Transcript Who is HCA?
Re-Engineering Medication Processes to Capitalize on Technology Jane Englebright, PhD, RN Vice President, Quality HCA Who is HCA? U.K. % %% % Switzerland %% % % % % %% % % % % % %%% % % %% %% % % % %% %% %% % % % %%% %% %%%% % % % % %%% %% % %% %% %%%% %% % % %% %% %% % % %%% % % % %%% %% %%% % % %% % % % %% %%%%% % % %% %% % % % % %% % % % %% % % % % %% % % % %%% %% % % %% % %% % % %% % %% US 176 Hospitals 92 ASC’s in 22 States INTERNATIONAL 8 Hospitals Institute of Medicine Reports on Medical Errors • 44,000 to 98,000 deaths/year • 8th leading cause of death in US • Provocative Statements: First Report: December 1999 – Most errors are caused by system failures rather than human error – All manual processes are subject to error – Many error reduction efforts do not take advantage of information systems • Conclusions – Status quo is not acceptable – 50% reduction of error over next 5 years HCA Patient Safety Goals • Establish patient safety as a visible commitment to putting patients first philosophy • Move from blaming people to improving processes • Improve use of technology to prevent and detect error • Use data to identify and measure improvements HCA Patient Safety Initiatives Bring Evidence-Based Patient Safety Practices to HCA Facilities to Address Areas of Concern for HCA Medication Safety Initiative EvidenceBased Patient Safety Practices: IOM Report ISMP Bates Areas of Concern for HCA: IOM Report Each HCA Facility Implements EvidenceBased Patient Safety Practices in Areas of Concern for HCA The Medication Safety Initiative Included: Rank Order of Error Reduction Strategies HCA Technologies Forcing Functions & Constraints eMAR ePOM Automation & Computerization Standardization & Protocols Checklists & Double-Checks High Risk Med Protocols Practice Guidelines Competencies Policies & Procedures Education & Information Awareness & Education Errors resulting in ADEs 6% 4% 42% intercept 0% intercept 34% 56% Bates DW et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995;274:29-34. Ordering Administration Transcription Dispensing Electronic MAR & Bar Coding eMAR Safety Features • Validates “Five Rights” of Medication Administration • Requires patient specific clinical data for certain medications (i.e, pulse rate prior to administration Lanoxin, review of potassium level before giving Lasix). • Sends a warning to alert nurse when the dose is to much or to little, or if the dose is being given to early or to late. • Single “source of truth” for patient medication status. HCA Clinical Information Systems eMAR & Bar Coding Deployment 172 Sites in 5 years eMAR & Bar Coding: (Company-wide Results-Year 2005) 115,933,163 Doses administered in 171 hospitals • 2,913,018 Error warnings • 2,121,315 Doses not given after warning Averted Errors eMAR Implementation • An interdisciplinary Steering Committee was responsible for planning; implementation; staff and physician education and management of any issues. Bar-coded Patient Armbands Electronic Safety Checking Bedside Verification Bar-coded Medication Doses Electronic Medication Administration Record & Charging Expected Outcomes • Fewer medication administration errors • More complete documentation • Staff perception of improved safety • Patient perception of improved safety • Improved accuracy of billing Measurement Plan: Understanding the Impact Medication Administration Errors •Incident reports •Avoided errors •Stories Completeness of MAR Chart audit Accuracy of Charges •Chart audit User Perception of Improved Safety •Survey Pharmacist and Pharmacy Tech Perception of Workload Changes •Survey Armband Audit Technology Change Process Change Culture Change HCA Patient Safety Implementation Model eMAR Works in Three Ways Blunt End Policies, procedures, resource allocation systems Process Redesign Direct Sharp End caregiver Monitored Process Clinical Decision Support Reports Results Project Timeline 6 – 7 months per hospital PreAssessment Kick Off Barcoding Meds, Hardware, Dictionary Changes, Testing Post End User Implement Training Support Go Live Project Workload: Fluctuations over 6 months 120 100 80 IT&S RT Nursing Pharmacy 60 40 20 0 1 2 3 4 5 6 Implementation Activities: Culture • Executive Walk-Arounds • “Do No Harm” video • “Verification” not “Scanning” • Patient Safety Principles: Double-Check Implementation Activities: Process • Functions Most Impacted . . . . – – – – – – – Nursing Pharmacy Respiratory Care IT&S HIM Finance Quality & Risk Process Re-Design • Develop a workflow study of the actual steps in the medication preparation and delivery process at your facility • Start at the patient and work backwards • Include Nursing, Respiratory Therapy, and Pharmacy Nursing Impact • Model of care delivery – Who do you want to give medications? • Medication distribution system – How do medications get from the pharmacy to the bedside? Pharmacy Impact • Accuracy and timeliness of order entry and turn around • Bar Coding ALL medications • Medication acquisition philosophy • Override policy adherence Creativity “Wire Tie” Respiratory Care Impact • Workflow: Sequential vs Concurrent Therapy • Scheduling