Redesigning the Medication Refill Process: A Multidisciplinary Kaizen Approach to Improving Patient and Provider Satisfaction

Disclosures Dr. Puja Samudra and Dr. Jibril Elabe have no disclosures or conflicts of interest

Goals and Objectives 1.Learn: –The definition of a Kaizen Event –How to select a topic and gather an appropriate team 2.Develop comfort in initiating this process in their own setting 3.Name and understand how the processes used in a Kaizen Event lead to both immediate rapid process improvement and long term change 4.Appreciate the tangible and intangible benefits of Kaizen over standard meeting based process change 5.Appreciate potential educational benefits to training physicians

Kaizen- what does it mean? Process of continuous improvement through making small changes for the better

Kaizen Event Process Plan Objectives and Scope of Event Train and Investigate Current State Perform Root Cause Analysis Develop Future State Plan Implement Action Items and Pilot Sustain and Follow Up on Metrics

Smiley’s Family Medicine Clinic Smiley’s Family Medicine GREEN Faculty Providers Nurse Practitioner Resident Providers Care Coordinator Patient Care Staff ORANGE Triage RN OB Coordinator RN Flow Nurse Pharm D Team Behavioral Team Triage RN OB Coordinator RN Flow Nurse Pharm D Team Behavioral Team

Lean Philosophy at Smiley’s Family Medicine Multiple efforts since 2006, starting with 5S process improving clinic organization Value Stream Map built with Lean consultant Developed standard work for patient care staff, front desk/call center and providers After Epic implementation in September 2012, the standard work needed significant updates

Leadership Level Decisions Steering Committee Residency Leadership Medical Director PCS Supervisor Front Desk Supervisor Identified Areas of Concern

Leadership Level Decisions Identified Areas of Concern Provider Concerns Patient Panel Feedback Patient Complaints PCS Concerns 3 Topics Selected for Meeting 1/14/13

Topic Selection at All Clinic Meeting All Clinic Staff Present Voted Medication Refill Process Selected Pre-visit Planning Medication Refills Visit Closure/ Check Out Topics Presented by Dr. Ramer, Medical Director

Topic Selection at All Clinic Meeting Process for PCS and Front Desk Physician Turn Around Time Second All Clinic Vote Medication Refill Process Selected Final Topic: Refill Process Physician Turn Around Time

Selecting Kaizen Team Representatives from the front desk, patient care staff and RNs included Resident on Ambulatory Family Medicine 2, a clinic heavy rotation, selected Leadership from 2 other department clinics included for cross-training Consultants with prior experience of Kaizen events led the event

The Kaizen Team

Clinical Staff Engagement At daily huddle meetings –Staff and providers encouraged to bring examples of problems –Given updates about Kaizen activities at daily meetings –Sheet posted on Huddle board with daily update Report out to “Event Champion” every evening Open house on Day 3 during lunch Formal presentation at all clinic meeting 2 weeks after event

Work Prior to Event Reviewed every medication refill fax received for 1 week and tracked it’s progress through the system Collected flash survey data from patients and clinical staff Scheduled future meetings with relevant parties during event

Day 1: Introduction and Defining the Problem Problem Description: Patient, provider and staff dissatisfaction with accuracy, volume, and turnaround time of refills. Errors can compromise patient safety. Objective: Implement detailed standard work, establish metrics for refills to improve safety, accuracy and turnaround time Background: Lack of detailed standard work Known errors and discrepancies with no clear follow up process Providers and staff spending excessive time on refills Majority of refills completed by providers, not RNs Out of Scope: Scheduled 2 Drugs, Prior Authorizations

Current State: Refill Data Duration of data collection: 7 days Number of Rx reviewed: 79 Average Rx turn around time: 33 hrs Accuracy Rate: 77% Duplication rate: 32%

Current State: Patient, Staff, and Provider Satisfaction Flash survey data from January 2013 reviewed that showed: 51% of patients answered “Yes, definitely” to: When I need medications refilled, my refill requests are handled in a timely manner. 62% of PCS responded “No” to: I know what to do when there is a discrepancy between the fax request and the EMR. 31% of providers felt that 25-50% of refills routed to their inbasket weekly were inaccurate

Day 1-2: Defining the Current State Team members worked in pairs Used direct observation of providers and PCS working on refill process Interviewed a clinic with RN-driven refills Interview with the on site pharmacist Interview with the flow nurse who managed most problems and Pharm D

Current State Map Bottle necks: front desk to PCS, PCS to provider and problem Rx to RN! Entry points: 6 faxes, phone, my chart & refill encounters!

