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Do you know what your staff are doing?

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Presentation on theme: "Do you know what your staff are doing?"— Presentation transcript:

1

2 Do you know what your staff are doing?
Performance improvement through tracers Margarita Fedorova, CPhT Cedars-Sinai Medical Center Pharmacy Technician Supervisor

3 Disclosure I have no relevant financial relationships with commercial interests pertaining to the content of this presentation.

4 Learning Objectives: Pharmacy Technicians
At the completion of this activity, the pharmacy technician will be able to: Describe the use of tracer methodology and the technician’s role in evaluating the medication use process (MUP) Discuss the development of a database collection tool for tracking compliance to medication use processes Identify opportunities to improve quality and patient safety Describe feedback forums to staff to improve performance

5 Learning Objectives: Pharmacists
At the completion of this activity, the pharmacist will be able to: Describe the use of tracer methodology and the technician’s role in evaluating the medication use process (MUP) Discuss the development of a database collection tool for tracking compliance to medication use processes Identify opportunities to improve quality and patient safety Describe feedback forums to staff to improve performance

6 Cedars Sinai Medical Center (CSMC)
Non-profit, acute, tertiary, teaching hospital 886 licensed beds 120 intensive care unit beds Level I trauma center, Comprehensive Stroke Center Department of Pharmacy Services: Decentralized clinical pharmacy services Emergency department and operating room services Solid organ transplant services Transitions of care services Outpatient pharmacy services including ambulatory care clinics Oncology services

7 “Always Survey Ready” On average, CMSC is subject to 15 regulatory surveys each year “Always Survey Ready” or “Ever-Ready” Compliance AT ALL TIMES to: Federal and state regulatory requirements : The Joint Commission(TJC) Drug Enforcement Administration(DEA) California Department of Public Health(CDPH) Title 22 California Board of Pharmacy Center for Medicare and Medicaid Services(CMS) Many others Ever- Ready like a Bunny

8 “Always Survey Ready”, cont.
Compliance AT ALL TIMES to: National organizations best practices: Center for Disease Control and Prevention (CDC) US Pharmacopeia (USP) California Society of Health- System Pharmacists (CSHP) American Society of Health- System Pharmacists (ASHP) Institute for Safe Medication Practices (ISMP) Many others Organization policies and procedures Goal: CONSISTENT applications of established processes

9 Who’s Looking? hardcoreinvestigations.net 1

10 THEY are Looking The Joint Commission (TJC) evaluates health care organizations to inspire them to excel in providing safe and effective care of the highest quality and value2 The California Department of Public Health (CDPH) is dedicated to optimizing the health and well-being of the people in California3 Centers for Medicare and Medicaid Services (CMS) Improve individual patient experiences of care along the Institute of Medicine’s six domains of quality: Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity4 CA Board of Pharmacy protects and promotes the health and safety of Californians by pursuing the highest quality of pharmacist’s care and the appropriate use of pharmaceuticals through education, communication, licensing, legislation, regulation, and enforcement5 To advance patient safety worldwide by empowering the healthcare community, including consumers, to prevent medication errors.

11 THEY are Looking Patient Safety
The Joint Commission (TJC) evaluates health care organizations to inspire them to excel in providing safe and effective care of the highest quality and value2 The California Department of Public Health (CDPH) is dedicated to optimizing the health and well-being of the people in California3 Centers for Medicare and Medicaid Services (CMS) Improve individual patient experiences of care along the Institute of Medicine’s six domains of quality: Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity4 CA Board of Pharmacy protects and promotes the health and safety of Californians by pursuing the highest quality of pharmacist’s care and the appropriate use of pharmaceuticals through education, communication, licensing, legislation, regulation, and enforcement5 To advance patient safety worldwide by empowering the healthcare community, including consumers, to prevent medication errors.

12 Assessment Question #1 In which of the following steps of the Medication Use Process (MUP) are technicians involved in? Administering Dispensing Hiding medications from the nurses Storage B & D only All of the above I don’t know

13 Technician roles in the Medication Use Process: Safety is a Key Factor in All Aspects
Selection & Procurement Storage Ordering & Transcription Preparation & Dispensing Administration Monitoring &Evaluation Purchasing Bar Coding Drug Supply Chain Security Act (DSCSA) Patient assistance Inventory Floor Stock Recalls Automation Outpatient Order Entry (OE) Distribution Order Pickup First dose dispense Phone Triage/Cust. Service Cart fill & Check Missing Med Invest. Order Status requests Compounding Packaging/Bar Coding IV preparation Procedural services Special Populations Automation IDS (Invest. Drug Serv.) Patient assistance No current role Cont. Regulatory Readiness IV rounds Unit Inspections Quality audits Error Investigation Identify Quality Improvement (QI) opportunity Identify Pts Omitted meds Transitions Of Care (TOC) Technician Focused Forum_V2RolesResponsibilities.pptx

