Office of Clinical Affairs: Evaluating the Current State of Medication Retrieval At Mott Children s Hospital

Office of Clinical Affairs: Evaluating the Current State of Medication Retrieval At Mott Children s Hospital University of Michigan Health System Final Report December 10, 2007 Deb Wagner, Pharm D Pediatric Safety Coordinator Jackie Lapinski Project Manager, Children s and Women s Project Healthcare Strategies and Solutions Diane DiMusto, IOE 481: Program and Operations Analysis Associate Jennifer Hand, IOE 481: Program and Operations Analysis Associate Amanda Kandt, IOE 481: Program and Operations Analysis Associate Aaron Potek, IOE 481: Program and Operations Analysis Associate

TABLE OF CONTENTS Executive Summary 3 Background..3 Methodology.3 Nursing Medication Retrieval Time..3 Missing Medication Cost...4 Communication Between Nursing and Pharmacy.4 Findings and Conclusions...4 Recommendation.5 Introduction.6 Background..6 Goals and Objectives..6 Key Issues 7 Scope of Project...7 Nursing.8 Surveys.8 Method..8 Findings 8 Time Studies 10 Method..10 Findings 11 Nurse Trip Tally Sheets.14 Method..14 Findings 15 Bed Census...15 Method..15 Findings 16 Omnicell Data..16 Method..16 Findings 16 Combined Time Studies, Nurse Trip Tally Sheets, and Omnicell Data 18 1

Method..18 Findings 19 Nursing Conclusions...20 Communication Conclusions...20 Nurse Medication Retrieval.20 Pharmacy.20 Surveys.20 Method..20 Findings 21 Phone Logs...22 Method..22 Findings 23 CareLink Data.23 Method..24 Findings 24 Medication Disposal 25 Method..25 Findings 26 Pharmacy Conclusions 26 Communication Conclusions 26 Missing Medication Requests...26 Medication Disposal..26 Summary of Key Findings..26 Nursing Savings...27 Pharmacy Savings...27 Cost of New Delivery Process.27 Recommendation.27 2

Executive Summary Background To provide premium care to patients, Mott Children s Hospital is interested in determining the best process for delivering medications to optimize bedside nursing time and minimize cost. As a first step toward this goal, the Office of Clinical Affairs conducted a Medication Manager Pilot in 2006 to assess a new method of delivering medications directly to a patient s bedside. In this pilot, Pharmacy technicians could be contacted via phone or pager, and these techs delivered medications from the Pharmacy directly to a locked box for medications located in each patient room. After the completion of the pilot, all 21 nurses who were interviewed described the pilot as Very Beneficial and expressed a desire to make the pilot permanent. However, this pilot did not assess any quantitative data regarding the new medication delivery process. Therefore, the Office of Clinical Affairs asked Healthcare Strategies and Solutions (HSS) to investigate and quantify the cost of the current medication retrieval process within the Pediatric Intensive Care Unit (PICU) and Pediatric Cardio Thoracic Unit (PCTU), and this data will be compared to data collected after the Medication Manager Pilot will be re-implemented in December 2007. The study of the current system will analyze the cost of the medication retrieval process, and it will assess the communication between the Pharmacy and nursing staff. The cost includes both the monetary cost of medications that are misplaced and replaced as well as the time nurses waste trying to track down these missing medications or ordering their replacements. In this final report, HSS will present the problem, methodology, findings, and recommendations for the PICU and PCTU medication retrieval process by quantifying the cost of the current medication retrieval process and evaluating the communication between nursing and Pharmacy staff. The recommendations for improvements will be implemented in the new Children s and Women s Hospital when it opens in 2011. Methodology To quantify the cost of the current system and analyze communication between Pharmacy and nursing, HSS collected various forms of data to ensure an accurate representation of the system within the PICU and PCTU. Specifically, the team investigated nursing time allocated to medication retrieval, cost of missing medications and communication between nursing and Pharmacy staff. Nursing Medication Retrieval Time To evaluate the time nurses spend retrieving medication, HSS collected two forms of data, and later, extracted information to make final conclusions about allocated nursing time. First, the team designed a tally sheet for the nursing staff to record each destination at which they collected medication. To verify the data collection period was representative of a typical time period in the PICU and PCTU, HSS obtained and analyzed the bed census data for these units for the past year. Second, HSS performed time studies in the PICU and PCTU to determine the time required for a nurse to retrieve medication from the Medication Room, Omnicells, and Pharmacy. Using these two measures, the team determined the time per day that the nursing staff allocated to retrieving medication. 3

Missing Medication Cost To calculate the cost of missing medications from the PICU and PCTU, HSS collected three forms of data over two weeks. First, the team developed forms for the Pharmacy to complete after every phone call to indicate if the phone call was concerning a missing medication from the PICU or PCTU. Second, HSS extracted missing medication requests from CareLink, and paired that information with the phone calls for missing medications. Together, the phone calls and CareLink messages regarding missing medications were used to approximate the number of missing medications per day. Lastly, to calculate the cost of missing medications, HSS recorded and calculated the cost of the disposed medications from the PICU and PCTU over 14 days. The disposed medications include both missing medications and incorrect medications, so HSS used the number of missing medications per day to calculate a proportion of disposed medications that were due to missing medications. Using these three measures, HSS found the yearly cost of missing medications. Communication between Nursing and Pharmacy To investigate communication between the nursing staff and the Pharmacy staff, HSS handed out surveys to 57 nurses and 18 pharmacists. The nursing survey asked nurses when and where the they expect to find medications for their patients. The Pharmacy survey asked if pharmacists knew where to drop off medications and if pharmacists thought missing medication requests had already been processed. Comparing the responses from the nursing and Pharmacy staff, HSS identified areas of miscommunication between the two departments. After evaluating the nursing time allocated to retrieving medications, the cost of missing medications, and the communication between nursing and Pharmacy, HSS developed key conclusions and recommendations. Findings and Conclusions Based on the tally sheets, the time studies, and the Omnicell data, HSS created the following table. Table 1. Key Times from HSS Data Collection All Nurses in unit: PCTU PICU Total Minutes Nurses Spent Retrieving Medications From Medication Room During 20 Days of Data Collection 1867 1078 Total Minutes Nurses Spent Retrieving Medications From Omnicell During 20 Days of Data Collection 986 506 Total Hours Per Day Retrieving Medications 2.38 1.32 4

