement allows you to hear the “voice of the
process” and take appropriate measures
• Measurement is integral to the process improvement
journey
• Measurement is the GPS for any organization
Foundations
Pharmacy
Technician
Driven
The Four Core Processes
Product Procurement, Storage
and Preparation Process
Drug Distribution Process
Order Review Process
Clinical Process
PHARMACY
Departmental Focus is to Serve
Patients
Nurses
Physicians
In all things - SAFETY
Technician
Driven
Pharmacist
Driven
But this is what pharmacy looks like
to an administrator!
Pharmacist
Driven
Landscape
• From the data sources mentioned we have created
a variety of MS Access 2010 databases, many of
whom talk to each other (relational)
• Data is imported from the sources monthly
o Electronic data acquisition is easier and more reliable than manually
collected data
• Reports are synthesized from the data
• When necessary data from more than one sources
is used
• MS Access allows linking data in different databases
thus allowing you to leverage the utility of the data
Roadmap
• Productivity
• Financial
• Operational
Productivity
• External Measurement
o Solucient
o Lazarus Report
• Internal Measurement
o Work
o Man-hours
o Ratios
• Per location
• Per patient volume
• Locations
o Main Hospital
o Women’s and Children’s Facility
o Madison Hospital
• Pharmacist vs. Technician measures
External Benchmarking
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•
Same data as the standard
report, but presented in a
different fashion for the
audience I intend to have
receive it.
Highlights two key features
both visually and with data
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•
At the bottom of staffing
7th percentile against a system goal
of 25th percentile
This particular quarter was much
lower than normal, we are usually
around the 15th percentile
Simpler format than the native
report
I know this does NOT help
those of you at the 80th
percentile!
External Benchmarking
The Lazarus Report
Huntsville Hospital Staffed Beds
Community - Percentile
25%
50%
75%
Component
2013
Pharmacists
Technicians
Administrative
Residents
Total
Variance
FTE Variance
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•
6.3
6.2
1.2
0.6
13.6
-4.2
-33.81
7.9
7.5
1.7
0.9
18.0
0.2
1.23
HH
8.6
8.2
1.0
1.0
17.8
-144.5
Staffing
69
65.47
7.9
8
Two benchmarking tools allow you to see the “rest” of the story
Here we can see how we compare against true “community” peers
versus true “University” hospitals
Allows a “reality” check and keeps us grateful for the Solucient peer
group
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5.0
4.8
0.8
0.5
11.1
-6.7
-53.97
University - Percentile
25%
50%
75%
800
7.6
8.7
10.0
7.1
9.3
11.4
0.9
1.3
1.7
0.7
1.3
2.1
16.4
19.4
25.2
-1.4
1.6
7.4
-11.01
12.43
59.15
As a very large and complex non-academic community teaching facility we don’t neatly fit into a
“standard” group
There are very few non-academic teaching facilities our size
Helps keep us mindful of what data an external consultant might
present us with
External Benchmarking
• This is about the extent of my external benchmarking work
• Solucient does not play a very active role in our staffing
maintenance
• This may not be the same for you
• My experience in my 3 large facilities where I’ve served as
a Director has been that internal productivity measurement
have been more important to my daily life as a manager.
• The keys to surviving external benchmarking are:
o
o
Have the right compare group
• Our compare group are large, highly complex facilities which, except for
our lack of a solid organ transplant program, I feel we compare very well to
Have the right workload benchmark
• CMI Adjusted Discharges – better
• Doses - worse
Internal Productivity
Monitoring
• Provides intelligence as to
o
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o
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The work actually done
How many resources this work consumes
Who is doing it
And how this all changes over time
• Internal productivity monitoring is vital to
o Assess reality vs. perceptions on
• Administration’s point of view
• Pharmacy Leadership’s point of view
• Staff’s point of view
• Allows you to assess the appropriateness of moving
resources from one function to another
Internal Measurement
Internal Measurement
Internal Measurement
Internal Measurement
Internal Measurement
•
•
This data allows us to examine our allocation of resources for
internal process improvement efforts
It also positions us with data to counter or confirm the
recommendations of external consultants should that day come
Internal Measurement
• Drill down
capability is
needed for the
“next question”
• This report drills
into our clinical
activity
• Allows us to
quickly find
what we are
spending our
time on
Internal Measurement
• Another drilldown
allows us to
review overall
clinical activity by
individual
pharmacist
• Its important to
look at the
opportunities
each pharmacist
has to avoid an
apples to
oranges
comparison
Internal Measurement
•
•
•
•
Another angle on
individual clinical
productivity
These two reports are
used by the respective
supervisors to monitor
clinical productivity
The trends can be
interesting
Fun to watch new
pharmacists emerge out
of training and gain
experience and
confidence
Internal Measurement
• Yet another
level of
drilldown
• We can review
the different
types of work
done, including
clinical activity
• We can also
contrast the
various job
classes against
each other
Roadmap
• Productivity
• Financial
• Operational
Financial Measurement
• Financial analysis for
many of us means
explaining drug budget
variances
• Many variables affect this
number
o Inpatient volumes
o Outpatient volumes
o Patient mix
• Length of stay = more
doses delivered!
