SKMC TRANSFORMATION PROJECT : VACCINE BAR
Transcription
SKMC TRANSFORMATION PROJECT : VACCINE BAR
2011 TRANSFORMATIONAL EVENT SHEIKH KHALIFA MEDICAL CITY: BULL’S EYE HITTING THE MARK WITH A NEW APPROACH TO VACCINE MANAGEMENT SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 2 Contents Introduction ............................................................................................................................................................... 3 1. Project Selection and Purpose ............................................................................................................................... 4 2. Current Situation Analysis .................................................................................................................................... 10 3. Solution Development ......................................................................................................................................... 13 4. Project Implementation & Results ....................................................................................................................... 16 5. Team Management .............................................................................................................................................. 30 Appendix 1 – Bar-Coded Vaccination Process ......................................................................................................... 31 Appendix 2 – In-House Developed Patient Education Materials ............................................................................. 32 Figures Figure 1 – 2010 Average Clinic Visit Time Sept-Nov (Minutes)................................................................................ 10 Figure 2 – Current State Clinic Patient Process Flow ............................................................................................... 11 Figure 3 – Erroneous Record Book Pre-Bar-Coding Implementation ...................................................................... 16 Figure 4 – Nurse Bar-Coding Training Process ......................................................................................................... 18 Figure 5 – Bar-Code Mapping Sheets ....................................................................................................................... 19 Figure 6 – Reduced Appointment Time Impact (One Clinic).................................................................................... 20 Figure 7 – Post-Implementation Clinic Patient Process Flow .................................................................................. 21 Figure 8 – Post-Implementation Patient Wait Time Reductions ............................................................................. 22 Figure 9 – Post-Implementation Patient Visit Increase ........................................................................................... 23 Figure 10 – Potential Revenue Increase Due to Increased Patient Visits ................................................................ 24 Figure 11 – Patient Education Materials Developed for Clinic ................................................................................ 25 Figure 12 – Post-Implementation Nurse Efficiency ................................................................................................. 25 Figure 13 – Post-Implementation Data Improvements ........................................................................................... 26 Figure 14 – Post-Implementation Record Keeping Improvements ......................................................................... 27 *Word count does not include Introduction, Criteria Questions or Image/Table Titles and Content SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 3 Introduction Sheikh Khalifa Medical City (SKMC) is committed to providing outstanding patient experience, superior clinical outcomes, and improved quality of life for the people it serves. The foundation of this commitment is built on the cornerstones of quality and patient experience. As a healthcare provider on the forefront of medicine, SKMC is always examining and implementing new processes and procedures that will benefit the patient and ensure quality outcomes. In January 2011 SKMC transformed the way it delivered care to patients receiving vaccinations. In order to accommodate the immense volume of patients seeking vaccinations, SKMC founded the Nurse Vaccination Clinic. The clinic provides patients with a direct avenue to receive vaccinations and allows physicians more time to see patients with more critical health issues. As was the practice for all vaccination treatments, nurses working in the Vaccination Clinic were required to manually administer and record all information specific to the patient’s visit for record keeping and billing purposes. This antiquated process was time and labor intensive, ultimately pre-occupying the nurses with administrative work and removing the emphasis on patient care. Thus was the case until the Nurse Vaccination team determined that bar-coding a longstanding technology used in other non-healthcare industries, could be adopted to improve their efficiency and accuracy, ultimately improving both patient care and the patient experience. Bar-coding has transformed the way vaccinations are administered at SKMC facilities, ultimately improving patient care and quality outcomes, aligning to the core commitments of SKMC. SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 4 1. Project Selection and Purpose 1A. Explain the methods used to choose the project. 