Process we are using: A3 Thinking

Transcription

1 Process we are using: A3 Thinking 1.Reason for Action Chief complaint 4.Gap Analysis Chasm between Current & Target 7.Completion Plan Project plan 2.Initial State Current process 5.Solution Approach Hypothesis 8.Confirmed State Sustainment measures 3.Target State By how much to improve? 6.Rapid Experiments 9.INSIGHTS Learnings & spread

2 REASON FOR ACTION We cause patient harm through vaccine errors including: Wrong order Wrong vaccine Wrong interval/time Wrong route Wrong patient Wrong dose Missed opportunity Incorrect/failures in storage Incorrect labeling/stocking Wrong documentation

3 This interdisciplinary team is seeking to design ideal workflows Specifically: Define vaccine process for CHMG Standardized storage: same storage and labeling for all vaccines at every practice based on template Dedicated oversight of vaccine process Clear role definition of vaccine coordinator with supervision and monitoring by Clinical Leader Each practice is responsible to report compliance Develop a CHMG standard of practice for vaccine management and administration Education Competency Ongoing auditing of vaccine process elements 3

4 CURRENT STATE Quality & Safety Recent errors related to: Administration of incorrect vaccine with look-alike/sound-alike names TDap vs Td vs DTap vs dt Pediatric vs Adult formulations and doses

5 CURRENT STATE Quality & Safety Source: PIDS data

6 CURRENT STATE Quality & Safety Recent errors related to: Reconstitution of HIB vaccine with non-hib sterile diluent

7 CURRENT STATE Quality & Safety: Family Health Center Concord Pediatric Flu HepatitisA Hepatitis B Pediarix (Dtap, IPV, Hep B combo) Varivax Adult Flu Hepatitis A Hepatitis B TwinRix (HepA/B combo) Zostavax # instances any of these vaccines are administered = Data taken from Vaccine Estimates Family Health Center

8 CURRENT STATE Quality & Safety Min = 6.6 fc Data from Fall 2013 measurements, Facilities

9 CURRENT STATE Effectiveness *Does not include FHC-Concord s Large Storage Refrigerator 4 practices do not have freezers Data from Fall 2013 measurements, Facilities

10 CURRENT STATE Effectiveness Vaccine Refrigerators

11 CURRENT STATE Effectiveness Vaccine Refrigerators

12 CURRENT STATE Timeliness & Effectiveness Recent errors related to: Administration of vaccines at incorrect intervals Administration of HIB diluent to patient in lieu of HIB vaccine

13 CURRENT STATE Human Development 24% of staff who administer vaccines have taken the CHMG Immunization Basics Class

14 CURRENT STATE Financial Sources: vaccines and doses on hand at FHC-Concord; McKesson pricing per dose

15 CURRENT STATE Financial Practice F Practice G Practice H Practice I Practice M Practice N Practice J Practice J Practice K Practice L Practice L Practice L Practice M Source: CHMG Practice reports and Pharmacy ordering reports

16 CURRENT STATE MAP

17 IDEAL STATE Pictorial & Attributes

18 FUTURE STATE MAP 50,000 Ft Level

19 TARGET STATE Target Current Metrics: Quality / Patient Safety FY 2013 Timeliness / Effectiveness 2013 Satisfaction / Team Development 2013 Financial / Growth 2013 Independent double-checks prior to vaccine administration 100% standardized Non-standard % of CHMG employees who administer vaccines attend Immunization Basics class Reduce financial impact of equipment-related storage malfunction/error (by use of pharmacy-grade refrigerators throughout CHMG primary care practices) Standardized labeling for all CHMG Primary Care vaccine refrigerators 100% of new hires beginning June % as of 04/11/14 50% $46, % standardized Non-standard Watch Metrics Increase in event reporting 01/01/ /01/2014 = 104 events reported 19

20 GAP ANALYSIS Phase 1 Parking LOT? ( ) A standardized process for moving vaccines when power outage expected Phase 2 Computerized order entry in CHMG A dedicated vaccine prep area that provides interruption-free work time A standardized procedure for vaccine administration Dedicated, uninterrupted time from vaccine order administration and documentation completed Best practice/evidence-based process Standardized set up of vaccine prep areas with visual management Standardized patient education Barcoding New EHR Establish min/max amounts for inventory process in collaboration with CH Pharmacy and NHIP