Financial Measurement
• I’ve found that some of
my most expensive
patients are outpatients
o Oncology
o IVIG
o Specialty drugs
• Monitoring the ratio of
inpatient discharges to
OP visits helps me detect
an increase in the
potentially high cost
outpatients
Financial Measurement
• This report details the
use of IVIG for a 5
quarter period
• From this I can see
where the IVIG was
used, Inpatient vs.
Outpatient
• This is valuable for
340B hospitals and to
pick up changes in
utilization between
these two classes
Financial Measurement
• From the same set of
data I can see the
trend over time
• Our patient volumes
related to IVIG have
declined
Financial Measurement
Net Drug Spend
$45,000,000
$40,000,000
$35,000,000
$30,000,000
$25,000,000
$20,000,000
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
• This “ugly” graph of
our drug spend
trend shows our
unadjusted drug
spend since 2005
• As Superman would
say “Up, up and
away!”
• What this shows is:
o Significant IP growth
o Significant OP growth
o Huge increase in IVIG
volumes
• But what is
happening now?
Financial Measurement
90,000
160,000
80,000
140,000
70,000
120,000
60,000
100,000
50,000
80,000
40,000
60,000
30,000
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Fiscal Year
Outpatient Episodes
Discharges
Adjusted Discharges
Discharges / Adjusted Discharges
Outpatient Episodes
Patient Volumes
180,000
• Volume adjustments
can make a HUGE
difference
• Here is what our
volumes look like,
probably much like
yours
• Inpatient volumes
show the impact of
the recession
• Outpatient volumes –
through the roof for a
while, then co-pays!
• Adjusted discharges
remain healthy
Financial Measurement
$140
$120
$100
$80
$60
$40
Cost per OP Visit
Cost per Discharge
Drug Expense per Statistic
$700
$650
$600
$550
$500
$450
$400
$350
$300
$250
$200
$20
$FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Period
Calc'd Inpatient Cost Per Disch
Calc'd Cost per Adj Disch
IVIG
Oncology
Calc'd Outpatient Cost Per Visit
• So after volume
adjustments the drug
spend trend is a little
clearer
• You can see the
impacts as outlined
below (primary drivers,
not exclusive)
• Drug shortages also
figure in
• Adjusted discharges
have fluctuated in a
narrow range since
2010
• To what do we owe
this latest upsurge to
Financial Measurement
Pharmacy Drug Spend Trends Analysis
Component
FY 14
FY 15
Delta Prior Year
Anti-Infectives
$ 7,038,556 $ 7,691,636
9.3%
Antineoplastics
$ 2,642,882 $ 3,320,128
25.6%
Autonomic Drugs
$ 1,578,237 $ 1,662,600
5.3%
Blood Products
$ 6,404,431 $ 6,655,548
3.9%
Cardiovascular
$ 1,143,689 $ 1,430,180
25.0%
Central Nervous System $ 3,441,326 $ 3,265,620
-5.1%
Gastrointestinal
$
993,639 $ 1,026,592
3.3%
IVIG
$ 6,235,010 $ 5,921,416
-5.0%
Other Pharmaceuticals
$ 6,657,142 $ 9,232,544
38.7%
Storeroom
$ 1,199,361 $ 1,221,368
1.8%
Unclassified Therapeutic $ 2,846,375 $ 3,381,476
18.8%
Totals
$ 40,180,648 $ 44,809,108
11.5%
Adjusted Discharges
79,404
82,192
Anti-Infectives
$
88.64 $
93.58
5.6%
Antineoplastics
$
33.28 $
40.39
21.4%
Autonomic Drugs
$
19.88 $
20.23
1.8%
Blood Products
$
80.66 $
80.98
0.4%
Cardiovascular
$
14.40 $
17.40
20.8%
Central Nervous System $
43.34 $
39.73
-8.3%
Gastrointestinal
$
12.51 $
12.49
-0.2%
IVIG
$
78.52 $
72.04
-8.3%
Other Pharmaceuticals
$
83.84 $
112.33
34.0%
Storeroom
$
15.10 $
14.86
-1.6%
Unclassified Therapeutic $
35.85 $
41.14
14.8%
Totals
$
506.03 $
545.18
7.7%
• By tracking all of our
medication purchases
by their AHFS class,
and grouping these
classes into “mega”
groups we can start to
drill into where the
changes are occurring
• Anti-neoplastic,
cardiovascular and
Other Pharmaceuticals
really stand out
Financial Measurement
• Drilling down into
“Other