HSS verified that this time spent retrieving medications was indeed representative of a typical time period based on a comparison of the census data during the 20-day collection period and the bed census data for the past year. In terms of communication, there is a clear discrepancy in the perception of nurses and pharmacists regarding the current medication process. One hundred percent of pharmacists said that they know where to deliver a medication within a pod, yet 40% of nurses felt that medications rarely to sometimes got delivered to the location the nurses expected. This miscommunication leads to misplaced medications. HSS determined that at least 40 calls are made or messages sent to the Pharmacy per day regarding missing medications. These missing medications that are incorrectly delivered to the wrong area are thrown away at the end of each day since they cannot be reused for safety reasons. During the 2-week period that HSS collected information about these discarded medications, the hospital disposed of $13,984.61 worth of medication. Of these disposed medications, 1/3 is due to missing medications rather than other circumstances such as dose changes. This value means that the hospital loses about $121,000 per year due to misplaced medications in just the PICU and PCTU alone. Recommendation HSS recommends that the Office of Clinical Affairs compares the data presented in this report to the data that will be collected during the new bedside delivery program to assess the best method for delivering medications to patients in the PICU and PCTU. The results of this analysis should save the hospital money, increase communication between nurses and pharmacists, and improve patient care. 5

Introduction The University of Michigan Hospital System (UMHS) would like to provide premium care to each of its patients by minimizing the time nurses spend retrieving medications. Currently, nurses at Mott Children s Hospital are responsible for ordering medications and transporting those medications from the delivery point to patient rooms as needed. The Office of Clinical Affairs is interested in investigating whether this process can be improved to alleviate the nurses of this responsibility. Therefore, HealthCare Strategies and Solutions (HSS) was asked to quantify the cost of the current medication delivery process in the Pediatric Intensive Care Units (PICU) and the Pediatric Cardio-Thoracic Intensive Care Unit (PCTU) both in terms of the time nurses spend retrieving medications from the Pharmacy, Medication Rooms, and the Omnicells, as well as the cost of medication that is thrown away in these units. HSS was also asked to assess the communication between nursing and Pharmacy staff. In December of 2007, UMHS plans to implement a Mott Medication Management Pilot in the PICU and PCTU that would improve this process, and data from that new process will be compared to the data in this report. The team investigated the current process from September through December 2007. The purpose of this report is to present the team s findings and recommendation for improving the medication delivery process in the PICU and PCTU. If the pilot is determined to be effective, this new process will be used in the new Children s and Women s Hospital upon opening in 2011. Background The current process requires nurses to make several trips to and from the medication delivery points to retrieve medications every time a patient requires it. The new process for the December pilot test would shift the responsibility of medication deliveries to Pharmacy technicians, and the medications would be delivered directly to the bedside of each patient. The change to the delivery process will improve the currently poor communication between the Pharmacy and nurses, according to the Pediatric Safety Coordinator. In the current process, the nurses are not notified when medications are delivered, resulting in an unnecessary delay in administering medications to patients. The new delivery process would increase nurse-patient interaction time since Pharmacy technicians would deliver medications to the bedside as needed in addition to the standard once-a-day delivery. The hope is that the new delivery process will allow for a more efficient use of nurses time by eliminating the medication retrieval task from nurses responsibilities. The process used in the pilot test should also reduce the cost of medication disposal due to missing medication and dose changes by improving communication between nurses and the Pharmacy. This pilot test was conducted from October 22 November 22 in 2006 in the PICU. Post-pilot analysis concluded that nurses favored the new process, but the analysis did not incorporate quantitative conclusions. Therefore, another pilot is needed to quantitatively evaluate the effectiveness of the new process. Goals and Objectives The main goal of this project is to quantify the cost of the current medication delivery process in terms of nursing time and medication disposal costs. After evaluating these aspects of the 6

current system, HSS identified opportunities to improve the quality of patient care by decreasing the time nurses spend retrieving medications and reduce hospital costs by increasing nursing- Pharmacy communication. This project will result in current medication retrieval data to compare to data recorded during the pilot for the new bedside delivery process. This comparison will determine if the pilot s method effectively reduces these times and improves communication between nurses and pharmacists. The goals for current medication delivery system evaluation are as follows: Quantify the time nurses currently spend transporting medication from the Medication Room, Omnicell, and Pharmacy to a patient s bedside Quantify the monetary cost of PICU and PCTU medication disposal Determine and recommend ways to improve the process for delivering medications to patients bedsides Key Issues Mott Children s Hospital is currently planning and building a new facility that will open in 2011. Before designing the medication routes in the Pediatric Intensive Care Units, the hospital staff would like to know the cost of the current medication delivery process. Managers at Mott want to compare their current medication delivery process to the Medication Management Pilot study due to the following concerns about the current process: Inefficient use of nursing time to transport the medications from the Medication Room, Omnicell, and Pharmacy to the patient s bedside Lack of quantitative data from previous Medication Management Pilot study Lack of communication between Pharmacy technicians and nurses Scope of Project This project quantified the cost of the current medication delivery process at Mott Children s hospital in the PICU and PCTU. This quantification involved data collection and analysis of the current situation, including: Number of nursing calls to Pharmacy due to missing medications Number of nursing orders via CareLink due to missing medications Cost of medications left in the Medication Room every day Number of trips a nurse makes to the Medication Room Number of trips a nurse makes to the Omnicell Number of trips a nurse makes to the Pharmacy Time a nurse takes to retrieve medication 7