14 Assessment Question #2 Which regulatory agencies have an oversight over the Medication Use Process that affect technician roles? CMS TJC CDPH CA Board of Pharmacy All of the above Your local cable company I don’t know

15 Core Technician Roles in Medication Use Process
Focus Areas for Regulatory Agencies and Safety Organizations TJC CMS CDPH ISMP Storage x Dispensing Evaluation in the MUP by Regulatory Agencies and Safety Organizations

16 Technician Role in Medication Use Process: Storage
Checking Beyond Use Dating (BUD)/expiration dates: Dating of open multidose vials IV Fluids outside of overwrap Compounded Sterile Products (CSPs) Monitoring refrigerator/freezer temperatures Ensuring medications are protected from light, when applicable Storing medications in the right location (refrigerator vs. warmer vs. room temperature) Removal of outdated medications Ensuring cleanliness of medication storage areas Techs are expected to:

17 Technician Role in Medication Use Process: Dispensing
Ensuring dispensing accuracy Right patient: use of 2 patient identifiers Right drug Right dose Right time Right route Ensuring safe use of Patient’s Own Medications (POM)* Alert pharmacist when POM are available to be verified  right medication administered to patient Alert nursing leadership when POM are left behind at discharge  minimal disruption to patient’s regimen and patient’s and organizational financial impact POM – help prevent financial hardship for patients *CSMC Process

18 Technician Role in Medication Use Process: Evaluation
Assess for dispensing and stocking errors HIPAA : safeguarding Protected Health Information (PHI) on and off the clock Discharge medications not provided to patient upon discharge Duplicate medications dispensed TCT process, Pyxis misfill

19 Technician Role in the Medication Use Process: Summary
Safe Medication Storage Safe Dispensing Evaluation Identification of opportunities to reduce waste and improve quality/performance Overall Medication Safety We use tracers to ensure that techs do all of these and more

20 Assessment Question #3 Tracer is a process to analyze an organization's systems, with particular attention to identified priority focus areas, by following an individual patient, resident, or individual served through the organization's care process in the sequence experienced by each individual. True False Difference between system tracer vs process tracer.

21 What is Tracer Methodology?
A process to analyze an organization's systems, with particular attention to identified priority focus areas, by following an individual patient, resident, or individual served through the organization's care process in the sequence experienced by each individual6 TJC uses tracer methodology to assess organization’s compliance to its standards Tracer methodology is utilized to follow technicians through the medication use process and ensure: Compliance to organization’s policies and procedures and regulatory requirements, and national standards Consistent application of established processes Methodology-a system of methods used in a particular area of study or activity. A key part of The Joint Commission’s on-site survey process is the tracer methodology. The tracer methodology uses information from the organization to follow the experience of care, treatment, or services for a number of patients through the organization’s entire health care delivery process. Tracers allow surveyors to identify performance issues in one or more steps of the process, or interfaces between processes System tracer activity: Includes an interactive session with a surveyor and relevant staff members in tracing one specific “system” or process within the organization, based on information from individual tracers. Medications tracer is the system tracer.

22 Why are Technician Tracers Needed?
General points: Increasing number of staff Increasing roles of technicians Increasing regulatory requirements More complicated medication regimens Increasing use of automation Implementation of CPOE Technician tracers or process tracers?

23 Why are technician tracers needed?, cont
Recent 26% increase in number of technicians to supervise. New Comprehensive Stroke Center designation Growing transplant program Change in technician practice model: Before After Technician order entry Decentralized distribution model Dispensing from the satellites Delivery from the satellites Floor stock from the satellite Computerized Physician Order Entry (CPOE) implementation Centralized distribution model(with responsibilities on the floor) Dispensing from the central location Deliveries from the central location Floor stock from the central location

24 Tracer Criteria Tracer criteria are developed and evolve based on:
Regulatory requirements Organization policies and procedures Previously identified gaps, deficiencies or problematic areas

25 Focus Areas Current CSMC tracer focus categories: Temperature Logs
Outdates Patient Own Medications Discontinued Medications Deliveries To The Wrong Location Transfer of medications Dispensing Error Stock Error HIPAA Meds In The Tube station Technician Name Posted Cleaning Medication Carts Signing Delivery Log Dating Of The Insulin Vials Answering Assigned Phone Unnecessary Refill Medication Cart Labeling Nothing Found Discharge meds left behind Other

