quality improvement in the retail setting stan jeppesen, pharm.d. washington state board of pharmacy
TRANSCRIPT
Quality Improvement Quality Improvement in the Retail Settingin the Retail Setting
Stan Jeppesen, Pharm.D.Stan Jeppesen, Pharm.D.Washington State Board of Washington State Board of PharmacyPharmacy
ObjectivesObjectives
Provide an introduction into flow Provide an introduction into flow chart analysischart analysis
Identify simple processes for Identify simple processes for monitoring system integrity and monitoring system integrity and identifying opportunities for identifying opportunities for process improvementprocess improvement
Identify basic principles of a PDSA Identify basic principles of a PDSA (Plan, Do, Study, Act) cycle(Plan, Do, Study, Act) cycle
ObjectivesObjectives
Review basic principles of Review basic principles of Continuous Quality Improvement Continuous Quality Improvement (CQI) that apply to conducting (CQI) that apply to conducting PDSA cycles and data collection PDSA cycles and data collection
Provide a simple examples of two Provide a simple examples of two PDSA cyclesPDSA cycles
Identify how the PDSA cycles can Identify how the PDSA cycles can be applied in the retail settingbe applied in the retail setting
Basic ConceptsBasic Concepts
Flow charts:Flow charts:• Describes the systemDescribes the system• Identifies the opportunities to be foundIdentifies the opportunities to be found
PDSA:PDSA:• Provides a simple, safe way to make small Provides a simple, safe way to make small
incremental changesincremental changes• Identifies the impact of the changeIdentifies the impact of the change
Management:Management:• Deals with FEAR so projects will be successfulDeals with FEAR so projects will be successful
What is a flow chart?What is a flow chart?
Flow charts are a step-by-step Flow charts are a step-by-step schematic picture used to schematic picture used to describe a process being studieddescribe a process being studied
Flow charts can be augmented Flow charts can be augmented with additional written and/or with additional written and/or schematic descriptions of the schematic descriptions of the individual processesindividual processes
Example: Handwritten Example: Handwritten chartchart
Example excel flow Example excel flow chart:chart:
What does it do for What does it do for you?you? Provides common reference pointsProvides common reference points
Standard language to use when Standard language to use when talking about an existing processtalking about an existing process
Describes new improved Describes new improved system(s).system(s).
What does it do for What does it do for you?you? It allows you to easily describe an It allows you to easily describe an
entire processentire process
Allows for identification of Allows for identification of processes and proceduresprocesses and procedures
It is a powerful communication toolIt is a powerful communication tool
Why Use It?Why Use It?
To help identify the root cause of To help identify the root cause of a problema problem
To help Identify opportunities for To help Identify opportunities for improvement(s) improvement(s)
Reference Reference AttachmentsAttachments See example flow chart See example flow chart
attachmentsattachments
See example data collection toolsSee example data collection tools
Example SymbolsExample Symbols
Handwritten ChartHandwritten Chart
Basic flow chartBasic flow chart
Flow chart c logsFlow chart c logs
Example Scan LogExample Scan Log
SCAN REPORT LOGSCAN REPORT LOG
WEEK WEEK OF:OF:
# OF # OF SCANSCAN
SS
NON-NON-MATCHMATCH
SCAN SCAN TOTATOTA
LL
TOTATOTAL RX’sL RX’s
%% COMMENTSCOMMENTS
DATEDATE 21912191 139139 23302330 20312031 111155
DATEDATE 19661966 158158 21242124 22032203 9696 Relocated Relocated scannerscanner
DATEDATE 18881888 111111 19991999 18791879 101066
DATEDATE 17671767 133133 19001900 20352035 9494 Staff educationStaff education
DATEDATE 17871787 162162 19491949 21422142 9191 Staff educationStaff education
DATEDATE 24782478 176176 26542654 20952095 121277
DATEDATE 18371837 169169 20072007 20722072 9797 Staff meeting Staff meeting topictopic
DATEDATE 22672267 161161 24292429 19921992 121222
DATEDATE 26522652 173173 28252825 22322232 121266
DATEDATE 24712471 176176 26472647 22502250 111188
Example # Technician Example # Technician work returnswork returns
NUMBER OF TECHNICIAN WORK RETURNSNUMBER OF TECHNICIAN WORK RETURNS
Month of: Month of: June 03June 03
## Month of:Month of:
________________## Month of:Month of:
________________##
11 22
22 44
33 44
44 55
55 66
66 22
77 33
88 00
99 11
1010 00
1111 55
1212 33
Expl.-Technician Expl.-Technician Returns by Error TypeReturns by Error Type
TECHNICIAN WORK RETURNS BY TYPE OF ERRORTECHNICIAN WORK RETURNS BY TYPE OF ERROR
DATDATEE
Wrong Wrong PatientPatient
Wrong Wrong DoctorDoctor
Wrong Wrong DrugDrug
Wrong Wrong StrengtStrengt
hh
Wrong Wrong QuantitQuantit
yy
WronWrong Sigg Sig
Wrong Wrong RefillsRefills
Wrong Wrong Exp.Exp.