1Aa. Describe the types of data and quality tools used to select the project, and why they were used The vaccination process in the Nurse Vaccination Clinic was slow and full of errors. When looking into how we could improve the process, potential solutions were evaluated using the following tools: Tool/Data Financial Feasibility Replication Results Focused – Measurable Data Patient Satisfaction Employee Satisfaction Cause for Use A financial review of each solution would ensure that the solution we choose would produce the greatest return on investment versus the cost of the solution A solution that is replicable throughout SKMC and all of SEHA would positively affect the largest number of patients and caregivers The ideal solution would improve the quality of care in a manner that could be easily measured and reported The ideal solution would have the greatest effect on patient care, experience and satisfaction The ideal solution would have the greatest effect on employee experience and satisfaction 1Ab. Explain the reasons why the project was selected The vaccination bar-coding project was selected because it performed the best against all of the above criteria. The matrix below highlights the reasons behind the selection of this project. Tool/Data Financial Feasibility Replication Results Focused – Measurable Data Patient Satisfaction Cause for Use The bar-coding solution would have no cost to the organization, maximizing return on investment. Internet contains free bar-coding software, uploaded to each workstation at no cost Patient Registration had several boxes of scanners in storage not being used No formal outside training on system SKMC- IT created an interface between bar-coding system and Cerner SKMC- IT created an interface between bar-coding system and Quality Department in-house Great financial returns through a more efficient, less time consuming process that allows more patients to be seen throughout the day Zero cost, in-house IT adjustments and utilization of similar equipment and software by system nurses created a great opportunity for replication Easy interfacing with other IT applications creates the opportunity to capture real-time, accurate data. More accurate and timely data helps the institution determine breakdowns in process and patient care, helping to prevent unwanted outcomes. It also produces tangible results that can be measured and benchmarked across the organization. If successful would efficiently stream-line patient throughput, allowing patients greater accessibility to appointments and more timely care. More SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING Employee Satisfaction 5 accurate data capture would ensure patient records were correct and retrievable in real-time should patient lose their documentation If successful would make work less manual- reducing errors and allowing nurses more time for direct patient care. More time focused on direct patient care resulted in better patient education and more efficient appointments 1Ac. Describe the involvement of potential stakeholders in project selection The stakeholders involved in the decision-making process were mainly internal SKMC staff, comprised of multi-disciplinary leadership team and nursing teams and patients, while a key stake-holder, were not directly involved in the selection process. They were, however, always first and foremost when developing the project. More detailed involvement by the stakeholders was as follows: Stakeholder Leadership Team Nursing Team Patients Involvement/Responsibilities The leadership team was responsible for reviewing solutions proposed by the nursing team and reviewing the quality/data results to determine the most effective solution. After implementation the leadership team would track the success of the solution and determine if it should… 1. Continue to be utilized 2. Be replicated across the enterprise 3. Be shared with external facilities as best practice The nursing team was responsible for coming up with the idea and effectively testing the selected solution, develop training curriculum, educate patients on the process, track results and train other nursing teams if implemented organization wide. In order for the project to be a success patients must benefit directly from it. The project must seamlessly anticipate and accommodate the patients’ needs, with easily measured results. Their waiting times, the accuracy for receiving the proper vaccination, and the number of visits must all show a quantitative improvement. Qualitatively, they must have a positive impression of the project as measured in patient satisfaction surveys/scores. 1B. Explain how the project supports/aligns with the organization’s goals, performance measures, and/or strategies. 1Ba. Identify the affected organizational goals, performance measures, and/or strategies. 1Bb. Identify the types of impact on each goal, performance measure, and/or strategy. 1Bc. Identify the degree of impact on each goal, performance measure, and/or strategy, and how this was determined. SEHA and SKMC have identified several key priorities focused on data integrity, patient access and provider productivity. This program successfully addresses all of these key priorities. SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING Degrees of Impact: ● = Significant; ● = Insignificant; ● = No Impact Goal/Measure/Strategy SEHA Initiative Code SKMC priority Code SEHA-1/1-2 SKMC- 01 1.1.5 TYPE Degree Positive ● Negative ● N/A SKMC-01 1.6.1 Positive ● Negative ● N/A SKMC-01 1.6.2 Positive ● Negative ● SEHA-3/1-12 SKMC-03 1.4.1 Positive ● Negative ● N/A 6 SKMC-02 2.3.1 Positive ● Negative ● Alignment Reasoning Goal/Measure/Strategy Identify & Resolve IT issues that affect data integrity and impact revenue and/ or expense Justification Could have a great impact on the process and collection of more accurate, real-time data and revenue Unsuccessful implementation would not result in significant changes compared to current data collection Exceed OSC volumes by 10% over budgeted by improving access, throughput and productivity Could have great impact on improving access, throughput and productivity Unsuccessful implementation would not result in significant changes to current throughput results Increased FMC volumes by 10% over budgeted volumes by improving access, throughput and productivity Could have great impact on improving access, throughput and productivity Unsuccessful implementation would not result in significant changes to current throughput results Meet productivity targets Could have great impact on productivity as a result of improved process and throughput Unsuccessful implementation would not result in significant changes to current throughput results Create signature programs/marketing for all areas that care for children. Could become a signature program for our FMCs that drastically improves patient education/throughput in these areas Unsuccessful implementation would not result in significant changes to current process; could look for other ways to meet goal SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 7 1C. Identify the potential stakeholders (who may be impacted by the project) and explain how they may be impacted by the project. 