The subsequent analysis of nurse medication transportation time helped to quantify the value of Pharmacy technicians delivering the medications to patients bedsides. The HSS team excluded a few items from the project to insure that Mott Children s Hospital received an objective analysis that addresses the main concerns of medication administration in the Intensive Care Units. First, the implementation of the Medication Management Pilot study was not completed by HSS; therefore, a comparative study between pre-pilot and post-pilot data was not performed. Additionally, HSS did not include a subjective analysis of the value of medications at the bedside in the final analysis since this study was already conducted. Also, the team did not measure errors relating to the type of medication and the required dosage. Finally, HSS did not investigate the optimal number of Pharmacy technicians needed. Future teams will evaluate the implementation and results of the Medication Management Pilot study. Nursing HSS divided the project into two major sections since two separate departments are involved in the medication administration process. The first department that HSS studied was the nursing department. Surveys To determine ways to improve the process for delivering medications to patients' bedsides, HSS investigated the communication between the Pharmacy and the nursing staff in the PICU and PCTU. HSS designed a two-question survey for the nursing staff. The nursing survey assessed how often a nurse knows when and where that nurse s patient s medication arrives from the Pharmacy to the Medication Room or the Omnicell. After distributing the surveys, HSS analyzed the data and formed recommendations. Method To survey the nursing staff from PICU and PCTU, HSS attended all nursing shift change meetings on October 15, 16 and 17 at 7am, 3pm and 7pm. HSS members administered the surveys at the nursing shift meetings that they attended. See Appendix D for the survey HSS gave to the nurses during each of these meetings. HSS measured the response to each survey question on a scale from 1 to 5, where 1 indicated the perception of Never and 5 indicated the perception of Always. Findings In the PICU and PCTU, the team surveyed 57 nurses. The results from question 1 and question 2 appear in Figure 1 and Figure 2, respectively. 8

Number of Responses 25 20 15 10 10 24 15 October, 2007 N=57 By HSS Program Operations Analyst Team 8 5 0 1:Never 2:Rarely 3:Sometimes 4:Usually 5:Always How often do you know when your medication arrives from the pharmacy? Figure 1. Histogram Results of Nursing Survey Question 1 40 Number of Responses 30 20 10 October, 2007 N=57 By HSS Program Operations Analyst Team 21 35 2 0 1:Never 2:Rarely 3:Sometimes 4:Usually 5:Always How often do your medications get delivered to where you expect? Figure 2. Histogram Results of Nursing Survey Question 2 Figure 1 illustrates that 14% of the nurses perceive that they usually know when a medication arrives from the Pharmacy, with an average response of 2.4, which corresponds with a rating between Rarely to Sometimes. Figure 2 shows that 61% of the nurses feel that medications 9

are usually delivered to where they expect, with an average response of 3.6, which corresponds with a rating between Sometimes to Usually. Time Studies To quantify the time nurses spend transporting medications, HSS collected data regarding the time spent by nurses retrieving medications from the Medication Room, Omnicell, and Pharmacy. HSS completed 20 hours of time studies. Method To ensure that HSS recorded representative times that nurses spend retrieving medications, HSS developed a data collection method to standardize the collection process. Through this data collection method, HSS devised a schedule to ensure that the timeframe of 7AM to 10PM, 7days a week, was depicted and designed a data collection form to ensure consistency in the time studies. The time study data collection from use by HHS is in Appendix A. The data collection form allows HSS to record numerous items, which include: Data per data collection shift o Unit o Date o Start Time for the data collection shift o End Time for the data collection shift Time data per Trip o Task o Start Time o Interruption Duration o End Time o Notes To further standardize the collection method, HSS defined the start and end points for each data collection item, which includes time to walk, time in the Medication Room, time at the Omnicell, and time at the Pharmacy. These start and end points are listed in Table 1. Table 1. Time study start and end points Time Measured Start Point End Point Walk Time Bedside Nurse steps out of the patients room Medication Room Nurse leaves the Medication Room Nurse steps into the patients room Nurse touches the key pad to gain access into the Medication room Nurse touches the Omnicell key pad Pharmacy Nurse steps away from the Pharmacy Omnicell Omnicell logs out the Nurse Nurse steps up to the Pharmacy window 10