of medication administration • Medication storage and distribution • Clear accountability for medication administration • Non-standard medication preparations • Order acknowledgement processes IT&S Impact New Member of the Clinical Team • WLAN Installation and Support • Computer Management • Equipment Maintenance, including pharmacy equipment • Downtime Processes HIM Impact Single MAR for each admission • Incorporate into discharge printing process Finance Impact Move to billing on Administration instead of billing as Dispensed • Improved Audit accuracy • Improved Charge capture • Decreased paybacks from insurance audits Quality & Risk Impact • Explaining it all to the Surveyor – Averted errors = Near misses – Areas with 100% utilization rates can have zero medication administration errors • Preserving Quality Control Activities – Order Acknowledgement – Chart Checks Practice Recommendations Infection Control Recommendations – Carts should be cleaned at least daily with hospital approved disinfectant – Carts may be used in isolation rooms – Carts should be cleaned before leaving the room if contaminated and when used in isolation – Patient Safety equipment can be safely used in all patient care areas – exception: Known SARS or Small Pox Pediatric/NICU Recommendations – Identify armband solution – Newborn Pre-registration Processes – Unit dose medications – Bar code identification of Breast Milk and documentation of feeding Psychiatric Recommendations – Don’t take the scanner into seclusion – Consider alternative form factors for scanners – Unit dose medications – Special armband needs Implementing eMAR • Roll out in waves • Bring up first 1 or 2 units – First unit that mostly discharges patients – Maintain for 1-2 weeks – Troubleshoot and resolve issues as they arise • Roll out remaining units quickly in related waves • Turn on Admin Billing Project Risks • Packaging and labeling errors in pharmacy • Changing federal regulations • Emerging barcode symbologies • Invalidating bedside verification with workarounds eMAR & Bar Coding Accountability Structure Executive Sponsor Frank Houser, MD Quality Vice-President Jane Englebright, PhD, RN Patient Safety IT&S Software Testing Support Development Operations Sponsor Charlie Evans Eastern Group President Patient Safety Team Leaders Quality, IT&S D&C, Risk, Communications Corporate CNO Council Business Owner Alicia Perry, PharmD Patient Safety eMAR Advisory Board Facility representatives Corporate SMEs Division CNO Workgroup Responsible Executive Facility CNO Patient Safety Specialist Manisha Shah, RRT Patient Safety IT&S Implementation Team Implementation Coord Equipment Ordering eMAR Coordinator CNO appointed role HCA Corporate Quality HCA IT&S Organization Advisory Groups Operational Accountability Structure Getting Staff to Use the Technology • “How is this going to help me do my job better?” • “Why is this necessary?” • “I didn’t go to school to become a computer genius!” • “I guess this keeps somebody employed!” • “Just when I thought I had myself organized, they come up with something new!” Answering the “Why?” • Keep the team engaged. Be patient as many do not adapt to change readily • Communication…e-MAR benefits vs. expectations • Focus on patient knowledge and patient safety • Ongoing involvement of core team • Keep the team focused on Patient Safety as a priority goal “Get it Right” • • • • • • • Equipment Analysis Pilot FIRST!!!! Communication Training/Education Troubleshooting Plan Competency Ongoing unit based resources Leadership Strategies • Staff Meetings • PATIENT SAFETY STRESSED • Expectations clearly communicated again • Non-compliance outcomes discussed • Accountability • Mandatory Education & Competency Assessment • Regular monitoring of usage reports • Prompt follow-up on negative usage patterns Leadership Makes a Difference Results from pilot hospital: • Usage STATS improved within one week of implementing accountability plan. • No formal disciplinary measures were required. • Satisfaction scores improved!!! Goal 90 – 100% Results • Averted Errors • Usage • Staff Perception First & Second quarter summary reports Malpractice claims related to medication administration have decreased by 16% Pharmacy Perception Survey I believe use of the eMAR and bar coding system is reducing medication errors in my hospital. 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Very Satisfied Somewhat Satisfied Satisfied Dissatisfied Very Dissatisfied Novice Staff Rely on e-MAR! • Pt. history - allergies etc… • Lab link • Reminder to document BP/HR/Pain Scale • Checks and balances • Look alike sound alike drugs… • Unusual doses flagged • Realistic expectations eMAR Maintenance Work • Software • Equipment • Culture transformation • Process change eMAR & Bar Coding • The Way We Do Meds at HCA – Single point of accountability within each hospital to assure optimal ongoing operation – Corporate eMAR Advisory Committee to address Culture-Process-Technology issues – Regular division meetings – Monthly conference calls/Quarterly web casts for sharing best practices and enhancements … the way we do things www.hcapatientsafety.com