1Ca. Identify potential internal and external stakeholders and explain how they were identified. 1Cb. Identify the types of potential impact on stakeholders and how these were determined. 1Cc. Identify the degree of potential impact on stakeholders and explain how this was determined. The potential stakeholders of this solution could ultimately be affected in a positive way on grand scale or a small scale; therefore the types of impacts have been categorized based on the roles and responsibilities of each stakeholder group (each affected by financial impact, process impact and the care delivery model) and the degree of impact. ● ● Degrees of Impact: = Significant; = Insignificant; Types of Impact: Financial, Process, Care Delivery ●= No Impact Internal Stakeholders Stakeholder Leadership Team Type Stakeholder Reasoning Responsible for approving implementation, the leadership team would ultimately have to track the success of the solution and determine if it should 1. Continue to be utilized 2. Be replicated across the enterprise 3. Be shared with external facilities as best practice Degree Justification Process ● ● Care Delivery ● Financial Nursing Team Financial Process Care Delivery Other SKMC Facilities Could be adopted across system resulting in a significant improvement in system’s current process Could revolutionize delivery model and all code –able items used for patient care Required to test the solution, develop training curriculum for internal team, and educate patients on new process. Develop new patient education tools/opportunities. Track results and if successful, train other nursing teams and implement across the organization. ● ● ● No implementation or removal costs Could adopt across system requiring team to train all nurses Could revolutionize vaccination delivery model and have significant effects on patient interactions/experience Could adopt new solution proved successful in the Nurse Vaccination Clinic. All stakeholders in other SKMC facilities would then be impacted. Process ● ● Care Delivery ● Financial No implementation or removal costs No implementation or removal costs Could be adopted across system requiring all facilities to be trained and implement new solution. Could revolutionize vaccination delivery model and have significant effects on patient interactions/experience SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING SKMC Quality Department Responsible for capturing the data transmitted by the bar-coding system and analyzing the results of the data. Department would also be responsible for transmitting data to all requesting governing bodies. If used successfully, it could revolutionize the data capture process. Process ● ● Care Delivery ● Financial Clinic Physicians Financial Process Care Delivery Clinic Registration Financial Process Care Delivery Clinic Security Minimal costs associated with interfacing with bar-coding applications. Could increase Quality team’s interface with all nursing workstations, capturing real-time, accurate data from all departments. Successful implementation and interfacing could result in more accurate data, analysis, and better informing strategic decision-making. A more efficient throughput model could reduce patient waiting time between seeing nurses and physicians resulting in increased patient satisfaction, better patient care, and more patient encounters. Improved patient throughput could increase number of patients seen each day Vaccination by nurses also allows physicians to be occupied by more complex cases. Improved patient throughput could require physicians to streamline their process of seeing patients. Improved patient throughput could allow physicians to focus on more complex cases and devote their time to the most critical patients. ● ● ● A more efficient throughput model could minimize waiting times and reduce overcrowding making patient registration more manageable, efficient, and pleasant Improved patient throughput could increase number of patients registered/ seen each day Registration Des employees would need to be able to support the increased patient volume Improved patient throughput could increase patient volumes and require the registration team to adopt a more seamless, efficient process in order to keep up with increased demand. Required to keep up with the increased demand and shortened intervals between appointments to maintain efficiency in the waiting areas. Success in keeping up has significant positive effect on patient experience and care deliver. ● ● ● A more efficient throughput model could minimize waiting times and reduce overcrowding which can result in the need for Security assistance due to patient frustration. No change, a security guard must be on duty during working hours Process ● ● Care Delivery ● Financial 8 Could face significantly less issues in the waiting areas if patient throughput improves and coinciding patient registration moves seamlessly. Less security issues could significantly improve the overall patient experience as it begins when the patient walks through the doors. SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 9 External Stakeholders Stakeholder Patients Type Financial Process Care Delivery Other SEHA Facilities Financial Process Care Delivery Health Authority-Abu Dhabi Financial Process Care Delivery Insurance Companies Financial Process Care Delivery Stakeholder Reasoning Patients could either benefit or not benefit from implementation of the solution. Their ability to adapt to the new system could greatly affect both the quantitative and qualitative results of the new solution. Their waiting times, accuracy for receiving the proper vaccination, and number of visits would affect the quantitative numbers. While qualitatively, their perception of the new system could affect patient satisfaction surveys/ scores. Degree Justification Could increase efficiency and number of nurses tasked with administering vaccines, costing patients less as nurse visits are less expensive than physician visits. Could significantly cut patient waiting times, improve patient access and overall patient experience Could significantly alter vaccine administration allowing for greater patientprovider interaction, more time for patient education and a greater feeling of satisfaction by the patient. ● ● ● Other SEHA facilities could