14-d - medina, kolesnik - streamlining operations through ...€¦ · streamlining operations...

3/12/2015

2015 NHIA Annual Conference & Exposition 1

Streamlining Operations Through the Use of Technology

Alexis Kolesnik RN MSN, Care Team LeaderJefferson Home Infusion

Rowell Medina PharmD, Clinical Infusion PharmacistJohns Hopkins Home Care Group

Disclosures

The speakers declare no conflicts of interest or financial interest in any service or product mentioned in this program.

Clinical trials and off‐label/investigational uses will not be discussed during this presentation.

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Definitions• Process Improvement: a method to introduce

process change to improve quality of a product or service, to better match customer and consumer needs

• Waste: anything other than the minimum amount of equipment, materials, parts, space and time which are absolutely essential to ass value to the product

• Resource: a place or thing that provides something useful

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Identify the Problem

Brainstorming Session– How are things done now: “As-Is”

– What process needs improvement?

– What are the requirements for the “to be”?

– Stakeholders

– Where is the waste?

– How are resources utilized?

WHAT METHOD WORKS FOR YOUR ORGANIZATION?

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Performance ImprovementMethods

• PDCA (Plan Do Check Act)

• Needs Assessment

• Lean & Six Sigma

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FOCUS-PDCA

Useful tool to guide and direct simple and complex process problem solving activities

Ask yourself……

What should this process look like if it were perfect??

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FOCUS- PDCA Stages• Find a process to improve

• Organize a team that knows the process

• Clarify current knowledge of the process

• Understand cause of process variation

• Select the process to improve

• Plan the improvement

• Do data collection, analysis and improvement

• Change data for process improvement and customer outcome

• Act to hold, gain and continue improvement

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Needs Assessment• Process for examining and framing people related

problems and performance improvement (PI) opportunities

• Initiated in response to a problem, opportunity or an ongoing learning or PI effort

• Compare current to desired condition• Focus:

– On a single individual– Job function– Entire organization– People related problem or PI

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Lean

• Most frequently used quality improvement approach

• Lean thinking was developed by the Toyota Motor Company

• Operations within an organization are categorized into 3 types using Value Stream mapping– Non Value added (NVA)

– Necessary but Non-Value added (NNVA)

– Value added (VA)

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Value Stream MappingIdentifies waste within the organization

• NVA: pure waste and involves necessary actions which need to be eliminated– Example: waiting times

• NNVA: wasteful but necessary under current operating procedures– Example: driving to pick up supplies from office

• VA: operations that involve production or implantation of raw product or service– Example: compounding pharmaceuticals or direct nurse-patient care

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Six Sigma

• Six Sigma originally was developed at Motorola, then championed by General Electric (GE).

• Focus is to identify the customers’ definition of quality and then develop a process that consistently produces a high quality error-free product.

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Lean vs. Six Sigma

Image credit: http://www.bpminstitute.org/resources/articles/integrating-lean-and-six-sigma

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Two separate entities, yet combined for a single approach:

Lean Sigma

• Focus on measuring and eliminating errors (Six Sigma) and ensuring an efficient work flow and value added (Lean)

• Measuring and maintaining process performance while recognizing the importance of maintaining a culture that supports rapid continuous improvement

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Visual Tools

• Value Stream Map

• Swim Lane Process Map

• Fishbone Diagram

• Spaghetti Diagram

• Descriptive Statistics

– Box plots, histograms, charts, etc

– Continuous data vs. categorical data

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Potential Solutions

• Multidisciplinary team

• Key process improvements

• Detailed and thorough

• Problem or root cause

• Timeline

• Communication

Dutton, Emma K. "Root Cause Analysis: Why Blaming the Individual Misses the Point." Web.Garrett, Rhonda. "Is Your Company Solving the Right Problems?" IndustryWeek. N.p., 1 July 2014. Web. 15 Nov. 2014.

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Monitor & Sustain

• Compare and contrast

• Audit results (good & bad)

• Cost benefit

• Sustained improvements

• Control plan

EVERYONE IS RESPONSIBLE

Garrett, Rhonda. "Is Your Company Solving the Right Problems?" IndustryWeek. N.p., 1 July 2014. Web. 15 Nov. 2014; and Piatt, Jason. "Five Keys to Effective Operational Problem‐Solving." IndustryWeek. N.p., 26 Feb. 2013. Web. 15 Nov. 2014.