Time in Medication Room Medication Room Only Medication Room from Omnicell Nurse pushes the first button on the key pad to gain access into the medication room Omnicell logs out the nurse inside the medication room Time at Omnicell Nurse first pushes the button on the Omnicell Time at Nurse steps up to the Pharmacy Pharmacy window Nurse s foot crosses the threshold of the Medication room Nurse first pushed a button on the Omnicell in the Medication room Omnicell logs out the nurse Nurse takes his/her first step to walk back to their respective pod Using the starting and ending points shown in Table 1 coupled with the data collection form, HSS performed a consistent time study. After collecting data of times spent by nurses walking to the Medication Room, the Omnicell and the Pharmacy, HSS fit distributions to the time samples collected. HSS combined the data from the time studies with the number of trips nurses made to retrieve medications to determine a total time for medication retrieval. The total time for medication retrieval is one factor that HSS needed to see if the PICU and PCTU need Pharmacy technicians to deliver medications to the bedside. Another factor is the percentage of time nurses spend retrieving medication during a 12- hour shift. Findings After collecting 20 hours of time studies, HSS combined the times into one excel sheet to analyze the results. HSS timed 173 different nurse trips to a variety of locations. HSS collected time at the Omnicell, time from the medication room to the bedside, and time in the medication room. Table 2 show the basic statistical results for time at the Omnicell, time from the medication room to the bedside and time in the medication room. Table 2. Time Study Results Time at Time from Medication Omnicell room to Bedside Time in Medication room Average 53.7 8.6226415 42.82061 Std Dev 43.2 3.8140752 38.08873 Max 160 25 247 Min 6 4 3 Median 40 9 30 Count 23 53 115 Correlation Coefficient for Lognormal Distribution 0.99 0.976 0.996 Lognormal Mean 3.787 2.094 3.388 Lognormal Std Dev.725.381.825 11

Table 2 also includes the correlation coefficient for the lognormal distribution. As shown in table 2, all three distributions have a high correlation coefficient to the lognormal distribution. Knowing the distribution of the times allowed HSS to perform further analysis on the times nurses spend retrieving patient medications. The probability plot for the time from the medication room to the bedside is shown in Figure 3. 99.9 99 95 90 Loc 2.094 Scale 0.3807 N 79 AD 0.896 P-Value 0.021 Percent 80 70 60 50 40 30 20 10 5 1 0.1 1 10 From MedRoom to Bedside (Seconds) Figure 3. Probability plot for time from Medication Room to patient bedside. Figure 3 shows that the lognormal mean and standard deviation for the time from the medication room to the patients bedside to be 2.094 and.381 respectively. HSS used the lognormal mean and standard deviation to generate times from the medications room to the bedside for each trip recorded on the nurse tally sheets discussed later in our report. The probability plot for the time in medication room is shown in Figure 4. 12

99.9 99 95 90 Loc 3.388 Scale 0.8249 N 142 AD 0.495 P-Value 0.212 Percent 80 70 60 50 40 30 20 10 5 1. 0.1 1 10 100 1000 Time in MedRoom (Seconds) Figure 4. Probability plot for time in the Medication Room Figure 4 shows that the lognormal mean and standard deviation for the time in the medication room are 3.388 seconds and.825 seconds respectively. HSS used the lognormal mean and standard deviation to generate times in the medication room for each trip recorded on the nurse tally sheets discussed later in our report. The probability plot for the time at the Omnicell is shown in figure 5. 13

99 95 90 Loc 3.787 Scale 0.7248 N 39 AD 0.357 P-Value 0.438 80 Percent 70 60 50 40 30 20 10 5 1 10 100 Time at Omnicell (Seconds) 1000 Figure 5. Probability plot for time at the Omnicell Figure 5 shows that the lognormal mean and lognormal standard deviation for the time at the Omnicell to be 3.787 seconds and.725 seconds, respectively. On average, nurses retrieve medication from the Pharmacy 6.8 times per day in the PCTU and 2 times per day in the PICU. By the nature of these trips, they are almost always unplanned because they normally occur when a missing medication is needed immediately. However, HSS was able to capture two trips and determined which took 165 seconds for trip 1 and 300 seconds for trip 2 to walk to the Pharmacy, retrieve the medication, and walk back to the patient s bedside. Nurse Trip Tally Sheets HSS created nurse trip tally sheets (Appendix B) to determine the number of trips nurses make to each location to they retrieve mediations. On the tally sheets the nurses marked the locations they went to find their patients medications. The nurses filled out the tally sheets for three weeks in the PCTU and both pods of the PICU. HSS used the tally sheet along with the time studies to quantify how much time nurses spend retrieving patient medications. Method Clerks in the PCTU and PICU placed the nurse trip tally sheets on the flow boards for each bed and replaced the sheets every 12 hours. Nurses were to indicate on the sheets each place they went to retrieve medications and whether they found everything, recording each trip as a separate line. At the start of the study, members of HSS attended each of the nurse shift report meetings for three days to educate nurses about the project as well as how to use the tally sheets. 14