benefit from/adopt the new solution given its zero cost, ability to be replicated, uniqueness to the market and opportunity to improve patient experience. Implementation of a similar solution could cost nothing (like SKMC) or could cost a minimal amount (mainly for the scanner) – depends on current technology capabilities. Would need to be trained and adopt process and technology, but could benefit from more efficient patient throughput and satisfaction. Could revolutionize care delivery model and significantly affect patient interactions and experience. ● ● ● Conveyance of more accurate, real-time data could improve the data collected by HAAD for SKMC. Adjustments in data capture process could also require HAAD to adjust its IT systems in order to accommodate SKMC’s data transfer. Depending on current technologies in place, may be required to update/adjust IT systems to accommodate data transfer from SKMC/other SEHA facilities. Significant change/increase in data capture could increase volume and quality of data captured, improving reporting, data analysis, and forecasting. Changes/increases in data capture effecting reporting and data analysis could significantly influence the care model and care delivery ● ● ● More accurate patient registration, documentation and coding could mean more efficient claims processing and diminishing rejection volumes. More accurate encounter data, improved patient throughput, and increased volumes could significantly increase the number of cases paid by insurance institutions Must be able to adapt to increase in volume and timely payment of claims ● ● ● Timely payment of claims helps overall financial record keeping and budgeting of the institution being paid. SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 10 2. Current Situation Analysis The new process created a more stream-lined workflow, as before two nurses were assigned to each patient, but with the new system it was reduced to one nurse resulting in improved nursing utilization and productivity. 2A. Explain the innovative approach/process the team used to identify the potential root cause(s) or improvement opportunity(s). 2Aa.Describe the innovative methods and tools used to identify possible root causes/improvement opportunities. 2Ab. Describe the team’s innovative analysis of data to identify possible root causes/improvement opportunities. The nurse vaccination team’s creation of the Nurse Vaccination Clinic led to an increase in the number of vaccinations administered by non-physicians, improving patient access to vaccination appointments, and opening up more physician appointments for sick patients. Aided by the Quality Department, the nurse vaccination team took raw data from the current state and previous year, and examined it to see if there were any significant changes in patient throughput. The team found that patients in the Vaccination Clinic in Family Medicine Clinics were spending an average of 75 minutes per vaccination before the project. This time has now been reduced to 45 minutes, reducing the time that patient spend in the clinic by 30 minutes. Figure 1 – 2010 Average Clinic Visit Time Sept-Nov (Minutes) 100.0 90.0 86.3 79.9 80.0 65.0 70.0 75.1 77.5 Al Zafranah Mushrif 61.9 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Al Bateen Al Khaleej Al Manhal Al Rowdha 2Ac. Describe how or if any of the stakeholders were involved in identifying the possible root cause/improvement opportunities. As a result of these findings, the nurse vaccination team took it upon themselves to map the patient process flow in the clinic as a way to determine waiting times and the opportunity for improvement. Figure 2 displays their findings. SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 11 Figure 2 – Current State Clinic Patient Process Flow Women’s and Men’s Waiting Area: 21 Minutes (after Registration) Registration: 4 Minutes Nurse Vaccination Visit: 21 Minutes Vaccination Site Review: 20 Minutes (required) The team discovered that the bottleneck was the administering of vaccines/nurse visit. The nursing team, with the support of the leadership team, needed to develop a solution that was more efficient both in process and time. If successful, it would reduce both the waiting room time and the nurse vaccination visit time. SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 12 2B. Describe how the team analyzed information to identify the final root cause(s)/improvement opportunity(s). 2Ba. Describe the methods and tools used to identify the final root cause(s)/improvement opportunity(ies). A crosswalk of the quality data (average times per appointment) and the patient flow map served as the main sources for determining the processes bottleneck. 2Bb. Describe the team’s analysis of data to select the final root cause(s)/improvement opportunity(ies). Review of quality data, coupled with insight into current visit process, lead the nursing team to determine the bottleneck was manual recoding of all patient vaccine information by hand. The manual nature of recording all patient and vaccine information by hand significantly delayed the patient and all subsequent patients and opened the door for errors to occur. Additionally, parent vaccine education was haphazard with no control over whether it was done or not, because the nurses were so busy with manual documentation. 2Bc. Identify the root cause(s)/improvement opportunity(ies) and explain how the team validated the final root cause(s)/improvement opportunity(ies). The nursing team continued to examine their findings and validated their hypothesis with Quality Department testimonials from patients who stated that the process was too long with too much waiting in both the waiting and exam rooms. These findings were presented to the leadership team who confirmed their hypothesis by examining all available evidence. SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 13 3. Solution Development 3A. Explain the methods used to identify the possible solutions/improvement actions. 3Aa. Describe the methods and tools used to develop possible solutions/improvement actions. The nursing team brainstormed a number of ideas that could have a positive affect on both the patient visit and the administering nurse’s work. They identified several ideas that could work toward meeting or exceeding both the patient’s and nurse’s expectations. 