Download Who is HCA?

Re-Engineering Medication
Processes to Capitalize on
Technology
Jane Englebright, PhD, RN
Vice President, Quality
HCA
Who is HCA?
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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