11 11 11
22 22 11 11
33 11 22
44 33
55 11 22 22
66 22 11
77 22 11
88 11 11
99 11
1010 33
1111 11
1212 22 22
Example 10-point check Example 10-point check loglog
PRESCRIPTION 10-POINT CHECK LOGPRESCRIPTION 10-POINT CHECK LOG
DATE:DATE:
MAYMAYNUMBERNUMBER
MISSEDMISSEDDATE:DATE:
JUNEJUNENUMBER NUMBER MISSEDMISSED
DATE: DATE: JULYJULY
NUMBER NUMBER MISSEDMISSED
11 88
22 11
33 11
44 44
55 33
66 22
77 00
88 66
99 55
1010 11
1111 44
1212 77
Example Counseling Example Counseling loglog
Counseling Reports – New prescription counselingCounseling Reports – New prescription counseling
Month of: ____________________Month of: ____________________
DATEDATE NUMBERNUMBER
COUNSELECOUNSELEDD
TOTAL TOTAL NEW RXNEW RX
% OF % OF TOTALTOTAL
ACTION TAKENACTION TAKEN
11
22
33 5353 116116 4646 Base lineBase line
44 5454 107107 5050 Base LlineBase Lline
55 4242 9797 4343 Staff EducationStaff Education
66 8787 108108 8181 NoneNone
77 7878 111111 7070 Staff EducationStaff Education
88 9999 125125 7979 Staff on ConferenceStaff on Conference
99
The PDSA CycleThe PDSA Cycle
Act Plan
Study Do
What is the PDSA What is the PDSA Cycle?Cycle?
Act• What changes are to be made?
• What is the next cycle?
•How do we hold the gains
Plan• Objective
• Questions and predictions (why)
• Plan to carry out the cycle (who, what, where, when, How)
Study• Complete analysis of the data
• Compare data with predictions
• summarize whatwas learned
Do• Carry out the Plan
•Collect the data
• Document problems and unexpected observations
• Begin data analysis
Reasons for Collecting Reasons for Collecting DataData Provide objective Provide objective
informationinformation Increase info about Increase info about
the change the change (Positive/negative) (Positive/negative)
Give some Give some expectation of the expectation of the change impactchange impact
Show if the gains Show if the gains are retainedare retained
Involve the staff Involve the staff in the changesin the changes
Provide economic Provide economic impacts impacts
Act Plan
Study Do
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
Model for ImprovementModel for Improvement
Source: Inst. For Healthcare Improvement, “IHI Quality Improvement Resources: A Model for Accelerating Improvement,” Boston, MA: Available at WWW.ihi.org/resources/qi/.
Example Handwritten Example Handwritten flow chartflow chart
Aim: Improve Counseling Aim: Improve Counseling FrequencyFrequency
Minimize the number of medication errors leaving the Pharmacy
A P
S D
A P
S D
A
S P
D
Improved Counseling Frequency
Cycle 5: Train additional Pharmacists.
Cycle 4: Revise the tracking system to use a paper receipt.