3Ab. Describe the team’s analysis of data to develop possible solutions/improvement actions. The nursing team also brainstormed ideas that could affect data capture, including: 1. Number of patients seen per day 2. Average duration of patient visits 3. Accuracy of patient records 4. Patient satisfaction in regard to wait times and quality of service Their final solutions were as follows: Solution Shortened Appointment Times Vaccine Bar-Coding Effect on Data Capture Points Shortened appointment time meant that we could increase the number of patients seen per day. Previously the waiting time for an appointment was 3 weeks. This was reduced to 10 days with the new system. The new system allowed better use of the parents’ time enabling us to begin education about the vaccination at registration and continuing through the vaccination and waiting area to allow opportunity for questioning etc. Would require education and adoption on the part of the nursing staff, but could significantly improve patient throughput and satisfaction as it would be a more efficient, faster, and smoother process. It could also significantly improve the accuracy of patient records by engineering out a lot of manual work which could result in human error. 3Ac. Indicate the criteria the team decided to use in selecting the final solution(s)/improvement action(s). When looking into the opportunity to improve the process, potential solutions were evaluated against the same criteria used in section 1Aa – Financial Feasibility, Replicability, Results Focused, Patient Satisfaction and Employee Satisfaction. 3B. Explain how the innovative final solution(s)/improvement action(s) was/were determined and how replicable the solution is. 3Ba. Describe the innovative methods and tools used by the team to select the final solution(s)/improvement action(s). As highlighted in table 1Ab, the vaccination bar-coding project was selected because it resulted in: Improved patient access (decreased waiting times, more available appointments) Improved patient satisfaction Improved patient safety Improved patient education Improved employee satisfaction SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 14 In addition to all of this, bar coding is easily replicable across both SKMC and SEHA and it was essentially free. 3Bb. Describe the team’s analysis of data to select the final replicable solution(s)/improvement action(s). The team compared each solution against the requirements from section 1Aa. As evidenced by the table below, vaccination bar-coding was documented as the solution that would have the greatest impact on current state, although the final decision was left up to the leadership team. ● Significant Positive Effect ● Minimal to No Effect Tool/Data No Process Change ● Continuing to frustrate Financial Feasibility Replication Medication Error Results Focused – Measurable Data patients could have longterm implications on patient visits and associated revenue ● N/A ● Significant Negative Implications Shortened Appt Times ● Shortened appointments ● No price for solution; mean more patient visits, mean more revenue change than favorable situation with more vaccination appointments available ● Errors in documentation favorable situation with patient visits increasing and patient appt times decreasing would likely increase due to more pressure on the staff show a less than favorable situation with vaccination appointments improvement in patient satisfaction related to care received, but not necessarily overall experience ● Data would continue to ● Data may show that Employee Satisfaction system-wide ● Data would show a more ● Data should show a ● Data would continue to ● Data may show an Patient Satisfaction success means more patient visits ● Can easily allow for more ● Replication is possible appointments ● Data would show no Vaccine Bar-Coding show a less than favorable situation with vaccination appointments employees’ accuracy improves and they feel less rushed while working ● Data should show a favorable situation with patient satisfaction, care and experience increasing ● Data may show that employees’ accuracy improves and they feel less rushed while working 3Bc. Describe the involvement of stakeholders in the selection of the final solution(s)/improvement action(s). The nursing team worked with the Quality Department to gather all of the required data to support their ideas and current state, these findings were presented to the leadership team. Their findings are captured in section 3Bb. The benefits to the patient and staff were so clear, that they decided to proceed immediately with the project. SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 15 3C. Explain the final solution(s)/improvement action(s), validation, and the benefits expected to be realized by implementing the team’s solution(s)/improvement action(s). 3Ca. Describe the final solution(s)/improvement action(s) and explain how the team validated the final solution(s)/improvement action(s). The initial idea for vaccine bar-coding stemmed from its use in the consumer market. For years stores have successfully used bar-codes as an automated way of capturing information needed for pricing and inventory tracking. The nursing team felt the same theory could be applied to bar-coding vaccinations, in that it would help them to accurately capture patient information required for patient records and coding and better keep track of inventory. They knew that successful implementation of a bar-coding system could yield real-time, accurate results in the electronic medical records system much like price tallying at the grocery store. Additionally, the team knew the solution would be successful if they could increase the number of patient visits and shorten the patient waiting time. 3Cb. Indicate the types of tangible and intangible benefits that are expected to be realized by implementing the team’s solution(s)/improvement action(s). The benefits expected to be realized by implementing the bar-coding solution were: Tangible •Decreased patient wait times •Decreased medical errors •Increased patient safety •Increased patient visits •Increased productivity •Decreased errors in coding •Zero cost •Real time data capture Intangible •Increased patient satisfaction •More focus on the patient and patient education •Increased employee engagement and satisfaction •Increased productivity •Replicable