Pharmaceuticals” we
find that the AHFS
category called
Enzymes is up the most
• This report shows the
activity for the same
time period
• Idursulfase is the
winner
Financial Measurement
• We find the spend
pattern for idursulfase
• Very consistent usage
• Checking our charge
history we find this one
drug is used by just one
patient
• This is becoming an
increasingly common
occurrence
Financial Measurement
• Take a step back and
look at the macro view
every now and then.
• Adjusted for volumes,
pharmacy has been
very flat over the past
several years
• This is a GOOD thing
Financial Measurement
• Worked and paid
hours are a focus
• In this environment, the
flatter this line, the
better!
• The statistic is adjusted
discharges
Roadmap
• Productivity
• Financial
• Operational
Operational Measurement
• We have to
balance our
staff between
two buildings /
pharmacies
that function as
wildly different
facilities
• Adult – intensive
care
• Pediatric
intensive and
women’s care
Operational Measurement
Period Ending 3/31/14
Pharmacy Adjusted Discharges
CMI
CMI Pharmacy Adjusted Discharges
Scheduled Hours Pharmacists
Scheduled Hours Technicians
Total Worked Hours
Per CMI Pharmacy Adjusted Discharge
Main
22,941
1.9297
44,268
43,451
32,752
76,203
1.72
W&C Madison
12,307
2,756
0.8976
1.1219
11,046
3,092
9,963
17,218
27,181
5,643
2.46
1.83
• This data helps
to analyze the
balance
between our
shared facilities
• W&C is “overstaffed” due to
its heavy
pediatrics
volume and
complexity
Operational Measurement
• Pyxis is a huge
job for our
technicians
• We keep a
close eye on
what it takes to
feed the
monster!
Operational Measurement
• We have a
variety of
reports we can
use to monitor
this process
• This report looks
at the resource
requirements for
each location,
each day
• This can serve as
a baseline for
PDCA efforts
Operational Measurement
• This report
allows a more
macro view of
the Pyxis
environment
Operational Measurement
• We monitor our
carousel traffic
as well
Operational Measurement
• We track the
utilization trends
• Can you guess
when our big
Pyxis batch is
run?
Operational Measurement
• This is an
example of a
daily carousel
detail report
looking at:
o Pyxis batch data
o Receiving
o Ins and outs by
location
o Activity by type
• Gives good
insight into the
carousel
Operational Measurement
• One of the
things we
measure for
order review is
orders per hour
• We do this by
facility and by
day of week
Operational Measurement
• We can drill down to the individual pharmacist and
by shift
Operational Measurement
• Another
interesting
macro view
over time
• Measures the
total orders
processed per
discharge for a
given month
In Closing
• Much of this data, when appropriate, is shared both
internally and externally
o Internally to monitor our processes and lay a foundation for improvement
o Externally to answer various questions about financial or productivity
performance
• The relative quickness and ease of our responses
externally gives a strong impression of “being on top
of things” or “being in the know” which are
important confidence builders in administration’s
eyes
• This data allows for the building of comprehensive
and accurate business plans
In Closing
• Look for data that already exists, capture it, and put
it to work
• Be judicious in performing manual data collection
o It is work in its own right
o It can be hard to do accurately
o But sometimes it must be done
• Data never lies, but it can mislead!
o Look for the larger context
o Try to use at least 2 points of view before coming to a conclusion about
what data is telling you
• Manage and manipulate the data carefully, but
recognize that most data is worthless until properly
managed or manipulated