Cycle 3: Orient one Pharmacist to the counseling tracking.
Cycle 2: Revise the counseling tracking using paper clips and train two Techs.
Cycle 1: Devise and test a system to track the number of patients counseled.
A
S P
D
pA D
S
Increase the number of Patients counseled.
Dat
a
Counseling logCounseling log
Counseling Reports – New prescription counselingCounseling Reports – New prescription counseling
Month of: ____________________Month of: ____________________
DATEDATE NUMBERNUMBER
COUNSELECOUNSELEDD
TOTAL TOTAL NEW RXNEW RX
% OF % OF TOTALTOTAL
ACTION TAKENACTION TAKEN
11
22
33 5353 116116 4646 Base line data – cycle Base line data – cycle 11
44 5454 107107 5050 Base line data – cycle Base line data – cycle 22
55 4242 9797 4343 Staff education - Staff education - cycle 3cycle 3
66 8787 108108 8181 NoneNone
77 7878 111111 7070 Staff education cycle Staff education cycle 44
88 9999 125125 7979 Discuss Discuss improvements & give improvements & give staff feedbackstaff feedback
99 Cycle 5Cycle 5
Counseling – flow chartCounseling – flow chart
Aim: Minimize medication Aim: Minimize medication errorserrors
Minimize the number of medication errors passing through the filling process
A P
S D
A P
S D
A
S P
D
Improved Rx Accuracy
Cycle 5: Give staff feedback on scanner stats and errors.
Cycle 4: Orient other Pharmacists to Scanner use.
Cycle 3: Orient one Pharmacist to the scanner in the new location.
Cycle 2: Try out the new location during the filling process yourself.
Cycle 1: Test out the new location of the scanner yourself.
A
S P
D
pA D
S
Utilize the Scanner for process control during the prescription filling operations.
Dat
a
Scan data logScan data log
SCAN REPORT LOGSCAN REPORT LOG
WEEK WEEK OF:OF:
# OF # OF SCANSCAN
SS
NON-NON-MATCHMATCH
SCAN SCAN TOTATOTA
LL
TOTATOTAL RX’sL RX’s
%% COMMENTSCOMMENTS
DATEDATE 21912191 139139 23302330 20312031 111155
DATEDATE 19661966 158158 21242124 22032203 9696 Relocated Relocated scannerscanner
DATEDATE 18881888 111111 19991999 18791879 101066
DATEDATE 17671767 133133 19001900 20352035 9494 Staff educationStaff education
DATEDATE 17871787 162162 19491949 21422142 9191 Staff educationStaff education
DATEDATE 24782478 176176 26542654 20952095 121277
DATEDATE 18371837 169169 20072007 20722072 9797 Staff meeting Staff meeting topictopic
DATEDATE 22672267 161161 24292429 19921992 121222
DATEDATE 26522652 173173 28252825 22322232 121266
DATEDATE 24712471 176176 26472647 22502250 111188
Management’s RoleManagement’s Role
Management role to optimize the Management role to optimize the system as a wholesystem as a whole– Win-Win for Patients, Physician, Family, Win-Win for Patients, Physician, Family,
organizationorganization– Meet the patient needsMeet the patient needs– Deliver top quality servicesDeliver top quality services
Institute TrainingInstitute Training Improve constantlyImprove constantly CQI Starts at the TopCQI Starts at the Top
Dealing with FearDealing with Fear
Employees/Staff are intrinsically motivatedEmployees/Staff are intrinsically motivated Performance rating can often be Performance rating can often be
destructivedestructive Employees often blamed for “System Employees often blamed for “System
Problems”Problems” Fear Stifles the human contributionFear Stifles the human contribution
– Lack of reportingLack of reporting - Cover up info- Cover up info– Distort informationDistort information - Inhibits - Inhibits
questionsquestions– Restrains expression and ideasRestrains expression and ideas
Implement a non-Implement a non-blame Environmentblame Environment To help reduce FEARTo help reduce FEAR Increase participationIncrease participation Increase data quality and Increase data quality and
reportingreporting Increase the success of the Increase the success of the
quality projectsquality projects
SummarySummary
Flow charts:Flow charts:• Describes the systemDescribes the system• Identifies the opportunities to be foundIdentifies the opportunities to be found
PDSA:PDSA:• Provides a simple, safe way to make small Provides a simple, safe way to make small
incremental changesincremental changes• Identifies the impact of the changeIdentifies the impact of the change
Management:Management:• Deals with FEAR so projects will be successfulDeals with FEAR so projects will be successful
SummarySummary
Keep it simpleKeep it simple Make it easyMake it easy This is Not HardThis is Not Hard Keep it a learning Keep it a learning
experienceexperience Have fun with itHave fun with it
Reach High for QualityReach High for Quality
Questions?Questions?
