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

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Do you know what your staff are doing?Performance improvement through tracers

Margarita Fedorova, CPhTCedars-Sinai Medical Center

Pharmacy Technician Supervisor

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Disclosure

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

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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 processesIdentify opportunities to improve quality and patient safetyDescribe feedback forums to staff to improve performance

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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 processesIdentify opportunities to improve quality and patient safetyDescribe feedback forums to staff to improve performance

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Cedars Sinai Medical Center (CSMC)

Non-profit, acute, tertiary, teaching hospital

886 licensed beds120 intensive care unit beds

Level I trauma center, Comprehensive Stroke Center

Department of Pharmacy Services:Decentralized clinical pharmacy servicesEmergency department and operating room servicesSolid organ transplant servicesTransitions of care services Outpatient pharmacy services including ambulatory care clinicsOncology services

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“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 22California Board of PharmacyCenter for Medicare and Medicaid Services(CMS)Many others

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“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

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Who’s Looking?

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THEY are LookingThe 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

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THEY are LookingThe 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

Patient Safety

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Assessment Question #1

In which of the following steps of the Medication Use Process (MUP) are technicians involved in?

a) Administeringb) Dispensingc) Hiding medications from the nursesd) Storagee) B & D onlyf) All of the aboveg) I don’t know

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Technician roles in the Medication Use Process:Safety is a Key Factor in All Aspects

Selection & Procurement Storage Ordering &

TranscriptionPreparation &

Dispensing Administration Monitoring &Evaluation

•Inventory•Floor Stock•Recalls•Automation

•Purchasing•Bar Coding •Drug Supply Chain Security Act (DSCSA)•Patient assistance

•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)

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Assessment Question #2

Which regulatory agencies have an oversight over the Medication Use Process that affect technician roles?

a) CMS

b) TJC

c) CDPH

d) CA Board of Pharmacy

e) All of the above

f) Your local cable company

g) I don’t know

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Core Technician Roles in Medication Use Process

Focus Areas for Regulatory Agencies and

Safety OrganizationsTJC CMS CDPH ISMP

Storage x x x x

Dispensing x x x x

Evaluation x x x x

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Technician Role in Medication Use Process: Storage

Checking Beyond Use Dating (BUD)/expiration dates:Dating of open multidose vials IV Fluids outside of overwrapCompounded Sterile Products (CSPs)

Monitoring refrigerator/freezer temperaturesEnsuring medications are protected from light, when applicableStoring medications in the right location (refrigerator vs. warmer vs. room temperature)Removal of outdated medicationsEnsuring cleanliness of medication storage areas

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Technician Role in Medication Use Process: Dispensing

Ensuring dispensing accuracyRight patient: use of 2 patient identifiersRight drugRight doseRight timeRight route

Ensuring safe use of Patient’s Own Medications (POM)*Alert pharmacist when POM are available to be verified right medication administered

to patientAlert nursing leadership when POM are left behind at discharge minimal disruption to

patient’s regimen and patient’s and organizational financial impact

*CSMC Process

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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

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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

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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.

a) True

b) False

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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 standardsTracer 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 standardsConsistent application of established processes

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Why are Technician Tracers Needed?

General points: Increasing number of staffIncreasing roles of techniciansIncreasing regulatory requirementsMore complicated medication regimensIncreasing use of automationImplementation of CPOE

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Why are technician tracers needed?, cont

Recent 26% increase in number of technicians to supervise.New Comprehensive Stroke Center designationGrowing transplant programChange 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

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Tracer Criteria

Tracer criteria are developed and evolve based on:

Regulatory requirements

Organization policies and procedures

Previously identified gaps, deficiencies or problematic areas

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Focus Areas

Current CSMC tracer focus categories:

1. Temperature Logs 2. Outdates3. Patient Own Medications4. Discontinued Medications5. Deliveries To The Wrong Location6. Transfer of medications 7. Dispensing Error 8. Stock Error 9. HIPAA 10. Meds In The Tube station