21 Parking Lot 1 Barcoding 2 New EHR 3 Establish min/max amounts for inventory process in collaboration with CH Pharmacy and NHIP 4 A standardized process for moving vaccines when power outage expected 5 Computerized order entry in CHMG 6 Lighting that meets industry standards 7 A dedicated vaccine prep area that provides interruption-free work time 8 A computer system that clearly showed the vaccines due 9 Barcoding for vaccines throughout CHMG 10 Variance of handouts end of visit summary 11 Cramped exam rooms 12 Limited exam room for post-vaccine monitoring 13 Comfort items (Child Life Specialist) 14 Outdated Centricity forms 15 Varying EMR tools populate flowsheetdifferently 16 Appt start times: consider accounting for Reg and MA time prior to provider visit (ie. Backing up appt time to accommodate)

22 SOLUTIONS APPROACH Item # If we had Then (expected Results) Wireless temperature monitoring, Standardized, pharmacy-grade refrigerators, A standardized process for vaccine storage and layout, Standardized staff reference tools throughout CHMG Independent double-checks Phase 1 Phase 2 A standardized process for moving vaccines when power outage expected Computerized order entry in CHMG Lighting that meets industry standards A dedicated vaccine prep area that provides interruption-free work time A standardized procedure for vaccine administration Dedicated, uninterrupted time from vaccine order administration and documentation completed Best practice/evidence-based process Standardized set up of vaccine prep areas with visual management Standardized patient education A computer system that clearly showed the vaccines due Barcoding for vaccines throughout CHMG Feasibility TBD We could be notified of temperature variances sooner We would have more reliable vaccine storage We would have few mistakes related to selection We would have up-to-date, standardized staff guidance Fewer errors would reach the patient We would reduce our cost associated with vaccine replacement We would have fewer ordering errors We would reduced our vaccine prep errors We would have fewer vaccine errors Variation could be eliminated and correct process would be clear Supply readiness would be obvious at a glance We would have up-to-date, standardized patient guidance We would have fewer ordering errors We would have fewer vaccine errors reach the patient 22

23 EXPERIMENTS + COMPLETION PLAN Phase 1 Plan Who When (week) Actions / Results / Follow-up Do ne ( ) 1 Standardized refrigerators including vaccine storage and layout Early FY15 07/25/14: refrigerator trial begins using best practice recommendations 08/08/14: observed tweak to recommendations resulted in two sound-alike vaccines now near each other; vaccines separated 09/04/14: remains generally satisfied with Helmerunit: Arrangement good Need dividers to accommodate water bottles per State/CDC guidelines; Research products for adjustable dividers Top shelf without front section poses challenges for labeling Internal refrigerator layout for each practice may vary slightly due to differences in quantity and stock Develop Kanban inventory management system when determining storage options to avoid multiple open same vaccines 10/01/14: Request for refrigerators approved by CEC 10/27/14: Refrigerators ordered, will be shipped in stages adjustable dividers working well 01/31/15: Refrigerators deployed to practices 2 Draft evidence-based layout for vaccine storage 07/25/14 3 Labels for refrigerator shelves 06/ /08/14: Labels too large per staff feedback; will design/propose alternative 09/04/14: Labels still too large per staff feedback; will design/propose alternative 10/27/14: speak with Security about use of badge maker for Refrigerator Vaccine Labels. This would allow color variation of labels as well as right-sized labels that are easy to clean. Terminology for labels finalized ( Purchased rather than non-state ) 10/28/14: Will utilize badge maker for Refrigerator Vaccine Labels 03/13/15: Meeting postponed d/t DNV visit; meetings now bumped to May May -June 2015: Distribution of labels to practices 4 Clips for refrigerator shelves 11/ /08/14: label clips slide on shelf bar; will validate over next few weeks 09/04/14: label clips slide on shelf bar. Research other options 10/27/14: label clips demo d

