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Presentation to 2010 annual conference in Cancun
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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 Blackwellrblackwell@ccbhs.org
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