model 3Cc. Explain how the team used data to justify the implementation of the team’s solution(s)/improvement action(s). The nursing team used existing data and practices to determine that several key factors justified implementation of the bar-coding solution, including: No associated costs and all necessary IT upgrades conducted in-house Used for years in countless other industries, for essentially the same purpose (proven technology) Patient experience would improve with greater accessibility and shorter wait times Extensive patient waiting times (evidenced in 2Ab), if reduced, could result in more patient visits and revenue (AED 45/nurse vaccination visit) More accurate, real-time data compared to the current erroneous process (see figure below) SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 16 Figure 3 – Erroneous Record Book Pre-Bar-Coding Implementation Red squares highlight whiteout blotches which indicate errors in record keeping by nurse performing manual process 4. Project Implementation & Results 4A. Explain how buy-in/agreement was achieved for implementation. 4Aa. Indicate the types of internal and external (if applicable) stakeholder involvement in implementation. 4Ac. Explain how stakeholder buy-in was ensured. Stakeholder Buy-In Achieved Implementation Involvement Internal Leadership Team Approved solution Nursing Team IT Team Quality Department Patients Provided with updates Monitored implementation and success of program Encouraged to accept solution Developed education materials for team Provided lengthy education on process and implementation Trained team Told it was a pilot and did not have to Implemented solution with continue if it did not work patients Monitored team success Free IT solution discovered by nursing Uploaded free internet software team – only needed to upload to to all nurse workstations numerous computers Developed interface with Cerner Nursing Quality team worked with IT Ensured that data was to develop interface with Cerner successfully being loaded into Cerner by bar-coding software External Informed of improved wait times and Served as recipients of piloted greater accessibility to appointments solution SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 17 4Ab. Describe how various types of resistance were identified and addressed. Resistance Nursing Team Identified Nurses expressed discouragement in the change of process and mastering of the new system Other SKMC Facilities Nursing Teams Once implemented and successful in FMCs, implemented in other SKMC facilities where nurses expressed discouragement in the change of process and in mastering the new system Addressed Shown the benefits of accurately recording data, quickly recording data and more time spent with patients Informed that program would not continue to exist if it was not successful Shown the benefits of accurately recording data, quickly recording data and more time spent with patients Provided contact information of original nursing implementation team for any outstanding questions as a result of using Monitored six weeks later by original nursing implementation team to ensure accuracy and appropriate procedure 4B. Explain the approach used by the team to implement its solution(s)/improvement action(s) and to ensure the results (which should be sustained for six months). 4Ba. Describe the plan developed by the team to implement its solution(s)/improvement action(s). The Nurse Vaccination team developed the bar-coding solution. The nursing team began by working with IT to upload the free internet application to the nurse workstations. Then the team collected barcode scanners (that were not being used) from Patient Registration. Once the workstations were fully equipped, the team mapped out the process for bar-coding. This included the steps for labeling vaccines, checking bar-codes and administering vaccinations using bar-code tracking. The process also included steps on ensuring the bar-code was accurately scanned and entered correctly into Cerner. The team decided it was best to map these steps to a PowerPoint presentation so that it could easily be shared (see Appendix 1). The team adopted the following training approach to help other departments adopt this technology: SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 18 Figure 4 – Nurse Bar-Coding Training Process Day 1 • Review of current process with nursing team • Review of benefits of barcoding process with nursing team • PowerPoint presentation on process Day 2 • Practice new process with oversight by original nursing team member • Given contact information of original nursing team should any outstanding questions exist or issues arise 6 Weeks Later • Review of nursing teams progress by original nursing team member to ensure successful, accurate implementation and procedure 4Bb. Describe the procedure, system, or other changes that were made to implement the solution(s)/improvement action(s) and to sustain the results. At the outset of implementation the team quickly learned that we could capture more data than simply what vaccine was given into the electronic medical record system. To leverage this, the team developed a mapping tool that linked injection sites and vaccine sequencing to bar-codes. These codes would easily allow nurses to scan the vaccine, body part and the series number into the system, swiftly and efficiently capturing all of the required information. This tool was laminated and distributed to the entire nursing team, ensuring that the process was smooth, efficient, and easily replicable across the system (SKMC and SEHA). SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 19 Figure 5 – Bar-Code Mapping Sheets Mapping to body parts Mapping to vaccine series number SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 20 Additionally, the team realized that while using bar-coding the average patient encounter only lasted 15 minutes, where they previously took 20 or more minutes). This resulted in at least a 25% increase in available appointments, so patient loads were increased and appointments made more readily available. Figure 6 – Reduced Appointment Time Impact (One Clinic) 33% increase 33% increase 4Bc. Describe the creation and installation of a system for measuring and sustaining results. The system for measuring results was already in place. All data on patient visits and wait times, etc. was already captured through the appropriate IT systems. The SKMC stakeholders (Nursing, Quality, IT) simply had to ensure that this data was being accurately captured in real-time with the new system and that the results were being communicated to the appropriate teams. In this way, we could ensure effective and timely implementation, monitor the results, and find-time the system as needed. The results are highlighted in the next section, 4Ca. 4C. Describe the results achieved. 