Problem Statement:

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

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

• Problem Statement:• High patient volumes (Increase of average daily

chemo infusions by 56% over 2 year period)• No change in process as service expanded over

previous years• Chemotherapy orders written and faxed over a 3

to 4 hour time frame• Increased potential for significant or dangerous

medication errors• Increased patient wait time

Cancer Center Rapid Improvement Event- Project Charter

Focus Area-Patient Arrives Chemo Delivered

Impact on Customer-Increased wait times, Potential for dangerous errors, Staff frustration, Confusion in communication

Major factors of variation-Multiple orders faxed simultaneously, lab wait times, reporting of values, timeliness for physician to see

patients, flexible patient arrival times.

Assumptions-Need less congestion within the process, ACCURACY is the most important outcome.

Constraints-Space, staff, supplies, complex process, EHR

system does not support OncologyKey Metrics-

Time from door to chemoMed Error Rate- near missesTimeliness of chemo administrationStaff frustration and confusion

Time Frame = 30 daysTeam Members-

Cancer Center DirectorPharmacy DirectorPharmacistsPharmacy TechCancer Center RN’sCancer Center secretaryLab ManagerProcess Facilitators

Ad Hoc members- Admitting staff, IS staff, Oncologists

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Staffing • Cancer Center staff

• 5 RN’s, 1 Nurse assistant• Pharmacy

• All oncology incorporated into daily workflow. Staff rotation.

• No proactive interaction between Pharmacy and Oncology staff.

Chemo Near Misses• 112 Near Misses/22 days (5 near misses per day)• Typically missing BSA or dose calculation questionsDrug Waste $$$• Total value of drug waste= ~$160,000 per year• Process for consistently billing for waste not fully

developed or implemented.• No consistent method to audit payments for

services

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

Actions tabled or delayed (6/16)• Bedside Registration

• Inadequate space to accommodate technology in current environment

• Nurse Navigator• Position is currently under evaluation

• Point of Care lab equipment• Improvements in scheduling reduced the need for specialized

equipment• Laptop or tablet for physicians to view lab values

• Computers (wall modules) available in each exam room.• Oncology Software system for order management

• Request to Administration for upgrade- approved and scheduled for FY15

• Lab results pushed to mobile device• Improvements in lab scheduling reduced the need for mobile device

alerts

Action Items Implemented (10/16)• Scheduling of Patient visits• Laboratory scheduling• “Team Approach” (Nurse and Physician rounding together)

• Improved communication = Improved patient flow• Patient demographics and information obtained during lab pre-work

• Vital Signs, weights, and Medication lists obtained when patients arrive for lab-work.• Inter-Disciplinary huddle daily

• Pharmacy, Nursing, Clerical staff, and Physicians (when possible)• Discussions regarding “What went well today, Opportunities, and future patients”

• Electronic order entry by physicians• Order sets created for “pre-meds” and IV’s

• Addition of Pyxis machine to Cancer Center• Specialized Pharmacist and Pharmacy Technician for Oncology• Reduction in the use of “Stat” lab orders

• Everything is Stat = Nothing is Stat• Standardization of solutions- utilizing pre-mixes when possible

• Stock pre-mixes and IV’s in Pyxis

Cancer Center Scheduling ChangesSchedulingMonday - Thursday

Friday

4 pts / RN = 12 -16 Chemo Pts 8-10 followups10 Labs (Day prior and Nadir's)= 10 labs infusions5 pts / Doc followups = 10-12 followups injections5 follow-up labs = 5 followup labs transfusions

1pt / Doc Consults = 2 Consults low risk chemo

Noon

"Lab only's" (RN-allday)Chemo capacity = 48/week Port Flush's (RN-allday)Current level = 42/week

(14% increase in capacity)

"Like Chemos"Monday Tuesday Wednesday Thursday

FridayAbraxane Erbitux/Alimta Avastin

Pharmacy- Oncology Center Changes• Addition of 1.0 FTE- Oncology Technician

• Responsibilities• Chemotherapy IV admixture• Daily rounding in Cancer Center• Standardization of work procedures- Standard Work Instructions• Daily review of drug charges and order entry• Tracking of drug utilization and drug waste

• Dedicated Oncology Pharmacist (reallocation of existing staff)• Responsible for all Oncology patient order processing, review, and IV

admixture checking• Daily Rounding in Cancer Center

• Dedicated Oncology Workspace• Isolated area for Oncology Pharmacist and Technician• Communication- dedicated Fax, Phone, Computer, Pharmacy Window

OUTCOMES:• Patient Wait times- decreased by 25%• Medication Error Opportunity Reduction- 65%• Before: 112 Near Misses/22 days (5.1 near misses/ day)• After: 36 Near Misses/20 days (1.8 near misses/day)

• Chemotherapy Patient Capacity Increase of 14%• Increase from 42 to 48 patients per week

• Drug Waste Reduction• $150,000 immediately• Combination of waste reduction and billing improvements

• Improved Revenue• $60,000 annual billing error discovery- Aloxi appropriate j-code

units• Patient eligibility screening- $$$• Pyxis capture of all floorstock charges- ~$20,000/year

OUTCOMES:• Staff -

• Decreased frustration considerably. New model is more efficient• Better communication• Interdisciplinary involvement

• Patient Outcomes-• More fluid process• Less waiting (25%)• 96% Patient satisfaction score• Less opportunity for Medication Errors (65% reduction)- potentially

devastating errors• Health Center-

• Revenue- Increased capacity (14%), decreased waste ($150,000), improved revenue/billing processes

• Responsive to Employee concerns employee satisfaction

The Future:• New free standing Cancer Center• New Electronic Health Record system• Nurse Navigator system (under

construction)

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