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Control Pyramid

Image credit: http://9001quality.com/records-control-procedure/173/12/15

E-mail Calendar System

Efficient Management of Patient Deliveries & Productivity Tracking

Rowell (Ro) Medina, PharmDJohns Hopkins Home Care Group

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Background

• Four teams– Disease state (3 adult teams)

– Age (1 pediatric team)

• Consists of– Pharmacist: clinical management

– Clinical Technician: supply & delivery management

• Electronic charting

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Previous State

• “Paper and pencil” scheduling

• Two calendars per team (RPh & CSR)

• Morning & afternoon rounds

• Unable to view workload or track progress

• Difficult to forward patients causing higher risks for missing deliveries

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Brainstorm

• Microsoft Outlook Calendar– Current E-mail system

– Secured & HIPAA compliant

– “LIVE”

• Separate calendar per team

• Use of appointments (30 minute blocks)– Notes

– Color coding

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Creating the Calendar• Outlook administrator creates a group outlook

account with a universal name (JHHCG_Infusion_Team)

• Create calendar(s) with custom names

• Define colors to match action items (within appt)

• Account administrator adds users to the group outlook account via Address Book

• Each user installs the group outlook account mailbox via Account Settings

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Use of Appointments

**Each appointment block represents one

patient delivery**

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Patient 1

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Patient 2

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Calendar Tools

• Color-code– Patient delivery list

– RPh “To-Do” list

• Track progress of each patient delivery

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Start of the Day

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Day in Process

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Completed Day

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View Multiple Days

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View Multiple Teams

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Intake Team• Consists of

– 2 Financial Coordinators– 1 Pharmacist– 1 Nurse– 1 Scheduler

• Scenarios– Adult RN (ARN)– Peds RN (PRN)– Drug only (Rx)– Enteral (ENT)

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Intake Calendar

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Financial Coordinator

• Scans referral into E-chart• Verifies insurance & benefits• Enters patient and assigns services (TPN,

antibiotics, etc.) into pharmacy system• Adds patient onto Intake Calendar• Hands off to:

1) Pharmacist2) Nurse3) Scheduler4) Teams

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Financial Coordinator Hand Off

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Intake Pharmacist

• Verifies orders

• Performs quality check (appropriate drug, correct dose, lab orders, etc.)

• Processes medication orders into pharmacy system

• Hands off to respective team

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Intake Pharmacist Hand Off

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Intake Nurse

• Performs quality check from a nursing perspective

• Enters patient into nursing system

• Calls patient/caregiver (“Welcome Call”)– Assessment

– Expectations

• Hands off to nurse scheduler

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Intake Nurse Hand Off

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Final Step for Intake: Nurse Scheduler

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Benefits• Real‐time• Used throughout JH Health System• User friendly• Efficient communication

– Smooth hand offs– Signals to work– Eliminated morning or afternoon rounds

• Track progress and productivity• Emergency preparedness plan

– Ability to work from home

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Limitations

• No warning when deleting patients or calendars (retrievable)

• Correctly forwarding of patients (copy & paste entire appointment with notes)

• Changes and updates cannot be made simultaneously by more than one person

• Administrator is needed to manage calendar(s) and allow users

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Interface for Pharmacy & Delivery Routing Systems

Synchronizing Drug Preparation & Delivery Management

Rowell (Ro) Medina, PharmD

Johns Hopkins Home Care Group

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PurposeProblem: Medications and supplies are not available or packaged timely resulting in disruptions and delays within the distribution and delivery processes (inefficient resource utilization and route planning).

Methodology: Lean Sigma Approach – DMAIC methodology

Remove/reduce non-value added activities (waste) from the existing process

Project Goal: Increase percentage of IV medications arriving at window on time to 100% and improve driver lead time by having IV medications ready at least 45 minutes prior to departure time.

