Bedside Medication Administration: Real World Considerations

1. Bedside Medication Administration: Real World Considerations Carlene Anteau, MS, RN

3. Agenda The Medication Use Cycle Non-Automated Medication Administration Impact of Automation on Medication Administration Process Implementation Success Factors

4. Where Do Med Errors Occur?

5. Closed Loop Medication Management  Here’s what McKesson’s solution set looks like in it’s entirety … Now let’s look a little more closely at the individual components … Here’s what McKesson’s solution set looks like in it’s entirety … Now let’s look a little more closely at the individual components …

6. Agenda The Medication Use Cycle Non-Automated Medication Administration Impact of Automation on Medication Administration Process Implementation Success Factors

7. Current MedicationAdministration Process The medication order process in most healthcare organizations involves many people attempting to communicate at different times by physical flag, documentation, voice and telephone. The dependencies to move from the physician’s decision to order a drug to the medication given to the patient are staggeringly complex and convoluted. Automation is limited to the pharmacy in general. This manual process is fraught with opportunities for error, delay and redundant efforts. Notice how much of the communication is not automated (identified by black arrows) Notice how many people are involved in getting an order processed Notice how often the lines of communication cross over one another without any definable feedback process Notice how man breaks in the flow of the process there are (boxes not connected to the one above them)The medication order process in most healthcare organizations involves many people attempting to communicate at different times by physical flag, documentation, voice and telephone. The dependencies to move from the physician’s decision to order a drug to the medication given to the patient are staggeringly complex and convoluted. Automation is limited to the pharmacy in general. This manual process is fraught with opportunities for error, delay and redundant efforts. Notice how much of the communication is not automated (identified by black arrows) Notice how many people are involved in getting an order processed Notice how often the lines of communication cross over one another without any definable feedback process Notice how man breaks in the flow of the process there are (boxes not connected to the one above them)

8. Agenda The Medication Use Cycle Non-Automated Medication Administration Impact of Automation on Medication Administration Process Implementation Success Factors

9. Future MedicationAdministration Process The medication order process in most healthcare organizations involves many people attempting to communicate at different times by physical flag, documentation, voice and telephone. The dependencies to move from the physician’s decision to order a drug to the medication given to the patient are staggeringly complex and convoluted. Automation is limited to the pharmacy in general. This manual process is fraught with opportunities for error, delay and redundant efforts. Notice how much of the communication is not automated (identified by black arrows) Notice how many people are involved in getting an order processed Notice how often the lines of communication cross over one another without any definable feedback process Notice how man breaks in the flow of the process there are (boxes not connected to the one above them)The medication order process in most healthcare organizations involves many people attempting to communicate at different times by physical flag, documentation, voice and telephone. The dependencies to move from the physician’s decision to order a drug to the medication given to the patient are staggeringly complex and convoluted. Automation is limited to the pharmacy in general. This manual process is fraught with opportunities for error, delay and redundant efforts. Notice how much of the communication is not automated (identified by black arrows) Notice how many people are involved in getting an order processed Notice how often the lines of communication cross over one another without any definable feedback process Notice how man breaks in the flow of the process there are (boxes not connected to the one above them)

10. Bringing Orders, Administration & Documentation to the Point-of-care Point-of-care scanning automates the “5 rights” Ensures legible and accurate M.A.R. Generates charges as a by-product of charting Options for PDA, tablet and PC -based charting Reports all “near misses” Benefits Proven reductions in medication errors

12. Reporting

13. Agenda The Medication Use Cycle Non-Automated Medication Administration Impact of Automation on Medication Administration Process Implementation Success Factors