Although 21 days of data were collected, HSS used the first 20 days when calculating statistics. The last day of data was eliminated due to insufficient sample size compared to the other 20 days. The remaining sample indicated the total number of trips and average number of trips per day to each location in each unit. In addition, HSS found the average number of trips to each location during a 12 hour shift for each bedside. Findings Table 3 summarizes the statistics calculated from the nurse trip tally sheets. Table 3. Nurse trip tally sheet statistics Average Number of Average Number of Trips / Day Trips 7AM-7PM / Bed Average Number of Trips 7PM-7AM/ Bed PCTU PICU PCTU PICU PCTU PICU Your Pod Med Room 93.9 54.2 5.9 4.3 6.5 3.8 Your Pod Omnicell 45.2 24.2 3.2 1.8 2.8 2.0 Other Pod Med Room 0.7 1.5 0.1 0.0 0.0 0.1 Other Pod Omnicell 0.2 0.6 0.0 0.1 0.0 0.0 Call to Pharmacy 4.7 5.1 0.3 0.4 0.3 0.3 CareLink Message 16.7 7.1 1.2 0.4 1.1 0.6 Trip to Pharmacy 6.8 2.0 0.5 0.1 0.4 0.2 As illustrated in Table 3, the most trips were taken to the nurse s own pod s medication room. In addition, these intensive care unit nurses take approximately the same number of trips during the 7AM-7PM day shift and the 7PM-7AM night shift, indicating a steady 24-hour operation. Although the standard deviations for these trips per shift are high due to the high variation of type of patient, illness, and number of medications needed, HSS used an average to account for extreme cases and incorporate the best and worst case scenarios. HSS compared the average number of CareLink messages recorded on the tally sheets (23.8 messages per day for both units) to the average number of CareLink messages recorded electronically (32.9 messages per day for both units) to determine an approximately 72% compliance for filling out tally sheets. Bed Census To verify that the data collection period for the nurse tally sheets represented a typical threeweek period, HSS obtained bed census data from January 1 st 2006 through November 1 st 2007. The bed census data contained the number of beds occupied in both the PCTU and PICU each day. HSS used the bed census data for the data collection period compared to the bed census data for the entire 22 month period to determine if the employment of the unit during data collection was representative of a typical employment. Since the collected data was used to extrapolate the nursing time spent retrieving medication, it was important to HSS to verify that this period represented the current state. Method HSS used the bed census data from October 15 th 2007 until November 1 st 2007 to represent the sample period, since these days corresponded with the days that tally sheets were collected. The entire period from January 1 st 2006 until November 1 st 2007 represented a typical time period, since it is long enough to offset any trends or variation. HSS calculated the average, minimum, 15

maximum, and standard deviation of the number of beds occupied during each period of time in each of the units studied. HSS then compared the statistics for the two periods of time to draw conclusions. Findings Table 4 shows the comparison of bed census statistics for the sample period to a typical period of time. Table 4. Bed census summary statistics for comparison Average/Day Minimum Maximum Standard Deviation PCTU PICU PCTU PICU PCTU PICU PCTU PICU Typical Period 13.0 12.8 6.0 5.0 15.0 16.0 2.2 2.4 Sample Period 12.9 12.7 8.0 7.0 15.0 16.0 2.2 2.5 As shown in Table 4, the sample period of time during which HSS collected data represents a typical time period. Both the average and standard deviation for the time periods differ by 0.1 beds at most in either unit. Since the number of beds during the sample periods represents the number during the typical time period verifies that conclusions drawn from the sample period data may be extrapolated for a typical time period. Omnicell Data To retrieve precise data on retrieval time for medications from the Omnicell, HSS worked with a Senior Applications Systems Analyst/Programmer to generate an Excel file from the Omnicell database with all the necessary information regarding nurse usage of the Omnicells within the PICU and PCTU. This information includes how many times medications were removed or delivered and the login and logout times for each transaction. These times validated the observations of the Omnicell that HSS conducted during time studies. Method Initially, HSS was hoping to obtain a report of login and logout times for every nurse in the PICU and PCTU. However, a Senior Applications Systems Analyst/Programmer explained that this would be very time consuming to generate, so HSS and its client, the Pediatric Safety Coordinator, decided the team could draw conclusions from a sample of nurses instead of the entire population of nurses from the PICU and PCTU. HSS requested a report of the user activity of 20 randomly selected nurses from the PICU or the PCTU for the week of October 22 - October 29. The team analyzed the distribution of the times outputted from the Omnicell, as well as, descriptive statistics to accurately describe a population of data based on the sample. The findings from the analysis of the Omnicell data supplemented the time data collected by performing time studies in the PICU and PCTU. Findings To analyze Omnicell data for a sample of 20 random nurses from either the PICU or the PCTU, HSS calculated descriptive statistics for the data in addition to fitting the data to a population distribution, which allowed the sample data to estimate a population of data. Population data is valuable because it aids in general predictions. 16

Overall, the maximum time spent at the Omnicell for one visit was 257.25 seconds and the minimum time spent at the Omnicell for one visit was 5.30 seconds. The time data per Omnicell visit is illustrated in Figure 6. 80 70 Number of Omnicell Visits 60 50 40 30 20 10 0 0 45 90 135 180 Time per Omnicell Visit (Seconds) 225 Figure 6. Time per Omnicell visit. As Figure 6 illustrates, the histogram of the data is skewed to the right. Due to the outliers, an average will not capture meaningful data. Rather, the best fit distribution of the data is the Lognormal distribution. The Lognormal distribution fit is shown in Figure 7. 99.9 99 C orrelation C oefficient Lognormal 0.994 95 90 Percent 80 70 60 50 40 30 20 10 5 1 0.1 10 100 Time per Omnicell Visit (seconds) Figure 7. Best fit distribution for the time spent at the Omnicell per visit. 17