4Ca. Indicate the types of tangible and intangible results that were realized. 1. Decreased Patient Wait Times (Tangible) – The new patient waiting times map (figure 7) reflects the new times and the improvement over the old times. SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 21 Figure 7 – Post-Implementation Clinic Patient Process Flow Women’s and Men’s Waiting Area: 2-3 Minutes (after Registration) Before: 21 Minutes After : 2-3 Minutes Saving 18 Minutes 90%. Registration: 5 Minutes Nurse Vaccination Visit: 15 Minutes Before: 21 Minutes After : 15 Minutes Saving 6 Minutes 25%. Vaccination Site Review: 20 Minutes (required) Data recorded from the bar code scanners into the electronic medical records system substantiates these findings as evidence by the graphs below: SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 22 Figure 8 – Post-Implementation Patient Wait Time Reductions “Well Baby” Vaccination Visits (3 Month Average: Sept-Nov) 100.0 90.0 86.3 79.9 80.0 77.5 75.1 70.0 65.0 60.0 61.9 54.5 52.8 50.0 44.1 41.7 37.7 40.0 30.0 35.7 31.1 27.3 33.5 35.8 This paragraph shows an average saving of 33minutes, or 44.9 % 30.7 20.0 20.6 10.0 0.0 Al Bateen Al Khaleej 2010 Average Clinic Visit Time (Min) Al Manhal Al Rowdha 2011 Average Clinic Visit Time (Min) Al Zafranah Mushrif Average Clinic Time Savings per Appt (Min) All Patient Vaccination Visits (3 Month Average: Sep-Nov) 100.0 90.0 87.9 82.0 79.6 77.3 80.0 70.0 65.3 62.4 61.3 60.0 55.1 50.0 46.2 42.0 40.0 34.3 31.1 30.0 20.0 37.7 31.4 35.8 30.9 26.5 22.2 10.0 0.0 Al Bateen Al Khaleej 2010 Average Clinic Visit Time (Min) Al Manhal Al Rowdha 2011 Average Clinic Visit Time (Min) Al Zafranah Average Clinic Time Savings per Appt (Min) Mushrif This paragraph shows an average saving of 31.4 minutes, or 41 % SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 23 2. Increased Patient Visits (Tangible) – As a result of decreased patient waiting times the nursing teams were now able to see more patients. On average, patients volume increased by xx number of visits or yy%. This is reflected in the graphs below. Figure 9 – Post-Implementation Patient Visit Increase “Well Baby” Vaccination Visits (3 Month Average: Sept-Nov) 1600 1400 This paragraph shows average patient volume /clinic increased by approximate ly 460 visits/85% 1200 1000 800 600 400 200 0 Al Bateen AL Khaleej Al Manhal 2010 Average Patient per Month Al Rowdha Al Zafranah Mushrif Average Patients Added per Month in 2011 All Patient Vaccination Visits (3 Month Average: Sep-Nov) 1600 This paragraph shows average patient volume /clinic increased by approximat ely 595 visits/79% 1400 1200 1000 800 600 400 200 0 Al Bateen AL Khaleej Al Manhal 2010 Average Patient per Month Al Rowdha Al Zafranah Mushrif Average Patients Added per Month in 2011 SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 24 A direct result of increased patient visits is a commensurate increased in revenue. The chart below highlights the increase in revenue that we expect, given that each vaccination visit with a nurse is charged at a rate of AED 45. Figure 10 – Potential Revenue Increase Due to Increased Patient Visits “Well Baby” Vaccination Visits (3 Month Average: Sept-Nov) SKMC Facility 2010 Average Monthly (Revenue) 2011 Average Monthly (Revenue) Al Bateen Al Khaleej Al Manhal Al Rowdha Al Zafranah Mushrif MONTHLY AVERAGE PER CLINIC ANNUAL AVERAGE PER CLINIC MONTHLY TOTAL ANNUAL TOTAL AED 19,785 AED 19,515 AED 51,780 AED 14,625 AED 23,670 AED 16,110 AED 23,670 AED 284,040 AED 145,485 AED 1,745,820 AED 40,380 AED 33,255 AED 61,095 AED 47,295 AED 48,150 AED 38,955 AED 48,150 AED 577,800 AED 269,130 AED 3,229,560 Average Monthly Additional (Revenue) AED 20,595 AED 13,740 AED 9,315 AED 32,670 AED 24,480 AED 22,845 AED 24,480 AED 293,760 AED 123,645 AED 1,483,740 Percentage Monthly Additional (Revenue) 104% 70% 18% 223% 103% 142% 103% 103% 85% 85% All Patient Vaccination Visits (3 Month Average: Sep-Nov) SKMC Facility Al Bateen Al Khaleej Al Manhal Al Rowdha Al Zafranah Mushrif MONTHLY AVERAGE PER CLINIC ANNUAL AVERAGE PER CLINIC MONTHLY TOTAL ANNUAL TOTAL 2010 Average Monthly (Revenue) 2011 Average Monthly (Revenue) Average Monthly Additional (Revenue) Percentage Monthly Additional (Revenue) AED 30,435 AED 22,305 AED 54,720 AED 16,215 AED 28,440 AED 17,850 AED 28,328 AED 339,930 AED 169,965 AED 2,039,580 AED 55,755 AED 42,900 AED 61,545 AED 52,395 AED 49,500 AED 41,115 AED 50,535 AED 606,420 AED 303,210 AED 3,638,520 AED 25,320 AED 20,595 AED 6,825 AED 36,180 AED 21,060 AED 23,265 AED 22,208 AED 266,490 AED 133,245 AED 1,598,940 83% 92% 12% 223% 74% 130% 78% 78% 78% 78% 3. More Time for Patient Education (Tangible & Intangible) – As a result of having to worry less about record keeping, the nurses found that they had more time to spend with the patient, an opportunity to provide more education on the importance of vaccinations. In addition, they found more time to answer patients questions related to other medical issues. The document in Appendix 2 was developed by the nursing team the nursing team. The materials are handed to each patient at registration and reviewed by the nurses with the patients. In addition, the team has found time to distribute and review other patient education materials placed throughout the clinics. SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 25 Figure 11 – Patient Education Materials Developed for Clinic The swift process of scanning bar-codes also increased the efficiency of nurses giving vaccinations. The nurses have improved their speed in giving vaccinations by an almost unbelievable 900%. Figure 12 – Post-Implementation Nurse Efficiency SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 26 Increased efficiency gives the nurses more time to work with patients and ensure they’re receiving the care they need, as evidenced by this patient quote: 4. Data Tracking Benefits (Tangible) – The