26 Development of a Tracer Database
Several methods exist to track tracer findings: Paper logs, notes in the file notes to yourself and store in a dedicated Outlook® folder Use Excel® spreadsheets Discuss evolution of database: from excel to access. Excel file got too big and difficult to use. Access database allows for 1) ease of use, 2) immediate notifications to supervisors, 3) reporting, consistent update of tables,

27 Development of a Tracer Database
Manual or Semi-Manual Processes Several methods exist to track tracer findings: Paper logs, notes in the file to yourself and store in a dedicated Outlook® folder Use Excel® spreadsheets Discuss evolution of database: from excel to access. Excel file got too big and difficult to use. Access database allows for 1) ease of use, 2) immediate notifications to supervisors, 3) reporting, consistent update of tables,

28 Assessment Question #4 What are the advantages of an Access® database in tracking tracer results when compared to other traditional methods? Data structure & Normalization Scalability Data and Referential Integrity Queries and Reports All of the above Helps to Win the Lottery I don’t know

29 Access® Database What is an Access® database?7
Microsoft Access®, often abbreviated "MS Access," is a popular database application for Windows Access allows users to create custom databases that store information (collection of records) in an organized structure The program also provides a visual interface for creating custom forms, tables and reports, and easy manipulate the data using queries Leave 4 bullets and discuss 1- Table Structures and Validation: Databases make it easy to store information in one place and reference it in multiple places. For instance, employee information or error information may be kept in a employee table or error table where the name, floor, error category, , etc. are kept. It is then referenced in other places such as queries, forms, and reports. If the employee's information changes, the new information is automatically updated in all the referenced places. The table designs also impose structure that lends itself to data types, validation and consistency for higher quality than what normally exists in spreadsheets. 2- : adding more records is free : If it's well designed, over time, new records are continually added without needing to add new fields. All the queries, forms, and reports continue to work without any changes. Different filters may be applied but the results are always consistent. There's no need to retest the formulas (cells) when new data is added. This allows accurate reports to be generated every year, quarter, month, week, day, etc. 3- Access databases provide many tools to maintain data quality. Lookup lists and validation rules for individual fields and records can be easily implement in Access at the table level. Forms can add additional rules during data entry to respond to user selection and events. Access also offers referential integrity between tables to ensure data is consistently defined across tables. 4- Microsoft Access queries and reports let you slice and dice your data and present it in detail or summary form regardless of how the data is stored or sorted in the underlying tables. It offers a great deal of power and flexibility to analyze and present results. Using groupings, it's easy to show aggregations as the data changes and groups get added or removed.

30 Access® Database, cont. Advantages of an Access® database8
Data structure and normalization through multiple tables Databases make it easy to store information in one place and reference it in multiple places Scalability, Data and Referential Integrity Databases provide many tools to maintain data quality and eliminate redundancies Queries and Reports MS Access queries and reports let you slice and dice your data and present it in detail or summary form Leave 4 bullets and discuss 1- Table Structures and Validation: Databases make it easy to store information in one place and reference it in multiple places. For instance, employee information or error information may be kept in a employee table or error table where the name, floor, error category, , etc. are kept. It is then referenced in other places such as queries, forms, and reports. If the employee's information changes, the new information is automatically updated in all the referenced places. The table designs also impose structure that lends itself to data types, validation and consistency for higher quality than what normally exists in spreadsheets. 2- : adding more records is free : If it's well designed, over time, new records are continually added without needing to add new fields. All the queries, forms, and reports continue to work without any changes. Different filters may be applied but the results are always consistent. There's no need to retest the formulas (cells) when new data is added. This allows accurate reports to be generated every year, quarter, month, week, day, etc. 3- Access databases provide many tools to maintain data quality. Lookup lists and validation rules for individual fields and records can be easily implement in Access at the table level. Forms can add additional rules during data entry to respond to user selection and events. Access also offers referential integrity between tables to ensure data is consistently defined across tables. 4- Microsoft Access queries and reports let you slice and dice your data and present it in detail or summary form regardless of how the data is stored or sorted in the underlying tables. It offers a great deal of power and flexibility to analyze and present results. Using groupings, it's easy to show aggregations as the data changes and groups get added or removed.

