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:

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.