24 EXPERIMENTS + COMPLETION PLAN Phase 1 Plan Who When (week) Actions / Results / Follow-up Do ne ( ) 5 Vaccine safety policy 06/ /27/14: in draft form 03/13/15: Meeting postponed d/t DNV visit; meetings now bumped to May 06/01/15: See Experiments + Completion Plan Phase 2 6 Immunization schedule/reference sheet standardization 01/ /27/14: compare forms and educate on the use of one, standard form for use throughout CHMG primary care offices. 7 New immunization form in Centricity 03/ /27/14: follow up regarding matching of vaccine names to Centricity form 03/13/15: Meeting postponed d/t DNV visit; meetings now bumped to June 06/01/15: See Experiments + Completion Plan Phase 2

25 EXPERIMENTS + COMPLETION PLAN Phase 2 Plan Who When (week) Actions / Results / Follow-up Do ne ( ) 1 CHMG Vaccine Philosophy (EBM) 06/01/15:, ask for interested providers CDC evidence-based recommendations 2 Vaccine Competency 06/01/15: begin drafting competencies for staff 06/30/15 Plus accompanying education 3 Vaccine Resource Person 06/01/15: Develop job description 06/30/15 Available to help in moment Thorough understanding of vaccine schedules and resources Remain current Good communication and mentoring skills Staff trainer Good error resolution skills Attention to detail Vaccine coordination knowledge and responsibilities Ordering NHIP (see DHHS job description) Audits Competency verification Analyzing reports Trending Able to provide feedback Liaison to NHIP (HOPS mtgs, annual conference, etc) Attendance at monthly meetings/education forums Double-checker Administer vaccines Knowledge of financial implications of vaccine process 4 1:1 MA to Provider ratio 07/15/15 5 Standardized Centricity reports for fall-outs 06/01/15: Leslie to contact Megan week of 06/08/15 6 Vaccine Plan of Care 06/01/15: Leslie to contact Megan week of 06/08/15

26 EXPERIMENTS + COMPLETION PLAN Phase 2 Plan Who When (week) Actions / Results / Follow-up Do ne ( ) 7 CHMG Vaccine Administration Policy 06/01/15: complete draft 06/30/15 8 Refrigerator 6S 9 Colored stickers for boxes of vaccines 06/01/15: research what is available 06/05/15 10 Standardization of vaccine prep area 06/01/15: design a potential layout with supplies needed 06/05/15 06/03/15: Requested pictures of prep areas from practices 11 Manual chart audit 06/01/15: notify of this collaboration 12 Cart/Tray for transporting vaccines from prep area to rooms 13 Scripting for vaccination education and positioning for patients 06/01/15: bring recommendations for carts 06/05/15 07/??/15 06/01/15: Draft completed. Will trial for 30 days beginning 06/08/15 14 Vaccine reaction kit 06/30/15 06/01/15: develop vaccine reaction kit Standardize and label location for each practice 15 New immunization form in Centricity 03/ /27/14: follow up regarding matching of vaccine names to Centricity form 03/13/15: Meeting postponed d/t DNV visit; meetings now bumped to June 06/01/15: Carried over from Experiments + Completion Plan Phase 1 Awaiting feedback regarding whether or not it would be better to move to new form prior to Cerner conversion

27 CONFIRMED TARGETS Phase 1 Metrics: FY15 FY14 % of CHMG employees who administer vaccines attend Immunization Basics class Reduce financial impact of equipmentrelated storage malfunction/error Standardized labeling for all CHMG Primary Care vaccine refrigerators Standardized method for transporting and storing vaccines during power outages Watch Metrics Increase in event reporting Results Target Current 33% as of 04/30/15 Loss as of 04/30/15: $15, % Roll-out in progress - June 2015 complete Roll-out in progress - June 2015 complete 33 events reported (09/30/14-05/05/15) 100% of new hires beginning June 2015 Quality / Patient Safety 2013 Timeliness / Effectiveness 2013 Satisfaction / Team Development % as of 04/11/14 Financial / Growth % ($46,340.91) 100% standardized 100% standardized Non-standard Non-standard 01/01/ /01/2014 = 104 events reported

28 Insights & Learnings Insights Phase 2 Positive: Got a lot done Hear different opinions and scenarios Gap analysis confirmed future state effectiveness All day Continued commitment to improving vaccine process We can see the light at the end of the tunnel! Caffeine + lunch Progress being made Kept on task We have a good plan Negative: First time we regrouped after months of not meeting was very difficult A long time to sit Some parts (ie. IT) are out of our control Neutral: Working lunch

29 We exist only to serve patients and their families

30 NH Department of Health and Human Services Award