14. Key Success FactorsLeadership

15. Unwavering Project Support from Executive Leadership Executives emphasize that change is NOT optional Leaders anticipate and plan for resistance to change Leadership participation spans entire project Multidisciplinary leaders advocate change—not an ‘IT project’ Not optional: St. Dominic had a goal of becoming paperless. The chief executive team made sure that all employees and physicians understood that automation was not optional Plan for resistance: Clinician resistance is often the death blow to system implementations. The St. Luke’s project team, knowing there would be resistance to change, worked with all levels of management to prepare them for complaints. The preparation ensured that all leadership and IT presented a visible unified front to system nay-sayers. At Carolinas, if a physician demands a paper report, the occurrence is documented, administration is alerted, the physician is called into the administrator’s office and a message about the system goals and usage is delivered. Then the physician is retrained. In such ways, physicians have learned to review online Span project: At Carolinas the role of the executive sponsor was to build and maintain momentum for the project throughout the hospital and throughout the implementation of the last application/module Multidisciplinary: Regional West says that change must be driven from clinician side with broad ranging, multidisciplinary decision making. IT will fail if it forces change on hospital. Pharmacy must be an active participant in any med safety project. If Pharmacy is coerced into participating, there will be problems. St. Luke’s believes that M/IVs must be a strategic initiative for not only nursing, but also Pharmacy in order to obtain the level of pharmacy compliance required for success.Not optional: St. Dominic had a goal of becoming paperless. The chief executive team made sure that all employees and physicians understood that automation was not optional Plan for resistance: Clinician resistance is often the death blow to system implementations. The St. Luke’s project team, knowing there would be resistance to change, worked with all levels of management to prepare them for complaints. The preparation ensured that all leadership and IT presented a visible unified front to system nay-sayers. At Carolinas, if a physician demands a paper report, the occurrence is documented, administration is alerted, the physician is called into the administrator’s office and a message about the system goals and usage is delivered. Then the physician is retrained. In such ways, physicians have learned to review online Span project: At Carolinas the role of the executive sponsor was to build and maintain momentum for the project throughout the hospital and throughout the implementation of the last application/module Multidisciplinary: Regional West says that change must be driven from clinician side with broad ranging, multidisciplinary decision making. IT will fail if it forces change on hospital. Pharmacy must be an active participant in any med safety project. If Pharmacy is coerced into participating, there will be problems. St. Luke’s believes that M/IVs must be a strategic initiative for not only nursing, but also Pharmacy in order to obtain the level of pharmacy compliance required for success.

16. It’s Not All About Technology!Process Re-design Must Occur

17. Willingness to Examine Processes There is always room for improvement Document current processes Examine end-to-end processes Clinicians define “as is” then “to be” processes Document future processes Standardize processes for quality and consistency of care Proactively facilitate multidisciplinary decisions End to End Processes: St. Luke’s examined all processes that touched med administration, not just those associated with M/IV. As a result, they redesigned processes that touched charting I&Os, vitals, pain mgmt, admissions/discharge/transfer, etc., within each unit going live. Additionally they redesigned processes that extend past the go-live units and touch other departments. As Is / To Be: St. Luke’s developed a check list of critical processes that were common across departments, and started building “as is” models for those processes in each unit slotted for roll-out. Then they worked with nursing in the unit to defined the “to be” of those processes. Next, they looked at processes that were specific to that unit only and developed the “to be” model for them. Lastly, they sold the recommendations to nursing managers and other impacted departments. St. Vincent, St. Dominic and St. Luke’s advocate tracking errors/flaws in existing processes, finding the source of the error and fixing the source. The old work-around for the broken process won’t work under the new system. Multidisciplinary and Standards: At Carolinas, a multidisciplinary clinical team of managers standardized all manual forms and processes to create unified language, content and workflow across disciplines and hospitals. These standards became the foundation of Clin Doc and ensured that the system would be widely accepted at go-live. In several hospitals, cross functional committees help make decisions about processes that are used in multiple departments (e.g., telemetry processes), or span multiple departments (e.g., nursing and pharmacy). Those decisions then become the mandatory standards for those processes across the hospital. Across the interviewed hospitals IT’s lack of bias toward any clinical area made it ideal for facilitating cross-functional decisions and helping develop/document the recommendations. End to End Processes: St. Luke’s examined all processes that touched med administration, not just those associated with M/IV. As a result, they redesigned processes that touched charting I&Os, vitals, pain mgmt, admissions/discharge/transfer, etc., within each unit going live. Additionally they redesigned processes that extend past the go-live units and touch other departments. As Is / To Be: St. Luke’s developed a check list of critical processes that were common across departments, and started building “as is” models for those processes in each unit slotted for roll-out. Then they worked with nursing in the unit to defined the “to be” of those processes. Next, they looked at processes that were specific to that unit only and developed the “to be” model for them. Lastly, they sold the recommendations to nursing managers and other impacted departments. St. Vincent, St. Dominic and St. Luke’s advocate tracking errors/flaws in existing processes, finding the source of the error and fixing the source. The old work-around for the broken process won’t work under the new system. Multidisciplinary and Standards: At Carolinas, a multidisciplinary clinical team of managers standardized all manual forms and processes to create unified language, content and workflow across disciplines and hospitals. These standards became the foundation of Clin Doc and ensured that the system would be widely accepted at go-live. In several hospitals, cross functional committees help make decisions about processes that are used in multiple departments (e.g., telemetry processes), or span multiple departments (e.g., nursing and pharmacy). Those decisions then become the mandatory standards for those processes across the hospital. Across the interviewed hospitals IT’s lack of bias toward any clinical area made it ideal for facilitating cross-functional decisions and helping develop/document the recommendations.

