Performance Improvement: Not Just a To Do But a Real Tool for Improving Your Business Lisa Siefert, RPh, FASHP, ASQ CMQ/OE Maura O Neill, MBA, RD, LD, CNSC Kathleen Iacuone, RN BSN Nita Meaux, RN, CRNI Rowell Medina, PharmD CE Credit in Four Easy Steps! 1. Scan your badge as you enter each session. 2. Carry your Evaluation Packet to every session so you can add session evaluation forms to it. 3. Track your hours on the Statement of Session Attendance Form as you go. 4. At your last session, total the hours and sign both pages of your Statement of Session Attendance Form. Keep the PINK copy for your records. Put the YELLOW and WHITE copies in your CE Envelope. Make sure an Evaluation Form is in your CE Envelope for each session you attended. Miss one? Extras are in a file near Registration. Fill out the information on the outside of the CE Packet envelope, seal it, and drop it in the box near Registration. Applying for Pharmacy CPE? If you have not yet registered for an NABP e-profile ID, please visit www.mycpemonitor.net to do so before submitting your packet. You must enter your NABP e-profile ID in order to receive CE credit this year! 2 Speaker Disclosures The speakers declare no conflicts of interest or financial disclosures. Clinical trials and off label/investigational uses will not be discussed during this presentation. 3 1
Quality or Process Improvement Modalities Lisa Siefert RPh., FASHP, ASQ CMQ/OE Corporate Manager, Accreditation, Quality, and Clinical Education Walgreens Infusion and Respiratory Services Lisa.siefert@walgreens.com Process Improvement Definitions Process improvement is an aspect of organizational development (OD) in which a series of actions are taken by a process owner to identify, analyze and improve existing business processes within an organization to meet new goals and objectives, such as increasing profits and performance, reducing costs and accelerating schedules. These actions often follow a specific methodology or strategy to encourage and ultimately create successful results. Process improvement may include the restructuring of company training programs to increase their effectiveness. Process improvement is also a method to introduce process changes to improve the quality of a product or service, to better match customer and consumer needs. 1 Refers to the act of changing a process to reduce variability and cycle time and make the process more effective, efficient, and productive. Cook, Sarah (1996). Process improvement: a handbook for managers. Gower Publishing Ltd, et al. Retrieved February 4, 2012. ISBN 0 566 07633 0 Okes, Duke and Westcott, Russel. The Certified Quality Manager Handbook 2 nd Edition. American Society for Quality. Quality Management Division. ISBN 0 87389 487 1. Crash Course in Quality Total body of knowledge Professionals focused on discipline Organizational strategy Problem solving tools Management and planning tools Innovation Hot Topic 2
Founding Fathers W. Wedwards Deming quality primary driver for business success Phillip Crosby quality as conformance to requirements must be measured Armand Feigenbaum Quality control strategic business tool Kaoru Ishikawa quality control Joseph M. Juran Quality features of products meet customer needs and quality is cost that consists of freedom from failure this higher quality costs less. CORE MEASURES 8 Six Sigma Quality improvement through use of standard process that is measured and improved upon utilizing statistical methods Six sigma process in which 99.99966% of products are expected to be free from any issue/defect (3.4 defects per million) Wikipedia: Six Sigma 3
Lean What Is a Lean Culture? Lean is an approach to improve quality, increase productivity, reduce costs, and increase customer satisfaction by eliminating waste and creating value. A lean culture is the sum total of all the lean tools, techniques, and knowledge that exist within an organization at the root level and that fuel the overall organizational alignment via collective lean thoughts, words, and actions toward the elimination of waste and the creation of value. Organizations that have a strong lean culture do two things: 1. They promote at least five key cultural enablers (safety, standards, leadership, empowerment, and collaboration), which allows the lean culture to exist 2. They build their business on the core fundamentals of respect for Individuals The lean handbook. Anthony Manos and Chad Vincent, editors. American Society for Quality, Quality Press. ISBN 978 0 87389 804 1 Muda 7 Wastes An easy way to remember the 7 wastes is TIMWOOD. T: Transportation I: Inventory M: Motion W: Wait O: Over processing O: Over production D: Defect Wikipedia: Muda Mnemonics accessed 2/5/13 5. Wikipedia: Muda Mnemonics An other easy way is NOW TIME: It's now time to eliminate Mudas: N: Non Quality O: Over production W: Wait T: Transportation I: Inventory M: Motion E: Excess processing Kaizen Japanese term that means gradual unending improvement by doing little things better and setting and achieving increasingly higher standards. Make famous by Masaaki Imai Book Kaizen: The Key to Japan s Competitive Success Okes, Duke and Westcott, Russel. The Certified Quality Manager Handbook 2 nd Edition. American Society for Quality. Quality Management Division. ISBN 0 87389 487 1 4
