2. Sarah Bush Lincoln is a rural regional health system located in Mattoon in East Central Illinois that received the state’s highest performance honors from Illinois Performance Excellence (ILPEx) in 2011. The financially strong and innovative hospital has 128 beds and provides a full range of ambulatory services including a Regional Cancer Center, Center for Interventional Pain, Diagnostic and Rehabilitation Services, Advanced Wound Center and a Heart Center in partnership with nationally renowned Prairie Heart Institute of Illinois.

3. Additionally, it has primary care clinics in nine area communities, as well as two Walk-In clinics and employs 125 physicians and mid-level providers. The organization employs nearly 2,000 people and was recently named a HealthStrong hospital, placing it among the top 15 percent of high performing hospitals nationwide.

4. Problem Statement: High patient volumes (Increase of average daily chemo infusions by 56% over 2 year period) No change in process as service expanded over previous years Chemotherapy orders written and faxed over a 3 to 4 hour time frame Increased potential for significant or dangerous medication errors Increased patient wait time Cancer Center Rapid Improvement Event- Project Charter

5. Focus Area- Patient Arrives  Chemo Delivered Impact on Customer- Increased wait times, Potential for dangerous errors, Staff frustration, Confusion in communication Major factors of variation- Multiple orders faxed simultaneously, lab wait times, reporting of values, timeliness for physician to see patients, flexible patient arrival times.

6. Assumptions- Need less congestion within the process, ACCURACY is the most important outcome. Constraints- Space, staff, supplies, complex process, EHR system does not support Oncology Key Metrics- Time from door to chemo Med Error Rate- near misses Timeliness of chemo administration Staff frustration and confusion

7. Time Frame = 30 days Team Members- Cancer Center Director Pharmacy Director Pharmacists Pharmacy Tech Cancer Center RN’s Cancer Center secretary Lab Manager Process Facilitators Ad Hoc members- Admitting staff, IS staff, Oncologists

8. Physician Order- Chemotherapy

9. Staffing Cancer Center staff 5 RN’s, 1 Nurse assistant Pharmacy All oncology incorporated into daily workflow. Staff rotation. No proactive interaction between Pharmacy and Oncology staff.

10. Chemo Near Misses 112 Near Misses/22 days (5 near misses per day) Typically missing BSA or dose calculation questions Drug Waste $$$ Total value of drug waste= ~$160,000 per year Process for consistently billing for waste not fully developed or implemented. No consistent method to audit payments for services

11. OPPORTUNITIES IDENTIFIED (16) Scheduling of Patient visits Laboratory scheduling Bedside Registration Nurse Navigator “Team Approach” (Nurse and Physician rounding together) Patient demographics and information obtained during lab pre-work Point of Care lab equipment Inter-Disciplinary huddle daily Laptop or tablet for physicians to view lab values Electronic order entry by physicians Addition of Pyxis machine to Cancer Center Specialized Pharmacist and Pharmacy Technician for Oncology Oncology Software system for order management Reduction in the use of “Stat” lab orders Lab results pushed to mobile device Standardization of solutions- utilizing pre-mixes when possible

12. Actions tabled or delayed (6/16) Bedside Registration Inadequate space to accommodate technology in current environment Nurse Navigator Position is currently under evaluation Point of Care lab equipment Improvements in scheduling reduced the need for specialized equipment Laptop or tablet for physicians to view lab values Computers (wall modules) available in each exam room. Oncology Software system for order management Request to Administration for upgrade- approved and scheduled for FY15 Lab results pushed to mobile device Improvements in lab scheduling reduced the need for mobile device alerts

13. Action Items Implemented (10/16) Scheduling of Patient visits Laboratory scheduling “Team Approach” (Nurse and Physician rounding together) Improved communication = Improved patient flow Patient demographics and information obtained during lab pre-work Vital Signs, weights, and Medication lists obtained when patients arrive for lab-work. Inter-Disciplinary huddle daily Pharmacy, Nursing, Clerical staff, and Physicians (when possible) Discussions regarding “What went well today, Opportunities, and future patients” Electronic order entry by physicians Order sets created for “pre-meds” and IV’s Addition of Pyxis machine to Cancer Center Specialized Pharmacist and Pharmacy Technician for Oncology Reduction in the use of “Stat” lab orders Everything is Stat = Nothing is Stat Standardization of solutions- utilizing pre-mixes when possible Stock pre-mixes and IV’s in Pyxis

14. Cancer Center Scheduling Changes Scheduling Monday - ThursdayFriday 4 pts / RN= 12 -16 Chemo Pts8-10 followups 10 Labs (Day prior and Nadir's)= 10 labsinfusions 5 pts / Doc followups= 10-12 followupsinjections 5 follow-up labs= 5 followup labstransfusions 1pt / Doc Consults= 2 Consultslow risk chemo Noon "Lab only's" (RN-allday) Chemo capacity = 48/weekPort Flush's (RN-allday) Current level = 42/week (14% increase in capacity) "Like Chemos" MondayTuesdayWednesdayThursdayFriday AbraxaneErbitux/AlimtaAvastin

15. Pharmacy- Oncology Center Changes Addition of 1.0 FTE- Oncology Technician Responsibilities Chemotherapy IV admixture Daily rounding in Cancer Center Standardization of work procedures- Standard Work Instructions Daily review of drug charges and order entry Tracking of drug utilization and drug waste Dedicated Oncology Pharmacist (reallocation of existing staff) Responsible for all Oncology patient order processing, review, and IV admixture checking Daily Rounding in Cancer Center Dedicated Oncology Workspace Isolated area for Oncology Pharmacist and Technician Communication- dedicated Fax, Phone, Computer, Pharmacy Window

17. OUTCOMES: Patient Wait times- decreased by 25% Medication Error Opportunity Reduction- 65% Before: 112 Near Misses/22 days (5.1 near misses/ day) After: 36 Near Misses/20 days (1.8 near misses/day) Chemotherapy Patient Capacity Increase of 14% Increase from 42 to 48 patients per week Drug Waste Reduction $150,000 immediately Combination of waste reduction and billing improvements Improved Revenue $60,000 annual billing error discovery- Aloxi appropriate j-code units Patient eligibility screening- $$$ Pyxis capture of all floorstock charges- ~$20,000/year

18. OUTCOMES: Staff - Decreased frustration considerably. New model is more efficient Better communication Interdisciplinary involvement Patient Outcomes- More fluid process Less waiting (25%) 96% Patient satisfaction score Less opportunity for Medication Errors (65% reduction)- potentially devastating errors Health Center- Revenue- Increased capacity (14%), decreased waste ($150,000), improved revenue/billing processes Responsive to Employee concerns  employee satisfaction

19. The Future: New free standing Cancer Center New Electronic Health Record system Nurse Navigator system (under construction)

20. QUESTIONS? Michael Craig R.Ph.| Director of Pharmacy Sarah Bush Lincoln Health System| www.sarahbush.orgwww.sarahbush.org (217) 258-2520| mcraig@sblhs.orgmcraig@sblhs.org