Day 2-3: Problem Bursts No Standard Work Everyone in survival mode to complete refill request. No standard way to deal with problems. Fairview Smiley’s Rx Duplicate Fairview Smiley’s pharmacy sending both Faxes and inbox request. No standard process. Provider Denials without Routing Provider’s using Forward to send messages rather than Routing it to appropriate department Providers not routing to any pool when denying medication refill requests Inbox

Day 2-3: Problem Bursts MANY FAX NUMBERS/MANY FAX MACHINES FOR INCOMING REFILLS PATIENTS CALL THE CLINIC FOR REFILLS, NOT AWARE OF MEDICATIONS, FAXES OR PHARMACY TO PHARMACY TRANSFERS MULTIPLE PHARMACIES IN PATIENTS RECORD, PATIENTS REQUESTING CHANGES TO PHARMACY AT CLINIC LEVEL FRONT DESK/CALL CENTER STAFF NOT ABLE TO CHANGE SELECTED PHARMACY FOR REFILL DIRECTLY: NEED WAY TO COMMUNICATE MORE INFORMATION ABOUT REFILL TO PROVIDERS/PCS. NO COMMUNICATION WITH PHARMACY ABOUT DISCREPENCIES WITH PATIENT INFORMATION AND PHARMACY NOT INCLUDED ON CLOSING THE LOOP

Day 3: Problem Analysis Why? Pharmacies resend requests for refused medications Why? Pharmacy is not aware that the medication was refused Why? They are not being notified Why? Providers do not route their refusal, so there is no follow up by PCS Why? No clear provider or PCS process, no training on routing

Day 3: Designing a Future State Map Biggest challenge: thinking out of the box –Initially had strong resistance to even considering RN based standard refills –Lean consultants encouraged us to consider all possibilities Eventually agreed that chronic medication refills should be done by RNs Protocols had already been designed before Epic and only needed minor adjustments

Day 4: Develop and Implement Action Items FIX FAX COVER SHEET: IDENTIFIED HIM REQUESTS FAX NUMBER SEPARATE MEDICATION REFILLS NUMBER PATIENT EDUCATION: KNOW/UNDERSTAND MEDICATIONS SHOULD USE PHARMACY TO PHARMACY TRANSFERS VERIFY WHICH PHARMACY THEY WANT ACUTE MEDS SENT TO VS. CHRONIC MEDS CALL CENTER STAFF EDUCATION: CAN EDIT PHARMACY INFORMATION IN MESSAGE SO PCS CAN FIX IT IMPROVE STANDARD REFILL MESSAGE TO CLARIFY MED QUANTITY (30 vs 90 DAYS) PHARMACY TO BE NOTIFIED BY SMILEY’S STAFF ABOUT DISCREPANT PRESCRIPTIONS IN PATIENTS RECORD TO “CLOSE THE LOOP” BEFORE IT GETS TO PROVIDER

Fairview Smiley’s Pharmacy Duplication process verified over a week, all faxes then shredded

Provider Medication Denial Process Key is routing messages, not forwarding, to appropriate party to avoid falling into a black hole New Tip Sheet made as a process change alert Providers educated about this at daily huddle and had to sign off Small Pilot started to test using a common Med Refill Pool rather than team based pools

New Standard Work Development Standard Work Creation for Rx Refill Requests for each department: FD/CC PCS RN Smiley’s Fairview Pharmacy Providers

Initial Pilot Refill FAX Refill PHONE Faxes: Front desk delivers faxes to RN basket q 1hr. Phone calls: Initiate refill and route to.smimedrefill pool RN sorts faxes & retains diabetic refills. Leaves other faxes in the basket for PCS. RN & PCS review refill, create refill encounter. RN & PCS verify that refill request is valid and complete Medical Records delivers faxes to RN basket 4x day RN/PCS reconcile refill discrepancies. RN approve or route refill request per refill protocol PCS route refill to clinician Clinician reviews and approves. If refused or patient to needs instructions, note it and route to.smimedrefill pool. RN/PCS review medrefillpool, flag encounter as RN or CMA, and notify patient and pharmacy of plan

