IIE June Conference R Blackwell

Richard BlackwellProject Director, Process Quality

Cermak Health Services

Background on Cermak Health Services Motivation for process improvement Process improvement in a jail – mistake proofing

and automating the administration of medications

Implementation issues What works, and what doesn’t Change Management

Part of the Cook County, Illinois Health & Hospitals System Located in the Cook County Jail Provides comprehensive health care for the largest single-site correctional

healthcare facility in the US◦ Provides comprehensive care for ~10,000 detainees◦ 150,000 sq ft in 129 bed infirmary plus satellite facilities within the jail; 100 acre campus

Skyrocketing prison population, 1970s-2005 2,212,475 incarcerated in USA at end 2003 Over 10 million detainees released annually

from prison and jails to community Approximately 4 million under age 30 Potential reservoir of infectious disease for the

community and site for intervention

Source: www.sentencingproject.org/pdfs/1044.pdf accessed 10/5/05, and Prisoners in 2003, Bureau of Justice Bulletin, NCJ 205335, Nov. 2004.

Over 33% of all inmates reported some physical or mental disability.

About 25% of jail inmates report they had been treated at some time for a mental or emotional problem.

Clinical studies suggest that 6 to 15 percent of persons in county jails have severe mental illness.

A large proportion are homeless.

Largely driven by two forces◦ Lawsuits by inmates (Estelle v. Gamble, 1976)◦ Lawsuits by employees (MDR-TB New York)

Emerging discipline◦ National Commission on Correctional Health Care◦ Public health interactions – CDC, HRSA◦ ACP ASIM, SGIM, APA, ICAAC, CROI

HIV/AIDS TB STDs Hepatitis B & C Other

communicable diseases (MRSA)

Foodborne outbreaks

Mental health Violence

prevention Substance abuse Chronic diseases –

hypertension, heart disease, diabetes, asthma

Cook County Health and Hospitals System◦ Created in 2007 to split governance off from the Cook

County Board of Commissioners◦ Has installed a new management team at CHS & is

providing the necessary financial support Cermak under pressure to improve patient

services◦ Lost accreditation (National Commission for

Correctional Health Care) in 2007◦ 2008 Department of Justice investigation led to a

Consent Decree and Court monitors◦ Patient safety incidents have occurred◦ Class action and private lawsuits

Starts with Six Sigma as a structured problem-solving approach◦ Methods: DMAIC, Lean, etc.◦ Tools: Process/problem & statistical analysis◦ Teams: develop buy-in by involving stakeholders

in development of solutions Uses Quality Management System

certification as a goal and a clubto drive organizational change

>20% of detainees receive medication, with many receiving more than 1

Patients are dispersed◦ 129-bed Infirmary for acute care◦ 3 step-down intermediate care units◦ General population is in 247 small living units

(~50 per unit) in 17 stand-alone Divisions A court has determined that detainees are

to receive all prescribed meds within 24 hours of prescription

New Rx are generated by several sources All Rx flow to the Pharmacy for verification,

recording, and dispensing Each patient has a medication profile that is

available via a paper Medications Administration Record (MAR)◦ The official record that determines how Nursing

administers all medications◦ Printed at the beginning of the month◦ Updated for changes during the month

Current process is fragmented, and lacks controls

Security concerns (it’s a jail!) Number of patients per nurse Detainees move around

◦ Transferred at short notice, or may be in Court or school at meds admin time

Meds distribution methods vary◦ Dose by dose administration of TB, HIV, psychotropics,

and controlled substances◦ 7-day self-packs (Blister Packs) when appropriate

Patient Data Management System replaces the manual process◦ Physician Order Entry: Patient

encounter data (including Rx) entered directly by physician or nurse into the patient’s medication profile

◦ PharmNet: used by Pharmacy to record and track dispensing and inventory

◦ Scheduling: maintains & manages patient encounters

◦ eMAR: electronic patient record contains all data (text and scanned) generated by patient encounters and medications

Automate to ensure “5 Rights”◦ Identify patient via bar-coded wristband◦ Pull up patient’s med profile from PDMS◦ Confirm medications to be administered

with bar code◦ Confirm administration event to PDMS◦ Record vitals, problems, special

conditions To be implemented with Wireless

handheld devices

• Right patient• Right time• Right drug• Right dose• Right route

• Right patient• Right time• Right drug• Right dose• Right route

Process analysis teams and Root Cause Analysis/FMEA to identify process requirements

Challenges encountered so far◦ Lack of experience◦ Organizational “Silos”◦ History & personalities◦ Resources◦ Vendor management◦ Project management

The Attractions The Problems

The mission Commitment to the

mission by key managers Exposure to real problems

faced by others not much like you

Opportunity to apply standard solutions in new ways

Low hanging fruit Immediate impact

Resources◦ No slack capacity◦ Naïve management◦ Facilities◦ Archaic processes & tools

Workforce◦ Entrenched, Unionized◦ Cynical◦ Aging

Purchasing constraints Inertia, confusion, poor

information Politics

Your Personal Approach Project Techniques

Patience and tenacity Flexibility &

willingness to compromise

Respect for diversity A good sense of

humor Thick skin

LISTEN Plan & coordinate SIMPLIFY Coach; don’t dictate Be ready to make mid-

course corrections SIMPLIFY

Basic Industrial Engineering◦ Process analysis and documentation◦ Process simplification◦ Cost analysis and reduction◦ Cost justification (e.g. ROI)◦ Mistake-proofing

Exposure to IT processes, especially requirements definition

Project management Change management

“Change management is a structured approach to transitioning individuals, teams, and organizations from a current state to a desired future state. Change management (or change control) is the process during which the changes of a system are implemented in a controlled manner by following a pre-defined framework/model with, to some extent, reasonable modifications.” - (Wikipedia)

Avoid overwhelming the organization Co-ordinate disparate & sometimes

conflicting efforts Help the organization evolve

Establish a Change Management Committee◦ All stakeholders, internal & external◦ Commitment by Sr. Management◦ Schedule & drive required meetings◦ Setup Corrective Action tracking tools

Train & develop the team◦ Communications◦ Planning process change efforts◦ Dealing with conflict◦ Tracking and closing Corrective Actions

CMC is a permanent commitment

Richard [email protected]