11. Technician Name Posted12. Cleaning Medication Carts13. Signing Delivery Log 14. Dating Of The Insulin Vials 15. Answering Assigned Phone16. Unnecessary Refill 17. Medication Cart Labeling 18. Nothing Found 19. Discharge meds left behind 20. Other

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Development of a Tracer Database

Several methods exist to track tracer findings:

Paper logs, notes in the file

Email notes to yourself and store in a dedicated Outlook® folder

Use Excel® spreadsheets

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Development of a Tracer Database

Several methods exist to track tracer findings:

Paper logs, notes in the file

Email to yourself and store in a dedicated Outlook® folder

Use Excel® spreadsheets

Manual or Semi-Manual Processes

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Assessment Question #4

What are the advantages of an Access® database in tracking tracer results when compared to other traditional methods?

a) Data structure & Normalization

b) Scalability

c) Data and Referential Integrity

d) Queries and Reports

e) All of the above

f) Helps to Win the Lottery

g) I don’t know

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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

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Access® Database, cont.

Advantages of an Access® database8

Data structure and normalization through multiple tablesDatabases make it easy to store information in one place and reference it in multiple

placesScalability, Data and Referential IntegrityDatabases provide many tools to maintain data quality and eliminate redundancies

Queries and ReportsMS Access queries and reports let you slice and dice your data and present it in detail or

summary form

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Access® Database, cont.

Advantages of an Access® database8

Data structure and normalization through multiple tablesDatabases make it easy to store information in one place and reference it in multiple

placesScalability, Data and Referential IntegrityDatabases provide many tools to maintain data quality and eliminate redundancies

Queries and ReportsMS Access queries and reports let you slice and dice your data and present it in detail or

summary form

Fully Automated

Process

Access® Database Field Relationships

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Database Input Form

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Database Results Findings by Location Findings by Employee

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How is data evaluated?Periodic evaluations (monthly, quarterly, annually) to:Identify trend directionAssess overall compliance to standards

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Top Issues Identified 2013 – 2015*

* Through August 2015

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Overall Issues Identified 2013 – 2015*

* Through August 2015Year 2013 Year 2014 Year 20150

50

100

150

200

250

Overall Issues Identified 2013-2015*

Problems Found Exponential (Problems Found)Nothing Found Exponential (Nothing Found)

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Assessment Question #5

How can tracer results be used to improve the Medication Use Process?

a) Identify Performance Improvement Opportunities

b) Staff Recognition

c) Performance Appraisal

d) A & B only

e) All of the above

f) I don’t know

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How is Data Used?

Staff engagement & recognitionStaff meetings/huddlesOpen forum meetings

Performance improvement initiativesDownward trends focus for performance improvement initiatives

Individual Follow-upStaff is notified immediately about findings

Periodic performance appraisal/discussions with the supervisor

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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) methodologyMonitor successful test of change implementationInitiate PI projects:Compliance to temperature recordingCompliance with removal of medications for discharged patientsMissing medication studyChange in insulin dispense methodology

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SummaryTechnicians 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 initiativesCompile objective data for staff recognition and individual feedback

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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

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References1. Hardcore Investigations[Internet] Available from: www.hardcoreinvestigations.net

2. The Joint Commission[Internet] Available from: http://www.jointcommission.org/the_joint_commission_mission_statement/

3. CDPH[Internet] Available from: http://www.cdph.ca.gov/pages/AboutUs.aspx

4. CMS[Internet] Available from: http://innovation.cms.gov/about/Our-Mission/index.html

5. CA Board of Pharmacy[Internet] Available from: http://pharmacy.ca.gov/about/mission_statement.shtml

6. The Joint Commission E- dition[Internet] Available from : https://e-dition.jcrinc.com/MainContent.aspx

7. Access Definition[Internet] Available from: http://techterms.com/definition/access

8. FMS World Class Software Solutions[Internet] Available from: http://fmsinc.com/microsoftaccess/dataanalysis/versus-excel.html

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