In Figure 7, the data closely fits the reference line, which implies that Omnicell data can be accurately represented with the lognormal distribution, which is supported with the correlation coefficient value of 0.994. The database Omnicell data supports the findings from the time studies collected; both data sets are represented by the same distribution. Using the lognormal distribution, HSS calculated the expected time and standard deviation of the time nurses spend retrieving medications from the Omnicell. The average time, according to the lognormal distribution, is approximately 3.69 seconds per Omnicell visit with a standard deviation of approximately 0.63 seconds. Since these statistics were most reliable, HSS used the database statistics when calculating nurse retrieval time correlated with the tally sheets, as discussed in nursing conclusions. Combined Time Studies, Nurse Trip Tally Sheets, and Omnicell Data Times at the Omnicell from the time studies and the Omnicell data are both highly correlated to the lognormal distribution with similar lognormal means and standard deviations. The similarity in the Omnicell times verifies the accuracy of the time studies performed by HSS. HSS used the results from the tally sheets, the time studies, and the Omnicell data to determine the number of seconds a day the nurses in the PICU and PCTU spend retrieving medication from the Medication Room and Omnicell. To determine the number of seconds a day the nurses spend retrieving medications, HSS correlated the number of trips recorded on the tally sheets to each location to the time found in the time studies and Omnicell data for each trip. Method HSS used the lognormal inverse function in Excel to generate a time for each tally sheet trip to the Omnicell and Medication Room. In the lognormal inverse function, HSS generated a random number between 0 and 1 for the probability variable of the cumulative distribution function. To define the lognormal distribution, the lognormal mean and the lognormal standard deviation values from the time studies and Omnicell data were inputted to receive random outputs that model the sample data. The lognormal mean and standard deviation values HSS uses are shown in the Table 5. Table 5. Statistics used to generate random lognormal values Omnicell Visit Time from Medication Room Time in Medication Room Lognormal Mean 3.69 2.094 3.388 Lognormal Standard Deviation 0.63 0.381 0.825 To generate the time per trip to the medication room and at the Omnicell, HSS added the lognormal inverses for the time from the bedside to the Medication Room twice, once for the destination and once back from their destination, to the lognormal inverse of the time in the medication room or time at the Omnicell. HSS assumed that the time it takes to walk to the Omnicell and Medication Room are the same because the Omnicell is in the Medication Room. HSS Omnicell times started when the nurses entered the Medication Room ended when the nurses leave Medication Room. HSS also assumed that the time it takes to walk from the bedside 18

to the Medication Room and time it takes to walk from the Medication Room to the bedside are the same. Findings Table 6 shows how many seconds the nurses in the PICU and PCTU spent retrieving medications from the medication room and Omnicell during the 20 day HSS collected data. Table 6. Tally sheet and time study correlated results Medication room (Seconds) Omnicell (Seconds) Day PCTU PICU PCTU PICU 10/15/2007 10057.77 4615.76 8877.07 2271.61 10/16/2007 13192.48 5117.88 5969.49 1773.99 10/17/2007 8842.42 3616.28 5183.42 2173.39 10/18/2007 4074.19 4162.26 2475.70 1279.34 10/19/2007 6111.81 4223.53 4096.08 996.95 10/20/2007 5844.48 1638.12 5669.92 521.30 10/21/2007 4252.63 2750.94 1549.48 602.08 10/22/2007 2790.44 1029.01 2662.71 478.83 10/23/2007 373.01 676.95 138.15 697.35 10/24/2007 7127.63 3894.37 4134.60 1878.32 10/25/2007 0.00 5216.46 86.82 2233.33 10/26/2007 8184.55 4133.04 2118.31 1347.32 10/27/2007 7693.83 1820.78 2536.59 536.46 10/28/2007 7823.45 2182.48 1866.34 777.39 10/29/2007 2396.65 5378.42 763.44 3417.78 10/30/2007 5166.12 3153.70 2060.08 2510.98 10/31/2007 7651.62 4349.86 4203.65 2227.16 11/1/2007 4859.44 2860.31 2980.43 2338.01 11/2/2007 4026.62 2231.77 1512.58 1433.85 11/3/2007 1575.86 1602.10 267.06 880.20 Total Seconds 112044.99 64654.03 59151.92 30375.66 Total Minutes 1867.42 1077.57 985.87 506.26 As shown in Table 6, over the 20 days HSS collected data, the total time nurses in the PCTU spent retrieving medication was 1867.42 minutes from the Medication Room and 985.87 minutes from the Omnicell for a total of 2583.29 minutes retrieving medication. In the PICU, nurses spent a total of 1077.57 minutes retrieving medication from the Medication Room and 506.26 minutes retrieving medication from the Omnicell, which totaled 1583.83 minutes retrieving medication. Table 7 breaks down the results from Table 6 even further. Table 7. Total time spent retrieving medication in the PCTU and PICU PCTU PICU Total Total Seconds 171196.91 95029.69 266226.59 Total Minutes 2853.28 1583.8281 4437.11 Total Hours 47.5547 26.397135 73.95 Average hours/day 2.38 1.32 3.70 19

As Table 7 explains, the nurses in the PCTU spend a total, on average, of 2.38 hours a day retrieving medication from the Medication Room and Omnicell. In the PICU, the nurses spent a total, on average, of 1.32 hours per day retrieving medication from the Medication Room and Omnicell. Nursing Conclusions Based on the nursing data collection, including surveys, time studies, nurse tally sheets, and Omnicell data, HSS has drawn some conclusions about the current state of the medication retrieval process. Communication Conclusions As shown by the survey data, nurses do not always know when or where their patient s medications are delivered. In reply to knowing when a medication arrives from the Pharmacy, nurses gave an average response of 2.4, which corresponds to between Rarely and Sometimes. In addition, only 61% of nurses feel that medications are Usually delivered to where they expect, with the other 39% of lower confidence. Both of these metrics indicate an opportunity for improvement in communication between nursing and Pharmacy to allow nurses to feel more confident about medication delivery. Nurse Medication Retrieval All nurses from both the PICU and PCTU combined spend an average of 3.7 hours a day physically retrieving medication. By changing the medication delivery process, this time could potentially be spent on other activities, such as increased time at the bedside. Pharmacy To evaluate the current state of the medication retrieval process, HSS investigated two measures regarding the Pharmacy, PICU and PCTU. First, the team investigated the perception of the Pharmacy staff regarding delivery of medications to the Medication Room and missing medications. Second, HSS calculated the cost of missing medications. Surveys To evaluate the perceived communication between the Pharmacy and the nursing staff in the PICU and PCTU, HSS surveyed both the pharmacists and the nurses in Mott Children s Hospital. The surveys were two different sets of questions both composed of two questions. In the Pharmacy survey, pharmacists were asked how often they know where to deliver the medication and how often they feel they have already processed a missing medication. The survey can be found in Appendix E. Method In the Pharmacy, HSS met with the Pharmacy Manager to coordinate the distribution of the surveys. The Pharmacy Manager sent out an email explaining the purpose of the project and requested that each pharmacist complete a survey. Copies of the surveys were placed in the Pharmacy, and a folder was placed in the Pharmacy to collect completed surveys. As with the 20