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Define

Define Measure Analyze Improve Control

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Voice of the Customer

• Distribution Team Goals– IV medications ready at staging window at the

start of a driver’s shift

• Patient Expectations– Deliveries to arrive at arranged time

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Define

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1. Clock In 2. Get Route 4. Move Packages

5. Move Delivery Van 6. Load Van 7. Start Route

Driver Start Up Tasks3. Get IV Medication

8. Patient Delivery

Measure

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CAPS

Vendors

Vendors

Value Stream Map Measure

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Key Metrics

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Measure

Metric Description Goal

IV Medication Staging Time

Window Due Time vs. At Window Time (actual)

100% arriving at Window Due Time

Driver Lead TimeTime Drug Available vs.Driver Departure Time

> 45 minutes

(Drivers normally require 45 minutes to fully load and prep before a route)

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What We Learned?

• Causes of medication staging delay

• Major Factor: Communication

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Analyze

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Communication

• No time on delivery ticket

• No time on compounding sheet

• Lack of prioritization

• “First in, first out” mentality

• Held deliveries

• Delivery by times

• Driver departure times

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Analyze

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5S Quick Hit:Medication Staging

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BEFORE AFTER

Improve

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11: 1:01:00 1:00 P1:00 PM

Production Prioritization: Pharmacy System Print delivery ticket with by time

Improve

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Limitation: Window Due Time automatically generates time 2 hours before 4 hour ETA block, so dispatch will have to manually change to a more reasonable Window Due Time.

Production Prioritization:Pharmacy View of

Delivery Routing System

Improve

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Production Prioritization:Dispatch View of Delivery Routing System

Improve

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IV Medication Staging Time

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80% of IV medications have consistently arrived by the Window Due Time.

There has been a significant decrease for those due after 5pm (13 orders to 0).

Drugs Arriving ‘On Time’ Drug Arriving ‘Late’

Improve

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Test Phase Post Implementation

Sample Size (n) 50 350

Data Range Oct – Nov 2013 Nov 2013 – April 2014

Mean Staging Time 140 minutes 81 minutes

Median Staging Time 68 minutes 53 minutes

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IV Medication Staging Time Improve

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Driver Lead Time

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Improve

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Monitor & Sustain

• Re-evaluate Pharmacy View screen to better fit their workflow

• Audit current data to ensure compliance between Pharmacy and Dispatch/Warehouse

• Implement a control plan

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Control

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Doe, John

Doe, John

Doe, John

ControlPatient Labels

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Packing Area

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Control

Pharmacy Baskets

Trash

Packing Materials

BEFOREPacking area/Work Station: 15 sq ft

of work space Trash

Packing Materials

AFTER:30 sq ft of work space

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Staging Area Control

BEFORE15 sq ft of work space

AFTER45 sq ft of work space

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Benefits• Patient and employee satisfaction

• Enhanced communication

• Decreased IV medication staging time

• Reduced operations costs

• Improved resource utilization and productivity

• Replacement of a manual delivery log

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Limitations

• Automatic generation of Window Due Time (6 hours before ETA)

• Missed tickets (forgetting to print ticket)

• Patients with multiple medications

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Electronic Route Optimization

Efficient Patient & Nursing Scheduling

Alexis M. Kolesnik RN MSN

Jefferson Home Infusion

Change Management

• Organizational change can be represented as three states of change

– Current State

– Transition state

– Future state

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Effective Change ManagementRequires involvement and action by

many within the department

• Coordinators

• Mobile Registered Nurses

• Intake personal

• Document trackers

• Administration

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Current State• Process varied among branches

• Paper/ pencil & word document templates

• Voicemail Reports

• No current electronic scheduling system

• Manual entry and calculation for mileage reimbursement

• Manual transfer of patient visits

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Current State Challenges • No safe guards in place, no double check

• Once it’s erased…. it’s gone (no history)

• Amount of non-productive time spent transferring patients

• Miscommunication of information

• Different systems in different locations

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NURSE 3 x NURSE 4 x

Stop, Sign PHER CC

Test, Five DA Copy, Right 19128 LDA LFTS

One, Way DA

Jefferson, One DC Center Center Two

Jefferson, Two DC Cancer Center Three

Jefferson, Three NEWTOWN SM DOSE

NURSE 1 x Nurse 2 x

Test, Two PIVPatient, Two LEVITTOWN

7D HOOKUP @ BODINE ~1130

Test, One DC1130 Test, Three 19125 LDA

Test, Four 19135 FACTOR

CANCER CENTER ONE

Cancer, TwoCancer, ThreePatient, One 230 5FU H/U

Example of Word Document Scheduling Template

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Outcomes of Current System• Potential for decreased patient satisfaction

due to missed / delayed visits

• Allocation of resources is inadequate

• Increase in frustrations and stressors

• Delayed treatments

• Increased wait times for patients

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Transition State• In- person work meeting with company

representative– Built our system

• Users

• Patients

• Visit types and durations

• Visit Groups

• Created excel spreadsheet for uploads of census

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Education• Outpatient Coordinators