Kaizen Event/Blitz Event/Blitz Team approach for a short time Utilize continuous improvement techniques, tools, and concepts U.S. Environmental Protection Agency. Lean Government: Region 7 and 4 States National Pollutant Discharge Elimination System (NPDES) Kaizen Event Case Study. August 2009. Fact Sheet. PDCA plan, do, check, act DMAIC define, measure, analyze, improve, control Root cause analysis 5 whys 5 Ss Problem Solving Tools Pareto chart Flowchart Cause effect analysis Check sheet Control Charts Histograms Scatter diagrams Resources American Society of Quality www.asq.org National Committee for Quality Assurance www.ncqa.org International Organization for Standardization 5
Performance Improvement Case Studies 16 Enteral Therapy Management: Refill Requests and Medicare Reimbursement Maura O Neil, MBA, RD, LD, CNSC Nutrition Program Manager Midwest Region Walgreens Infusion Services Maura.oneill@walgreens.com Problem Identification and Improvement Process Problem Identification: Identify problem and its scope Is it worth solving? Do nothing? What do you get when you address the problem deliverables? www.youtube.com/watch?v=uncoo9q_yam by Executive Approaches to Strategic Excellence. Accessed January 2013 6
Problem Identification and Improvement Process FISH Focus Improve Sustain Honor (4 for 50 rule) www.youtube.com/watch?v=dvxkl4/5jgw by Jay Arthur Identification of Problem (Focus) Enteral census gained through organic growth and acquisition, resulting in: Unique enteral management systems Inconsistent documentation Difficulty in assessing Medicare compliance Potential Impact Reimbursement CMS Refill Record Requirements (Centers for Medicare & Medicaid Services) A valid refill record must contain four elements: 1. Date of refill request 2. Beneficiary s name or authorized representative if different from the beneficiary (list relationship to patient) 3. Consumable vs. non consumable a. Consumable For supplies that are used up, assess quantity of each item beneficiary has remaining to document the amount remaining will nearly be exhausted on or about the supply anniversary date b. Non consumable For more durable items that are not used up but may need periodic replacement, assess whether supplies remaining are functional. If replacement is requested, document functional condition of item being replaced in sufficient detail to demonstrate the cause of the dysfunction that necessitates replacement 4. Description of each item being requested http://www.cgsmedicare.com/jc/pubs/news/2012/0812/cope19798.html 7
Processes Used to Identify Failure (Focus) Existing knowledge of systems (varying software platforms) Intuition and Observation Data collection (forms, notes, policies) for measurement and analysis Data Analysis (Focus) Data obtained to validate problem revealed three (3) focus areas: Free texting refill record: Inconsistent documentation Refill Record Form in place: Occasional Inconsistencies Refill Record Form in place: Billing would prefer faster system access to refill record forms Processes Implemented (Improve) Regular Email Reminders Enteral Management Policy and Procedure Use of Enteral Management TooI Importance of documenting all refill request elements Internal Audits to assess compliance Increased communication and data sharing between Reimbursement Department and Branch Management 8
DENIAL PERCENTAGE SNAPSHOT (over past year) Medicare Denial Percentages for Part B Therapies 73% 27% INCOMPLETE REFILL REQUESTS OTHER REASONS FOR DENIALS THERAPY COMPARISON: INCOMPLETE REFILL REQUESTS Percentage Incomplete Refill Requests 8% ENTERAL OTHER PART B THERAPIES 92% Positive Outcomes & Continuation of the Process Improvement Cycle (Sustain) Increase use of standardized monitoring system Continue to improve uniform system designed to comply with CMS regulations and guidelines Ongoing enhancement of data collection system so data can be measured and analyzed for the purposes of improvement and control 9