31 Fully Automated Process
Access® Database, cont. Advantages of an Access® database8 Data structure and normalization through multiple tables Databases make it easy to store information in one place and reference it in multiple places Scalability, Data and Referential Integrity Databases provide many tools to maintain data quality and eliminate redundancies Queries and Reports MS Access queries and reports let you slice and dice your data and present it in detail or summary form Fully Automated Process Leave 4 bullets and discuss 1- Table Structures and Validation: Databases make it easy to store information in one place and reference it in multiple places. For instance, employee information or error information may be kept in a employee table or error table where the name, floor, error category, , etc. are kept. It is then referenced in other places such as queries, forms, and reports. If the employee's information changes, the new information is automatically updated in all the referenced places. The table designs also impose structure that lends itself to data types, validation and consistency for higher quality than what normally exists in spreadsheets. 2- : adding more records is free : If it's well designed, over time, new records are continually added without needing to add new fields. All the queries, forms, and reports continue to work without any changes. Different filters may be applied but the results are always consistent. There's no need to retest the formulas (cells) when new data is added. This allows accurate reports to be generated every year, quarter, month, week, day, etc. 3- Access databases provide many tools to maintain data quality. Lookup lists and validation rules for individual fields and records can be easily implement in Access at the table level. Forms can add additional rules during data entry to respond to user selection and events. Access also offers referential integrity between tables to ensure data is consistently defined across tables. 4- Microsoft Access queries and reports let you slice and dice your data and present it in detail or summary form regardless of how the data is stored or sorted in the underlying tables. It offers a great deal of power and flexibility to analyze and present results. Using groupings, it's easy to show aggregations as the data changes and groups get added or removed.

32 Access® Database Field Relationships
Each table is an entity All tablets link to each other thru primary keys, such as ID ( Category All) to Prob_Grouper (data) IDNum (Supervisor) to Supervisor (data) Rec (Obs_Type) to Obs_Type (data)

33 Database Input Form

34 Database Results Findings by Location Findings by Employee
Highlight inactive employee process

35 How is data evaluated? Periodic evaluations (monthly, quarterly, annually) to: Identify trend direction Assess overall compliance to standards Periodic evaluations  exported to excel and graphs are utilized to display results and identify trends.

36 Top Issues Identified 2013 – 2015*
This demonstrates sustainability over time. * Through August 2015

37 Overall Issues Identified 2013 – 2015*
* Through August 2015

38 Assessment Question #5 How can tracer results be used to improve the Medication Use Process? Identify Performance Improvement Opportunities Staff Recognition Performance Appraisal A & B only All of the above I don’t know

39 How is Data Used? Staff engagement & recognition
Staff meetings/huddles Open forum meetings Performance improvement initiatives Downward trends  focus for performance improvement initiatives Individual Follow-up Staff is notified immediately about findings Periodic performance appraisal/discussions with the supervisor Each employee's participation contributes to Cedars-Sinai's effort to be a preferred healthcare employer. Understanding levels of engagement helps an organization set goals, identify successes and focus on opportunities. In the healthcare community, higher engagement scores also are tied to higher patient satisfaction scores.

40 Performance Improvement (PI) Initiatives
Based on tracer results we: Identify areas requiring process re-designing and implement changes utilizing the Plan, Do, Study, Act (PDSA) methodology Monitor successful test of change implementation Initiate PI projects: Compliance to temperature recording Compliance with removal of medications for discharged patients Missing medication study Change in insulin dispense methodology The Plan phase allows you to plan the details of the test and make predictions about the results...not guesses. Using all the background and planning information, you should be able to estimate what will happen. The Do phase, is when you conduct the test and collect the data. The Study phase is when you compare the results of the test with your predictions, and finally, the Act phase is where you take action based on the new knowledge you have obtained Plan What were the objective(s) of the test? What were the predicted outcomes? What was the test plan? Do Was the test done? What were there problems/unexpected observations? What data was collected and analyzed? Study What did the data show? Were the results of the test similar to or different from the predictions? Can you summarize what was learned? Act What changes made it through the test and were implemented? What had to be changed and tested again?

41 Summary Technicians play an integral role in ensuring a safe medication use process. Increased regulatory oversight warrants the need for an “Always Survey Ready” state. Tracers provide an objective method to assess technician’s compliance to established processes and standards Access® databases have many advantages to: Record, track, and report tracer findings to various forums. Identify performance improvement/process redesign initiatives Compile objective data for staff recognition and individual feedback

42 Acknowledgements CSMC Pharmacy Technicians and Administrative Staff
Karen Youmbi, PharmD, BCPS Kimberly Snodgrass, PharmD, BCPS Bruce Vinson, PharmD, FASHP Rita Shane, PharmD, FASHP, FCSHP Roman Fedorov, MCSD

43 References Hardcore Investigations[Internet] Available from: The Joint Commission[Internet] Available from: CDPH[Internet] Available from: CMS[Internet] Available from: CA Board of Pharmacy[Internet] Available from: The Joint Commission E- dition[Internet] Available from : dition.jcrinc.com/MainContent.aspx Access Definition[Internet] Available from: FMS World Class Software Solutions[Internet] Available from:

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45 Thank you for attending. Please write down your CE secret code
Thank you for attending! Please write down your CE secret code. All ACPE credit must be claimed online no later than November 20, See Seminar Program Book for details.


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