•Stan Jeppesen, Pharm.D.•Investigator for the Washington State Board of Pharmacy
•(206) 528-0732 Seattle Office
ReferencesReferences
Kohn LT, Corrigan JM, Donaldson MS. Kohn LT, Corrigan JM, Donaldson MS. To Error is Human.To Error is Human. Institute of Medicine, National Academy Press 1999.Institute of Medicine, National Academy Press 1999.
Institute for Healthcare Improvement, BMJ Publishing Institute for Healthcare Improvement, BMJ Publishing Group. Group. www.QualityHealthCare.orgwww.QualityHealthCare.org
Juran JM. Juran JM. Juan on Quality by DesignJuan on Quality by Design. The Free Press, . The Free Press, 1992.1992.
Deming WE. Deming WE. Out of the CrisisOut of the Crisis. Cambridge, MA; MIT Press . Cambridge, MA; MIT Press 1986.1986.
Pharmacists Quality Improvement Project I, February Pharmacists Quality Improvement Project I, February 21, 2002. Qualis Health. 21, 2002. Qualis Health. www.qualishealth.orgwww.qualishealth.org
Pharmacists Quality Improvement Project II, March 14, Pharmacists Quality Improvement Project II, March 14, 2003. Qualis Health. 2003. Qualis Health. www.qualishealth.orgwww.qualishealth.org
When an Error OccursWhen an Error Occurs
What do you do??What do you do?? What does the patient want?What does the patient want? What is your liability?What is your liability? How do you handle it?How do you handle it?
When an Error Occurs -When an Error Occurs -What do you do?What do you do? Complete an error report?Complete an error report? Admit no guilt or participation?Admit no guilt or participation? Determine the cause or who?Determine the cause or who? Hope the incident goes away?Hope the incident goes away?
What does the patient What does the patient want?want? An acknowledgement of the errorAn acknowledgement of the error An admission of guiltAn admission of guilt An admission of alarm over the An admission of alarm over the
potential harmpotential harm That the cause will be fixed and That the cause will be fixed and
not repeatednot repeated That they or someone else won’t That they or someone else won’t
get hurt in the futureget hurt in the future
Why do patient report Why do patient report errorserrors No sense or admission of caringNo sense or admission of caring Fear that “they” will do it again Fear that “they” will do it again
and hurt someoneand hurt someone Denial by the staff that they Denial by the staff that they
made a mistakemade a mistake No apologyNo apology It has occurred twice beforeIt has occurred twice before They made it appear to my faultThey made it appear to my fault
What is Your Liability?What is Your Liability?
Has the patient been injured?Has the patient been injured? Did the patient suffer a financial Did the patient suffer a financial
loss?loss?
What are we afraid of?What are we afraid of?
Lawsuits ? Legal Liability ?Lawsuits ? Legal Liability ? Lower the Patient trust..?Lower the Patient trust..? Disclosure of embarrassing Disclosure of embarrassing
situation?situation? Revealing a personal failure?Revealing a personal failure? Self-esteemSelf-esteem ??
What should patient What should patient be informed of?be informed of? What happenedWhat happened What the error wasWhat the error was Why error happenedWhy error happened What has been learned –how it What has been learned –how it
will be preventedwill be prevented How sorry you are…the apologyHow sorry you are…the apology