Acknowledgements (Honor) Thank you to the following Walgreens Infusion Experts : Sue Greenwell, Enteral Patient Services Representative, Dallas Sherry Owens, Regional Reimbursement Manager, Dallas Carolyn Keefer, Nutrition Support Dietitian, Kennewick Lee Badragan, Corporate Medicare Reimbursement Manager, Deerfield Sharon Niewinski, Senior Analyst Corporate Medicare Reimbursement, Deerfield Nursing Mileage Kathy Iacuone, RN BSN Nurse Manager Coram, Tampa, FL Kathleen.Iacuone@coramhc.com Problem Identification Company Scoreboard indicated that Tampa branch had higher mileage per visit than national average Preliminary attempts to decrease mileage included: Made staff aware for better territory management Increased per diem staff to offer better options for staffing cases 10
Root Cause Analysis Most high mileage visits were occurring oncall A single nurse covered the western central Florida territory including 18 counties Drive time of 5 hours end to end Calculated costs associated with adding a second on call nurse and compared to costs associated with high mileage and drive time Results Results came quickly! Dec 2011 48.26 mi/vs Jan 2012 42.59 mi/vs Feb 2012 41.50 mi/vs March 2012 38.10 mi/vs Added Bonus In addition to achieving reduced costs in the form of lower mileage and driving time, we realized some unexpected benefits: Nurse Satisfaction increased dramatically because of the smaller territory coverage On Call Scheduling is now fully managed by the two on call teams, with rare management intervention The nurses now take ownership for their coverage areas and work to keep mileage and expenses as low as possible while meeting patient needs 11
34 Conclusion Always a work in progress! Mileage rates fluctuate depending on seasonal influences Achieved a new low of 34 mi/vs in June First Step: Know your mileage per visit! Without data collection and trending, problems go unnoticed Delivery Failures and Costs Nita Meaux, RN CRNI Heart Failure Program Director Director of Risk management Walgreens Infusion Services Nita.meaux@walgreens.com 12
Problem Identified QAR (quality assessment reports) showed trend of increasing costs and patient complaints due to late or incorrect deliveries 37 PDCA Model Plan Do Check Act PI Process Implemented 38 Plan Evaluate all QARs (during past quarter) relating to delivery issues Assess Cost of additional nursing visits required due to late or incorrect delivery Cost of additional supplies needed to replace erroneous deliveries Cost of additional deliveries (personnel or courier) 39 13
DO Included pharmacy, warehouse, and delivery staff in evaluating cause of errors and late deliveries Identified areas for improvement Current P/P not being followed Late labs causing delays in compounding Inconsistent orientation of PSR/warehouse staff Failure to adhere to double check process New referrals causing changes in schedule Courier delivering for several businesses simultaneously (adding time to each route) Nurse scheduler not consistently coordinating delivery time with visits scheduled 40 DO Implemented mandatory in services for all staff involved in picking, packing, checking or delivery Revised work flow to ensure double check completed prior to packing (2 signatures required) Collaborated with nursing to ensure blood draws done one day ahead when possible Assigned responsibility to specific staff for obtaining lab results ASAP 41 DO Implemented intake pharmacist to handle all new referrals or changed orders Negotiated with courier service to avoid other deliveries causing delay for our patients Nurse scheduler notified of any delays in delivery 42 14
CHECK Observed QAR trends at 30, 60 and 90 days At 90 days, 90% improvement in overall costs associated with additional deliveries or nursing visits necessary due to late or incorrect deliveries Improved patient satisfaction scores Improved nurse satisfaction 43 ACT Pharmacy Manager and Warehouse Manager ensured ongoing monitoring of processes and orientation of new staff PI committee continued to monitor QARs, patient complaints and costs associated with delivery failures for additional quarter then at least one quarter annually Ongoing use of PDCA process for sustained improvement 44 Decreasing Drug Order Process Time Rowell D. Medina, PharmD Infusion Clinical Pharmacist Johns Hopkins Home Care Group Pharmaquip Baltimore, MD E mail: rmedina7@jhmi.edu Phone: 410 288 8074 15