automated system of bar-coding has significantly cut down the amount of time staff have to spend gathering, recording and analyzing vaccination patient data, as data appears in real-time throughout the SKMC system. Figure 13 – Post-Implementation Data Improvements 350 300 300 250 200 150 100 60 60 60 50 0 0 20 0 0 Time taken to receive the Time taken to insure of Time taken to enter the data Time taken for Validating documents by messengers receiving the all documents in the system by the quality the data and closing from nurses. from the clinics statistician. Before bar coding and Computerization in mins / day After bar coding and Computerization in mins / day Overall time for running the report in mins / day 600 500 Paragraph shows a stunning 96% reduction in administrative time 480 400 300 200 100 20 0 Before bar coding and Computerization in mins / day After bar coding and Computerization in mins / day SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 27 Additionally, the accuracy is now better: Percentage of defects in the bar-coding system is 0% There is no need for correction after extracting the data And there are significant paper savings: [A Green Initiative] Reduced number of reports with data all in central location No lose files used for collating data No need for copying data to send to other clinics and entities 5. Electronic Record Keeping (Tangible & Intangible) – The automated system of bar-coding allows clinicians to immediately identify the vaccines previously administered to the patient. Additionally, patient records can now easily be retrieved for patients should they need proof of vaccination. Figure 14 – Post-Implementation Record Keeping Improvements 6. Improved Employee Satisfaction and New Opportunities (Intangible) – With more time to work with the patient and less time focused on paperwork, the nursing team has become much more satisfied with their work. Encouraged by the success of the system they are more engaged at work and are even proactively looking into other ways of using bar-coding as evidenced by this letter to the Unit Manager: SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 28 4Cb. Explain how the project’s results link with the organization’s goals, performance measures, and/or strategies. As shown by the table below, this project has helped SKMC become better aligned with many of SKMC’s and SEHA’s patient-focused key performance indicators SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 29 4Cc. Explain how results were shared with stakeholders. Stakeholder Leadership Team Nursing Teams Results Communication Provided with quarterly updates by nursing implementation team Provided with data reports from Quality Department on patient visits, appointment durations and process improvements Provided with data reports from Quality Department on patient visits, appointment durations and process improvements Provided with Patient Satisfaction Survey results at the end of each appointment SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 30 5. Team Management 5A. Explain how the team members were selected and how they were involved throughout the project. The team was comprised of nurse vaccination leadership and staff, spearheaded by the Unit Manager. The pilot group was located at Manhal Clinic and the staff from that team was selected by the Unit Manager. The collaborative nursing team at Manhal Clinic was responsible for: Securing the free internet bar-coding application Securing IT resources to install the bar-coding application Notifying the IT department if the technologies did not interface correctly Collecting unused bar-code scanners from within FMC Mapping out the bar-coding process (see Appendix 1 for PowerPoint presentation) o Labeling vaccines o Checking bar-codes during shifts o Administering vaccinations, ensuring the bar-code was accurately scanned and interfaced correctly with Cerner Developing the bar-code mapping sheet (see section 4Bb) Developing training curriculum for other nursing departments (see section 4Ba) Creating patient education tools (see Appendix 2 and section 4Ca result 3) Mapping current state and post-implementation state patient process flow (see sections 2Ac and 4Ca result 1) Monitoring implementation success and adjusting the process where needed (e.g., reducing patient appointment times from 20 minutes to 15 minutes) 5B. Explain how the team was prepared to work together in addressing the project. The team was initially brought together by the Unit Manager and responsibilities were distributed. The team continued to meet on a weekly basis to provide status updates and work through issues. It was at these meetings that any member of the team could voice questions, concerns and provide insightful ideas on the new solution. From these meetings came the development of off-shoot projects like the patient education materials and reduction of patient appointment times. The team worked collaboratively to continually monitor efficiency and effectiveness of the project. Today they continue to educate new nursing teams as we continue to replicate this process throughout SKMC and review the success of the bar-coding process. 5C. Explain how the team managed its performance to ensure it was effective as a team. The team used quantifiable data to ensure its’ effectiveness. The results tracked and presented in section 4 highlight the effectiveness of the team and new process. The team internally managed itself by reviewing that data, mapping current and post-implementation patient flow and tracking error rates. Rates in recording patient information were communicated to the team regularly. As they began to replicate the bar coding throughout SKMC, they also had to track the progress of the departments they had trained. In order to ensure their effectiveness outside of the pilot team, they would return to each trained unit six weeks after their education period to ensure that the trained department was following the right process and achieving results similar to or exceeding those of the pilot group. SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING Appendix 1 – Bar-Coded Vaccination Process (Most recent version – November 2011) 31 SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING Appendix 2 – In-House Developed Patient Education Materials 32 SKMC TRANSFORMATION PROJECT : VACCINE BAR-CODING 33