18. Defined Vision & Goals with Validation of Achievement Project Vision: a universal rallying point Every decision, process change, and metric supports the goal Project sponsor communicates vision effectively Set expectations with managers and staff Define measures of “success” according to stakeholders and communicate results Utilize reports to identify issues with compliance Vision: St. Luke’s found that if the hospital staff shares the common goal, then decisions made that support that goal will earn support much more easily. Plan of care projects succeeded at University and St. Joseph/Tenet because nursing management saw care plans as the driving force behind patient care. Communication: Carolinas’ and Regional West’s communication programs drove the project’s continued success. They define the unified and consistent messaging from the executive and IT teams to the rest of the hospital. The messages are re-confirmed every time there is a go-live. Expectations: Early on set accurate expectations: e.g., the goal of Meds IVs is not to save nurses’ time; the goal is to ensure patient safety. Measures: St. Luke’s IT and clinical advisory committee worked together to develop metrics that would determine if the implementation was successful. Successful metrics were widely communicated by live-unit nursing managers to other nursing managers. Reports: At Regional West, the interest of managers is maintained through Clin Query reports that demonstrate the usefulness of Clin Doc. Managers will be trained in how to do their own Queries. IT departments that actively leverage Query, have done so through initiating ideas for reports with department managers then working with those managers to expand that report. In this way they demonstrate the value of Horizon Clinicals by using its data to influence managerial decisions.Vision: St. Luke’s found that if the hospital staff shares the common goal, then decisions made that support that goal will earn support much more easily. Plan of care projects succeeded at University and St. Joseph/Tenet because nursing management saw care plans as the driving force behind patient care. Communication: Carolinas’ and Regional West’s communication programs drove the project’s continued success. They define the unified and consistent messaging from the executive and IT teams to the rest of the hospital. The messages are re-confirmed every time there is a go-live. Expectations: Early on set accurate expectations: e.g., the goal of Meds IVs is not to save nurses’ time; the goal is to ensure patient safety. Measures: St. Luke’s IT and clinical advisory committee worked together to develop metrics that would determine if the implementation was successful. Successful metrics were widely communicated by live-unit nursing managers to other nursing managers. Reports: At Regional West, the interest of managers is maintained through Clin Query reports that demonstrate the usefulness of Clin Doc. Managers will be trained in how to do their own Queries. IT departments that actively leverage Query, have done so through initiating ideas for reports with department managers then working with those managers to expand that report. In this way they demonstrate the value of Horizon Clinicals by using its data to influence managerial decisions.