Purpose Define Problem: Increasing demand (11.4% vs. last year) for infusion drug preparation leading to added pressure and higher stress, longer work hours and increased potential for medication errors Methodology: Lean Sigma Approach DMAIC methodology Remove/reduce non value added activities (waste) from the existing process Define Measure Analyze Improve Control Project Goal Decrease drug order process (lead) time by 25% Monday, April 8, 2013 Medina 46 Value Stream Map Measure Process time = 44 Min. Wait time = 110 Min. >70 % of time = Wait Monday, April 8, 2013 Medina 47 What We Learned? Analyze 7 Types of Waste: Defects, Overproduction, Motion, Inventory, Waiting, Over Processing, and Transportation Key Opportunity: Wait time between process steps Need of 2 Project Phases: Phase 1: Clinical team area (front end) Phase 2: Production area (back end) Brainstorming. Spaghetti Diagram Travel distance = 206 ft. Monday, April 8, 2013 Medina 48 16
Interventions: Phase 1 Improve Production Area Copier Before 195 ft. Copier Fax Fax Production Area Copier & Fax After 91 ft. Copier & Fax Monday, April 8, 2013 Medina 49 Interventions: Phase 1 Improve Reduced wait time: Refill mixing reports (70%) are now printed in Production Area and don t require a duplicate RPh signature All mixing reports were printed in the clinical office area Staff kept running back & forth b/w clinical and production area Enhanced communication with an intercom and light signals Switch Intercom Clinical Area Production Area Packaging Area Monday, April 8, 2013 Medina 50 1 5 4 6 4 1 5 2 2 Before 206 ft. Interventions: Phase 2 3 After 105 ft. 3 6 Improve Redesigned production pharmacy layout using 5S Elements Sort, Set in order, Shine, Standardize and Sustain 1) Divided workstation table 2) Relocated Production RPh s office 3) Enlarged stock room (for growth) 4) Relocated & added a (2 nd ) clean room pass through windows 5) Relocated printers and drug storage 6) Relocated & enlarged delivery window Monday, April 8, 2013 Medina 51 17
Interventions: Phase 2 Improve Added walkway pass through Created kitchen triangle design concept Monday, April 8, 2013 Medina 52 Interventions: Phase 2 Improve Relocated Production RPh office increase line of sight New location of RPh office with window The view from RPh window Meds to be checked! Monday, April 8, 2013 Medina 53 Signals to work: Kanbans BEFORE Interventions: Phase 2 AFTER Improve Added a 2 nd clean room pass through IN OUT Production leveling tool: Heijunkas Heijunka Items for the next day Monday, April 8, 2013 Medina 54 18
Metric Baseline Post Project Lead time reduction Goal 33 min. 20 min. 25 min. (25%) Outcomes Actual 39% Reduction Staff Engagement (5pt. scale) Overall Satisfaction Materials & equipment to do my job 2010 2011 2012 2.9 4.3 4.6 3.8 4.4 4.6 Opportunity to do 3.4 4.2 4.8 my best every day Opinions Count 2.6 3.9 4.2 Monday, April 8, 2013 Medina 55 Control Plan Control Monday, April 8, 2013 Medina 56 Conclusion Lean Sigma Methodology is a useful tool to evaluate and identify pharmacy workflow inefficiency, remove process waste, reduce lead time and impact medication safety. A control plan with updated standard operating procedures is needed to outline key metrics and process documentation to be maintained in order to monitor and sustain (Kaizen) improvements. It also provides basis for further enhancements. Monday, April 8, 2013 Medina 57 19
Summary Performance Improvement is an ongoing process which requires interdisciplinary collaboration, analysis and implementation Regardless of the method utilized, a team approach can truly make the PI process a powerful tool for improving operations, reducing risks, and increasing employee and patient satisfaction. 58 59 References 1. Cook, Sarah (1996). Process improvement: a handbook for managers. Gower Publishing Ltd, et al. Retrieved February 4, 2012. ISBN 0 566 07633 0 2. Okes, Duke and Westcott, Russel. The Certified Quality Manager Handbook 2 nd Edition. American Society for Quality. Quality Management Division. ISBN 0 87389 487 1 3. Wikipedia: Six Sigma accessed 1/31/13 4. The lean handbook. Anthony Manos and Chad Vincent, editors. American Society for Quality, Quality Press. ISBN 978 0 87389 804 1 5. Wikipedia: Muda Mnemonics accessed 2/5/13 6. American Society for Quality. Plan Do Check Act Cycle. http://www.asq.org/learn about quality/projectplanning tools/overview/pdca cycle.html 7. Mindtools.com. Plan Do Check Act (PDCA). http://www.mindtools.com/cxctour/pdca.php 8. International Community for Project Managers. The PDCA Cycle of Systematic Development. http://www.theicpm.com/quality management/3413 the pdca cycle of systematic development 9. Najmi, Adeel & Sidhu, Sanjiv. Creating Greater Agility with Plan Do Check Act. http://www.i2.com/supplychainleader/issue3/html/scl3_creating_greater_agility.cfm 20