– Changes in work rules and process

– Scheduling patients

– Remove discrepancies between offices

This step took several sessions and reinforcement was needed throughout the pilot

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Reinforcement in certain areas was necessary to avoid future errors

• Plotting the visits

• Manipulating them on the schedule

• Sequence in which visits were plotted or deleted

• No reoccurring visits entered, leaving patients off schedule

“It does not matter how slowly you go as long as you do not stop.”

‐Confucius

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Pilot Group• Five clinicians

– Different working styles

– Various levels of computer knowledge

– Different geographical areas

– Comfort levels varied

– Different levels of understanding of what this program is intended to do

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Concerns and Issues@ follow- up sessions

• Missing patient demographic information

• Visit type incorrect

• Additional information vital to the visit not apparent (NO NOTE)

• Assignments changed after deadline with no notice

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Positive Feedback

• Assignment is easily accessible

• Changes are immediate through out the day

• Travel reimbursement procedure fast and efficient

• Ability to look at future visit dates

• Use the system for daily patient logs

• Ability to see six week work schedule

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Implementation

• Small groups for training

• Reinforced having an open mind

• Leave negativity at the door

• Follow up meetings for issues or concerns

• Open door policy

“Progress is impossible without change, and those who can not change their minds cannot change anything” -- George Bernard Shaw

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Calculated Miles

Visit start and end times

Travel Reimbursement & Nurse Visit Logs

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Phone Application

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Multiple Uses

• Intra disciplinary use

• Data collection

• Inclement weather contingency plan

• Create territories (future state)

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Intra- Disciplinary UseThere are several other benefits in using a electronic scheduling system:

• Visit tracking

• Nurse authorization report

• Document tracking report

• Travel reimbursement

• Visit type reporting

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Data Collection

Previous system had no reliable means to collect data regarding

– Number of visits for a specific visit type

– Productivity

– Number of completed nursing visits

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Inclement Weather Contingency Plan

• View of map and all the plotted visits

• Coded by color for scheduled clinician

• Outliers are visible immediately

• If weather map indicates inclement weather for a certain region the amount of visits in the area is apparent

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Visit Map:

Peg indicate patient home and colors indicate which nurse is assigned

Filter: allows you to see particular visits type. This example is all CHEMO disconnects

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Local Weather Map

Compare visit map to this to determine what areas will experience traveling difficulties

#1 PRIORITYSafety and wellbeing

of our staff and patients

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Benefits of the Electronic Route Optimization Program

• It’s a LIVE system!

• Up to date, real time information

• “Nurse suggest” feature that allows the system to find you a clinician who is readily available to see a patient (determined by skill set and geography)

• Clinicians see changes to assignment immediately through internet connection

• Travel reimbursement process is faster, resulting in more productive time

• Visit are reoccurring and not missed, and a history is saved of all changes to the visit or patient profile

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Return on Investment60 days pre-implementation

60 days post- implementation

Months Miles Paid Mileage paid @ 0.56

July & August 2014 40344 $22592.64

Nov. & Dec. 2014 36339 $20349.84

- 4005 miles

$2242.80Net Savings

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Future State• Entire department utilizing program

• Purchasing smart phones for each clinician to utilize mobile application and GPD features

• The ROI pays for the system, net savings increases with the use of more accurate mileage reporting

• Patient and clinician satisfaction increases

• Patient outcomes improve as a result of efficient patient scheduling

• Allocation of resources improve

• Non-productive time decreases

• Eliminate the 2 offices, building one central scheduling hub that utilizes all available resources (clinicians)

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QUESTIONS?

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14-d - medina, kolesnik - streamlining operations through ...€¦ · streamlining operations...

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