Transcript No Slide Title

Manager Toolkit for the Medication
Administration Process
Optimizing Medication Administration Project
7/31/09
August
September
I
October
C
December
January
A
Phase 2
Progress Since Last Update
Overview
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Linkage to BPE/BP/EFP: Safe and without error
- Process finalized and approved by practice committee and medication safety committee (see
attachment A)
- Policy modified (see attachment B)
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Problem: The current medication administration process is inefficient and prone to error.
The current process requires many work steps (total process takes over 8 minutes) and
multiple interruptions that cause workflow constraints and nurses not consistently verifying
the “7 rights.” (right drug, patient, dose, time, route, rationale, documentation) As a result,
there is a greater risk for medication errors. Further, our HCAHPS scores for
communication regarding medication was at 58% “top box” in FY2008 (baseline).
Goal/Benefit: Implement a standardized medication administration process which
eliminates inefficient work steps, minimizes interruptions, prompts less log-ins, and
improves bedside documentation in an effort to better use real-time information related to
the 7 rights of medication administration, reduce errors, improve nurse productivity, and
improve patient satisfaction scores to 59%. Phase 2: implement technology to enhance
process
- Education plan developed (see attachment C)
- Sustainability (Control) plan developed (see timeline and attachment D)
- Communicated policy changes and education plan to chairs of respective committees
Next Steps
- Practice to approve policy (August 4th)
- Education to approve roll-out plan (August 4th)
- Education plan presented to managers (August 5th)
- Workplan and expectations, Tools, Resources, Manager accountability plan
- Policy roll-out (August 31st)
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Scope: Full house roll-out.
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Deliverables:
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A safer and more efficient medication administration process
Decrease in medication errors
- Quality Council to approve reg review additions (Sept 1st) (see attachment D)
- Podcast out (September- Date TBA)
- Unit to complete observations using paper form (September)
- Unit to complete observations via regulatory review (October-ongoing)
- DMAIC team to conduct staff interviews (September and October)
- Staff to complete survey monkey (November- early) (see attachment E)
- DMAIC team to f/u re: survey monkey results (November- late)
Key Metrics
• Total medication errors
• Number of near misses
• Medication administration time
• HCAHPS Communication Regarding Medication Scores
Issues/Concerns/Roadblocks
Education must reach staff by August 31st
Contingency Plan– Check in meetings with managers (A/D/R)
Adherence to expectations for non-compliance
Executive Sponsors: Janney/Fennessy/Zoph
Sponsors: Payson/Dejuras//Jacobsen
Project Owners: Ashley Currier, Denise Anderson
Improvement Leader: Ryan Inlow
Medication Administration Process Implementation
Manager Workplan
August
2009
Education
(All RNs)
6th-31st
check in with
manager
from team
(Ashley,
Denise and
Ryan)
25th
Policy
in
effect
31st
September
2009
October
2009
Observations by units
and DMAIC team
(*use observation form)
November
2009
December
2009
Observations submitted via the regulatory review
*ongoing—5th of every month*
Unit check-in sessions with staff
F/U with units re: regulatory review data
(Ashley, Denise and Ryan)
(Ashley, Denise, and Ryan)
Manager & leadership
best practice
discussion sessions
(optional—dates TBA)
Encourage Staff to view
Sept. podcast
Implementation Phase
2010
Survey Monkey
to staff
(re:
interruptions
check in)
Date TBA
F/U with units
re: survey
results
(Ashley, Denise
and Ryan)
Unit check-in sessions re:
action items from survey follow up
(Ashley, Denise and Ryan)
Launch
Phase
2
(potential
technology
enhancemen
ts/barcoding)
Control Phase
Education Roll-Out Plan
• Attend Manager meeting to discuss
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New Policy changes (Main policy and Appendix D)
Expectations of manager to assist with education (using toolkit)
– Copy of Policy *changes highlighted
– Copy of Appendix D *modified
– Talking points for managers
– Changes to highlight
– Expectations to discuss
– Observation and reg review plan
– Case Study ELM (in place of September M and M—tentative)
– Interruption/distraction action item reminder and follow-up plan (survey)
– Job Aid and Badge cards
Incorporation of observations into regulatory review
– Observation form distributed
Unit check-in sessions (completed by DMAIC team)
Manager/leadership help sessions (coaching or observation assistance)
Survey Monkey out to staff re: interruptions/distractions check in
Staff Survey
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Control Phase
Surveys will be completed by staff to acknowledge interruptions
that are still occurring and the impact of these interruptions
Survey questions include:
In the past month:
– My patients have had water at the bedside and available for medication
administration.
– I have had the dietary supplies that I need to administer medications.
– I have had the medications available from the pharmacy.
– I have minimal interruptions from the care team while passing medications.
– The computer at the bedside was operational and ready to use during medication
administration.
– I have not been interrupted by the patient to attend to care needs such as turning,
cleaning up or assisting to the bathroom during medication administration.
– I have the equipment I need to administer medications such as infusion pumps and
data scopes.
These results will be reviewed with the units and/or DMAIC team
and action items will result