19. Strong Clinical Representation Patient Safety must be the primary driver Strongly encourage patient/med bar coding Involve physicians, nurses, pharmacists and ancillaries in implementation process Informal unit leaders are key participants Clinicians define “what the users want” Creatively tailor the system Foster support in their departments Demonstrate the system’s value through reporting Involve clinicians: St. Dominic and St. Luke’s created physician committees who tracked project direction, made decisions, and expressed the needs of the physician community. At St. Luke’s, nurses participants were chosen for their roles as informal leaders on their units. At Carolinas, representatives from all areas of nursing at all 8 hospitals standardized all manual forms and processes in preparation for the Clin Doc implementation. The dynamics between the clinical departments (e.g., Pharmacy and Nursing) is critical. Pharmacy needs to be an active participant/decision maker in the Med Safety solution. Define what the users want & foster support For St. Dominic, in the implementation of Critical Care, the project team worked tightly with specialty areas in Critical Care to define each one’s specific base screen and assessment screen needs. Using clinician-centered customization, they won over Critical Care staff. St. Luke’s project team worked with Physicians to customize specific flowsheet views (they asked ‘what data do you use to make decisions, and what is the flow in which you need to see it?’). Department nurses worked with IT at St. Luke’s to develop the ‘to-be’ model. Their involvement gave credibility to the process changes and ensured nurse manager support. Creatively tailor the system: University’s goal of integrating NIC/NOC standards into Care Plans was accomplished through system changes. They taught nurses to think of Orders as Interventions, they built guidelines to support those interventions, and they re-organized the content in charting to support them. In order to have their Plans of Care online, St. Dominic added problems into Clin Doc using a taskforce of clinicians to define the problems with their related interventions and goals. Clinical Query Day 1 of a go-live, nurse managers need to receive 2 reports: 1 that tells them % compliance rates (JCAHO triggers, risks, nutrition screening, etc.), and another as an exception report. These reports save chart audit time and demonstrate the success of the roll-out.Involve clinicians: St. Dominic and St. Luke’s created physician committees who tracked project direction, made decisions, and expressed the needs of the physician community. At St. Luke’s, nurses participants were chosen for their roles as informal leaders on their units. At Carolinas, representatives from all areas of nursing at all 8 hospitals standardized all manual forms and processes in preparation for the Clin Doc implementation. The dynamics between the clinical departments (e.g., Pharmacy and Nursing) is critical. Pharmacy needs to be an active participant/decision maker in the Med Safety solution. Define what the users want & foster support For St. Dominic, in the implementation of Critical Care, the project team worked tightly with specialty areas in Critical Care to define each one’s specific base screen and assessment screen needs. Using clinician-centered customization, they won over Critical Care staff. St. Luke’s project team worked with Physicians to customize specific flowsheet views (they asked ‘what data do you use to make decisions, and what is the flow in which you need to see it?’). Department nurses worked with IT at St. Luke’s to develop the ‘to-be’ model. Their involvement gave credibility to the process changes and ensured nurse manager support. Creatively tailor the system: University’s goal of integrating NIC/NOC standards into Care Plans was accomplished through system changes. They taught nurses to think of Orders as Interventions, they built guidelines to support those interventions, and they re-organized the content in charting to support them. In order to have their Plans of Care online, St. Dominic added problems into Clin Doc using a taskforce of clinicians to define the problems with their related interventions and goals. Clinical Query Day 1 of a go-live, nurse managers need to receive 2 reports: 1 that tells them % compliance rates (JCAHO triggers, risks, nutrition screening, etc.), and another as an exception report. These reports save chart audit time and demonstrate the success of the roll-out.

20. Strong Clinical Representation (cont.) Gain physician acceptance Visible commitment: House-wide presence of the system Ease of access: Effective and accessible devices Education: Give physicians specific and on-going support Most information in this slide came from Covenant Knoxville & Central Baptist Deep deployment: The carrot for physician use is having all information available in one place—make it easy to give up paper. Don’t move on until lab, rad and all charting information is available in the first unit. Physicians should ease into computer use with reviews. Data entry comes later Broad Deployment Roll-out fast and house-wide—shows administrative support and prohibits sending patients to a non-Care Mgr unit. Rip off the band-aid fast Remove paper as a choice Visible commitment Prepare with Administration for resistance In multi-hospital systems go live on CM everywhere so that physicians get used to using it. Ease of access There should be no waiting to see a chart—enough devices for everyone A variety of types of devices that are conducive to the workflow of eacy type of care giver Care manager should be where ever it is needed (in room, at nursing station, at dictation station) Educate/Support physicians: Be available on the morning after go-live to train physicians when it is most relevant to them. St. Vincent wished it had shown physicians the MIV MAR for pre-go-live feedback. Physicians should hear goals—increase patient safety, not increase nursing efficiency—to avoid complaints. St. Luke’s has a Physician Info Mgmt team of 4 IS analysts that intercept MDs and take care of issues during/after implementations. Carolinas conducted 1 on 1 meetings with physicians at all hours to present Clin Doc, get feedback and answer questions. They followed MDs on rounds to show the system. Most information in this slide came from Covenant Knoxville & Central Baptist Deep deployment: The carrot for physician use is having all information available in one place—make it easy to give up paper. Don’t move on until lab, rad and all charting information is available in the first unit. Physicians should ease into computer use with reviews. Data entry comes later Broad Deployment Roll-out fast and house-wide—shows administrative support and prohibits sending patients to a non-Care Mgr unit. Rip off the band-aid fast Remove paper as a choice Visible commitment Prepare with Administration for resistance In multi-hospital systems go live on CM everywhere so that physicians get used to using it. Ease of access There should be no waiting to see a chart—enough devices for everyone A variety of types of devices that are conducive to the workflow of eacy type of care giver Care manager should be where ever it is needed (in room, at nursing station, at dictation station) Educate/Support physicians: Be available on the morning after go-live to train physicians when it is most relevant to them. St. Vincent wished it had shown physicians the MIV MAR for pre-go-live feedback. Physicians should hear goals—increase patient safety, not increase nursing efficiency—to avoid complaints. St. Luke’s has a Physician Info Mgmt team of 4 IS analysts that intercept MDs and take care of issues during/after implementations. Carolinas conducted 1 on 1 meetings with physicians at all hours to present Clin Doc, get feedback and answer questions. They followed MDs on rounds to show the system.