nursing surveys, the Pharmacy survey questions were rated on a scale from one to five, where one indicated the perception of Never and five indicated the perception of Always. Findings Within the Pharmacy, 16 pharmacists were surveyed. The results from question 1 and question 2 from the Pharmacy survey appear in Figure 8 and Figure 9, respectively. Number of Responses 12 10 8 6 4 October, 2007 N=16 By HSS Program Operations Analyst Team 12 2 2 2 0 1:Never 2:Rarely 3:Sometimes 4:Usually 5:Always How often do you feel a "missing order" has previously been processed and dispensed? Figure 8. Results of Pharmacy Survey Question 1 21

Number of Responses 12 10 8 6 4 October, 2007 N=16 By HSS Program Operations Analyst Team 5 11 2 0 1:Never 2:Rarely 3:Sometimes 4:Usually 5:Always How often do you know where within a pod to deliver the medications? Figure 9. Results of Pharmacy Survey Question 2 Figure 8 illustrates that 75% of the pharmacists feel that a missing order has Usually been processed, with an average response of 4 (Usually). Figure 9 shows that 69% of the pharmacists feel they Always know where to deliver medications within a pod, with an average response of 4.69, which corresponds with a rating between Usually to Always. Phone Logs To determine the number of calls to the Pharmacy regarding missing medications, HSS designed a phone log sheet and asked the Pharmacy Manager to train everyone in the Pharmacy to complete the sheet. The purpose of this data collection was to determine the number of calls that the PICU and PCTU make to the Pharmacy regarding missing medications under the current medication retrieval process. This number can be used with the CareLink data to obtain an approximate total number of missing medications per day in the PICU and PCTU. HSS then used the total number of missing medications per day to determine the cost of disposing these medications. Method A call log was placed by each phone in the Pharmacy, and every time the phone rang, the pharmacists recorded where the call was coming from and whether the call was regarding a missing medication (see Appendix C for a copy of a log sheet). The completed sheets were placed in a designated folder and replaced with a new sheet every 24 hours at 7am. This data was collected for two weeks, from October 15 to October 29. HSS only used the first 12 days of data, as compliance dropped toward the end and many sheets had not been turned in. 22

When collecting Pharmacy phone logs, HSS noticed some of the sheets did not have dates or were not filled in for the complete shift. To address the compliance issue, HSS asked the Pharmacy Manager to remind the Pharmacy of the purpose of the study and instructions for phone log data collection. Findings The 12 days of data revealed that nurses from both the PICU and PCTU make approximately 7 calls to the Pharmacy per day as illustrated in Figure 10. Figure 10. Daily number of calls from PICU/PCTU to Pharmacy Day to day, the number of calls received by the Pharmacy regarding missing medications is in control within three standard deviations of the mean. In other words, the number of calls to the Pharmacy day to day is predictable, and throughout the 12-day period, number of calls ranged from 4 to 13. Although compliancy improved after HSS talked with the Pharmacy manager, it is still likely that calls that were coming into the Pharmacy were not being marked on the phone log. Also, four of the collected sheets did not have dates, so those sheets were not included in the totals in Figure 10. Therefore, the approximation of 7 calls per day to the Pharmacy represents a lower bound estimate, and the true average is probably higher. HSS believes that the compliance issues will not affect their results for percent of calls due to missing medications but should be accounted for in total number of calls to the Pharmacy. CareLink Data To evaluate the number of missing medications that are requested through the CareLink system, HSS requested CareLink data from the Pharmacy. The CareLink data covered the same two 23

weeks HSS collected the phone log data in the Pharmacy. The CareLink data was used to find the number of requests for a medication that the nurse could not locate. This number was combined with the number of calls nurses make to the Pharmacy regarding missing medications to approximate the total number of medications that nurses cannot locate per day. Method HSS received two weeks of messages through the CareLink system on October 15 and received another two weeks of messages on October 29. The team looked at 12 days of data, from October 15- October 26, since these dates corresponded with the dates for the phone log data collection. The CareLink data was sorted in Excel to retrieve the number of messages related to missing medications. Findings HSS found that 24.14% of all CareLink messages from the PICU and PCTU were requesting medications that the nurses could not locate. The totals of missing medication requests sent through CareLink for the 12-day period that HSS analyzed is listed in Figure 11 below: Figure 11. Daily CareLink Messages from PICU/PCTU to Pharmacy The number of CareLink messages received by the Pharmacy regarding missing medications is in control within three standard deviations of the mean. In other words, the number of CareLink messages received by the Pharmacy day to day is predictable. These daily totals include multiple requests for the same missing medications, so this data represents a high-end estimate for the number of messages regarding medications that nurses cannot locate. As can be seen in the 24