Initial Implementation Plan Standard work training: Kaizen team did training through March 15 th Pilot: Initial plan through March 15 th. Assessment planned in March to determine whether pilot should be rolled out to the rest of the clinic

Initial Proposed Timeline

Kaizen Follow Up Metrics Outcome Measures: Monitor Bimonthly 1. Average Turnaround time: Number of hours elapsed between refill fax received and provider routing refill to pharmacy Target: 24 hour turnaround 2. Accuracy: Percent of non duplicate refills routed with correct dosage, sig, quantity to the provider Target: 90% accurate Process Measures: - Weekly spot checks by team members - Monitor number of refills done by RN and total number of refills

Follow up Challenges Both providers involved had schedules that kept them away from clinic over the next week RN training completed on schedule, but Triage RN chose to retire Several PCS career transitions and clinic understaffed until July, 2013

1 Month Follow Up Team Meeting Unable to expand RN role or advance on pilots due to lack of staff Providers still not fully trained due to limited availability of training providers DatesNumber of Refills Turnaround Time (hrs) % Accuracy% Duplicates 1/28 – 2/ %32% 3/4 – 3/ %22%

3 Month Follow Up Data Dates 1/28 – 2/45/20 – 5/24 Including Outliers 5/20 – 5/24 Excluding Outliers Number of Refills Turnaround Time (hrs) Accuracy 77%99%97% Duplicates 32%33%34%

3 Month Audit Feedback PCS not sure how to format note to provider that medication request is not consistent with records and providers do not always check comments Providers sometimes forget to attach to their colleague’s Inbox for coverage when away Providers who are on rotations where they do not use Epic frequently have delays in completing refill encounters There is no process for PCS to remind providers that they still have open refill encounters after hours There is no oversight process to ensure refills do not get missed Pilot providers and PCS like the common Med Refill Pool

New Process Implementation Providers expected to check Inbox 2 times a day and address refills as a high priority Providers to have covering provider marked in Epic when away for greater than 24 hours Following workflow initiated to avoid misses Provider has 24 hours to complete or decline a Refill Request PCS page the provider with a reminder to complete the encounter Refill Request forwarded to Preceptor for completion 24 hrs

Final 8 month Follow Up Data Dates 1/28 – 2/45/20 – 5/24 Including Outliers 11/11 – 11/15 Number of Refills Turnaround Time 33 hours39 hours20.4 hours Accuracy77%99%100% Duplicates32%33%7%

Future Plans: Meeting 11/27 Will review data from follow up collection Most likely will expand common med refill pool Will discuss whether to expand RN role

Resident Perspective Learned more about the Kaizen process itself Learned more about how to improve system based practice Learned to appreciate the different team members perspectives Learned more about the administration aspect of clinic operations Increased appreciation for the quality improvement curriculum

Reflections Working with an interdisciplinary team: –Improved insight, cooperation, trust and communication –Led to more efficient and practical change in a shorter time period Purpose of a Kaizen event is to make continuous improvements, and may not effect change immediately To effect change, follow up and continued efforts are essential

Kaizen Version 2.0 Kaizen events are now being embedded in the curriculum of ambulatory family medicine for senior residents End of Visit process divided into 4 smaller areas of focus –Identifying and developing pilots to standardize end of visit process –Standardize approach to scheduling referrals and imaging –After Visit Summary Documentation concerns –Primary care physician follow up coordination Key differences in new process: –Only 3 days spent on each event with work distributed over the year –Recent event identified and implemented provider and front desk process change with follow up instructions in Epic –More time spent on front desk staff education and pilot implementation –Pilot initiated during event with clear provider follow up plan

Acknowledgements Nancy Arntson, RN Timothy Ramer, MD, Medical Director Peter Harper, MD, Clinical Service Unit Director Smiley’s Refill Kaizen Team Entire Smiley’s Family Medicine clinic staff for their support