21. Strong Clinical Representation (cont.) Supportive Pharmacy Director Early involvement of the Pharmacy in the implementation process Pharmacists are more likely to resist if not involved in the early decision making process Develop methods to improve communication between pharmacy and clinicians Patient Safety: Clinicians and pharmacist will become frustrated with the system if it is believed they will realize a time savings through an automated ordering system. Pharmacy Director Support: Pharmacy director must understand that patient safety is the primary goal and that automation will enhance this objective. Involvement of Pharmacy: Pharmacist and staff need to be involved early in the implementation process. Communication: The use of liaison between Rx and floor units coupled with joint committee meetings help to stay on top of developing problems and increase understanding of issues. If it is logistically possible for a facility to have a decentralized Rx it will increase pharmacist/RN contact. Access to Care Manager: Access to a terminal loaded with Care Manager assists the pharmacist’s ability to ascertain the problem an RN is reporting with a med order.Patient Safety: Clinicians and pharmacist will become frustrated with the system if it is believed they will realize a time savings through an automated ordering system. Pharmacy Director Support: Pharmacy director must understand that patient safety is the primary goal and that automation will enhance this objective. Involvement of Pharmacy: Pharmacist and staff need to be involved early in the implementation process. Communication: The use of liaison between Rx and floor units coupled with joint committee meetings help to stay on top of developing problems and increase understanding of issues. If it is logistically possible for a facility to have a decentralized Rx it will increase pharmacist/RN contact. Access to Care Manager: Access to a terminal loaded with Care Manager assists the pharmacist’s ability to ascertain the problem an RN is reporting with a med order.

22. Strategic Preparation, Roll-out and Follow-up Support Preparation Ensure comfort with system and processes through shadow system usage Roll-out Start with supporting units, end with the tough sell Sequence similar units together Follow-up Offer full, co-located support 1 week after go-live Reinforce classroom training with on-the-job mentoring Preparation: At St. Vincent, super users prepared for go-live by simulating the process of documenting in the system. While one nurse did traditional paper documentation, the super users would shadow chart in the system. This helped work through any remaining kinks and it demonstrated the system’s usability. Roll-out: St. Luke’s offers classroom training with a written competency exam followed by a 4-hour preceptorship. In the preceptorship a newly trained nurse performs med administration (with Meds IVs and related charting) under the supervision of an experienced nurse. During the preceptorship, the new nurse must pass a skills competency check list. Those that don’t pass are retrained. Regional West has a similar process Follow-up: Providence applied a representative to consistently follow up with each live unit for at least 4 weeks after implementation. The goal was to monitor progress on the floor and work out all obstacles. When negative trends are identified in nursing or pharmacy, they either work to re-direct the specific mis-directed individuals, or offer advanced training to correct the trends. The advanced training will be retrofitted into the orientation training curriculum. All clients interviewed had a sufficient number of FTEs supporting Care Manager. It averaged 62 beds per care manager FTE, but it was as high as 94 and as low as 33 beds per FTE. Preparation: At St. Vincent, super users prepared for go-live by simulating the process of documenting in the system. While one nurse did traditional paper documentation, the super users would shadow chart in the system. This helped work through any remaining kinks and it demonstrated the system’s usability. Roll-out: St. Luke’s offers classroom training with a written competency exam followed by a 4-hour preceptorship. In the preceptorship a newly trained nurse performs med administration (with Meds IVs and related charting) under the supervision of an experienced nurse. During the preceptorship, the new nurse must pass a skills competency check list. Those that don’t pass are retrained. Regional West has a similar process Follow-up: Providence applied a representative to consistently follow up with each live unit for at least 4 weeks after implementation. The goal was to monitor progress on the floor and work out all obstacles. When negative trends are identified in nursing or pharmacy, they either work to re-direct the specific mis-directed individuals, or offer advanced training to correct the trends. The advanced training will be retrofitted into the orientation training curriculum. All clients interviewed had a sufficient number of FTEs supporting Care Manager. It averaged 62 beds per care manager FTE, but it was as high as 94 and as low as 33 beds per FTE.

23. Other Keys to Medication Administration Success

24. Supporting the Change Process

25. Communication

26. System Integration

27. Comfort with Technology

28. Devices

29. Policies & Procedures

30. Progressively Introduce Technology