figure, these totals are consistently less than 50 messages per day, fluctuating from 25 to 47 requests. The daily totals for number of calls and messages from the PICU/PCTU to the Pharmacy regarding missing medications are combined in Table 8 below. Table 8. Daily Number of Calls and Messages from PICU/PCTU to Pharmacy Total requests for missing medications Total for 10/15: 38 Total for 10/16: 57 Total for 10/17: 47 Total for 10/18: 41 Total for 10/19: 38 Total for 10/20: 30 Total for 10/21: 32 Total for 10/22: 39 Total for 10/23: 36 Total for 10/24: 48 Total for 10/25: 33 Total for 10/26: 41 Number of days: 12 Overall Total: 480 Average per day: 40 Medication Disposal To quantify the cost of missing medications within the current medication retrieval process, HSS collected the number of disposed medications from PICU and PCTU. Every 24 hours, Pharmacy technicians collect all medications in the Medication Rooms that were not used the previous day. These medications were left in the Medication Room because a nurse could not find it, the medication was in the wrong location, or the dose was incorrect. The collected medications are thrown out unless they are a stock medication, in which case, they will be restocked in the Pharmacy. Method From October 15 to October 29, HSS collected the name, type, quantity, and dose of each medication disposed of from the PICU and PCTU to determine a cost of disposed medications. The Pharmacy separated the medications left in PICU and PCTU in a different bin from the other Mott Children s Hospital units. Once the medications were recorded, they were placed in the designated trash bin to insure these medications were not counted again the following day. 25

HSS worked with its client to obtain the cost information of disposed medications according to the medication name, the dosage, and concentration. HSS then calculated each medication cost by multiplying the raw cost with the concentration for each recorded medication. Findings With the cost data per disposed medication, HSS quantified the total cost due to medications left in the Medication Rooms of the PCTU and PICU. The total cost for the two week period analyzed by HSS was $13, 984.61. This total does not include the cost of medications meant for the PICU and PCTU that were erroneously delivered to other units in the hospital, as HSS only analyzed the medications that were disposed of in those units themselves. Pharmacy Conclusions Based on the Pharmacy data collection, including surveys, phone logs, CareLink messages, and medication disposal, HSS has drawn some conclusions about the current state of medication delivery. Communication Conclusions As shown by the survey data, there is a discrepancy in the perception of nurses and pharmacists regarding the current medication process. One hundred percent of pharmacists said they to know where to deliver a medication within a pod, yet 40% of nurses felt that medications rarely to sometimes got delivered to where the nurses expected. The lack of communication between nursing and the Pharmacy is highlighted by the fact that the average pharmacist believes that a reported missing medication has already been delivered. Missing Medication Requests When nurses can not find the medications that pharmacists believed have already been delivered, the nurses have to request replacements. This request can be done over the phone, through a CareLink message, or by personally walking down to the Pharmacy. HSS used phone logs and electronic CareLink message information to quantify these requests for missing medications. The resulting data indicated that at least 40 calls are made or messages sent to the Pharmacy per day. Medication Disposal These missing medications are thrown away at the end of each day. During the 2-week period that HSS collected information about these discarded medications, the hospital disposed of $13,984.61 worth of medication. Of these disposed medications, HSS determined that 1/3 were due to missing medications rather than other circumstances such as dosage changes. This proportion was generated by dividing the average requests received for missing medications per day by the average number of medications that were discarded per day. The implication of this calculation is that the hospital loses about $121,000 per year due to misplaced medications in just the PICU and PCTU alone. Summary of Key Findings HSS assimilated the data from the nurse data collection and Pharmacy data collection in order to evaluate the merit of the Medication Manager Pilot. 26

Nursing Savings Based on the tally sheets, the time studies, and the Omnicell data, HSS determined the total time nurses spend retrieving medications for the entire unit (see Table 9). Table 9. Key Times from HSS Data Collection PCTU PICU Total Hours Per Day Retrieving Medications 2.38 1.32 HSS verified that this time spent retrieving medications was indeed representative of a typical time period based on a comparison of the census data during the 20-day collection period and the bed census data for the past year. HSS then found the cost associated to the times spent in Table 9, based on nursing salaries from each unit. Using an average of Clinical Nurse I and Clinical Nurse II hourly rates for all seniorities from the University of Michigan Professional Nurse Council Contract Agreement, HSS multiplied this average nursing rate by the total hours spent retrieving medications in a year. For the nurses to retrieve medications, $35,600 of their salary is spent annually on this task. The Medication Manager Pilot would shift this task to Pharmacy Technicians, allowing this portion of nursing salaries to potentially be spent on other tasks that have greater added value to bedside nursing. Pharmacy Savings HSS calculated Pharmacy savings based on the percentage of missing medications found from the phone logs and CareLink messages, paired with the medication disposal data. The total amount spent annually on missing medications that are later disposed is $121,000. Under the Medication Manager Pilot, this type of error will be eliminated; therefore, this entire current cost is potential savings. Cost of New Delivery Process The hospital will have to spend about $100,000 to hire the required Pharmacy technicians for the Medication Manager Pilot. This figure includes salary and benefits for Pharmacy technicians that will be employed 16 hours a day, 7 days a week. Recommendation HSS recommends that the Office of Clinical Affairs implement the Medication Manager Pilot that will require Pharmacy Technicians to deliver the medications to the bedside in the PICU and PCTU. While the pilot will cost $100,000, there is a potential monetary savings of $121,000 in missing medication costs and a reallocation of approximately $35,600 in nursing time. HSS also believes the Medication Manager Pilot will increase communication between the Pharmacy and nursing departments. In addition, HSS recommends that the data presented in this report be used as a baseline for comparison to the data that will be collected during the new bedside delivery program. This comparison can be used to assess the best method for delivering medications to patients in the PICU and PCTU for implementation in the new Mott Women and Children s 27