When researching new automation to compliment current pharmacy processes, often the emphasis is placed on how that technology will be integrated into the established pharmacy operation. However, as we are now a few decades into the use of certain technologies, we must also look at the end-of-life circumstances posed by these solutions, and determine whether we will continue to use replacement technology in the same way, or if recent developments have created an opportunity to retool processes to better utilize the modern solutions now available. What was new and worked well for us ten years ago may not be the best fit for our needs today or in the future. Thus, when systems begin to approach the end of their useable life, it is the perfect time to analyze your processes and determine whether a more substantial change would benefit your practice.
Peninsula Regional Medical Center (PRMC) located in Salisbury, Maryland is the region’s largest tertiary care facility with 363 acute care beds, 28 nursery beds, and 30 transitional care beds. Spurred in part by the approach of the end-of-life phase of our central pharmacy medication robot and automated dispensing cabinet (ADC) technology, the pharmacy is currently in the midst of a medication distribution shift from a centralized, robot-centric model to a point-of-care model that will use dual carousels in the pharmacy while augmenting the scope of our ADCs. This shift comes as the direct result of clear and earnest communication among pharmacists, physicians, and nurses, whose input and feedback on processes has not only lead to the planning and acquisition of different automation technology, but also is leading to more efficient, cost- and time-effective patient care services.
Transitioning through Automation
In December of 1999, PRMC installed its first medication storage and retrieval robot in the central pharmacy. A dynamic piece of automation at the time, this robot served as the launching pad for technology-based medication safety efforts within our pharmacy practice. In rapid succession, we installed ADCs enterprise-wide in 2000, followed by bedside bar code medication administration shortly thereafter. Prior to adding the robot automation to our workflow, we performed a manual cart fill requiring pharmacy technicians to manually pick all medications from static shelves and a pharmacist to manually double check each one. We were able automate this process through the robot thereby increasing filling accuracy and cutting labor time significantly, both significant improvements in the late 90’s. With these obvious advantages over the manual system, it was not long before pharmacy staff began to rely heavily on this robotic technology.
In 2006, after several years’ experience with the robot-based distribution system, we conducted an online survey of nursing satisfaction with medication distribution to test the effectiveness of our pharmacy services. The survey consisted of fourteen questions and used a 4-point Likert-type scale to gauge both positive and negative responses (see Figure 1). Upon tabulating the results, questions four and five, which centered on medication turn around time and accurate medication delivery, received the least favorable scores. In addition, the optional free text comments revealed nursing’s further dissatisfaction with the time taken for delivery of medications to their unit. It was evident from this survey that even with the efficiencies provided by the robot-centric distribution model, nurses were not satisfied with the turn around time and delivery of their medications.
Analysis and Continuous Improvement
In early 2010, our robot vendor reminded us that the average working life cycle of the robot was approximately fifteen years. The realization that we were nearing the end-of-life period for the robot coupled with the need to improve medication turn-around times begged the larger question that had been lingering for some years. Was it a better idea to rethink the entire distribution model and make a more global, positive change that would satisfy both pharmacy and nursing’s needs? In addition to the robot, we determined that the majority of our automated dispensing cabinets also would need to be replaced in the near future due to equipment age. Armed with this knowledge, a placeholder was inserted into the capital budget process for the subsequent fiscal year, even though a final plan for our medication dispensing system was not fully developed.
With the support of administration, we assembled a multi-disciplinary team to determine the course we would take for medication distribution going forward. In order to gain input from as many shareholders as possible, the team was made up of representatives from pharmacy, nursing, nursing administration, and performance improvement engineering. The initial action of the team was to evaluate two distribution models—centralized and point-of-care decentralized. To enable this, we developed a critical-to-quality (CTQ) scoring matrix (Click here to download a PDF of the Figure.). The three primary categories for scoring were patient safety, operational efficiencies, and cost containment with individual line items under each category.
At this point, the team embarked on several site visits to facilities that were operating either centralized or point-of-care distribution models. During the site visits, it was apparent that both types of distribution models could be successful depending on the circumstances faced at each facility. During each visit, group members scored the individual line items on the CTQ matrix as they observed them. Scores were then tabulated for each line item, based on their ranking and weight. At the end of this exercise, we determined that the point-of-care model scored higher than the centralized distribution model and decided that converting our distribution model was in the best interests of our institution.
Making the Decision to Change
Once we made the decision to make a fundamental change to our distribution model by changing from centralized to decentralized point-of-care, we attempted to figure out what a high-level vision of the point-of-care model would look like for us. We established the following goals based on our current and projected workflow:
The next step in this process was crucial—deciding on a vendor that could meet the manifold needs of this change. Since we would be starting fresh with entirely new equipment, our preference was to have one vendor supply the ADCs, anesthesia cabinets, and carousel units, as we saw the integration of these three core units as an important factor.
We narrowed our list of vendors to three choices and met with each one to develop an equipment list that would meet our needs. Each company provided an initial proposal for dispensing cabinets, an anesthesia dispensing system, and carousels. We then arranged to have a demonstration fair for the selected vendor products. Attended by nurses, pharmacists, pharmacy technicians, anesthesia providers, and information services representatives, we established efficiency of use and patient safety as the main drivers of our decision making, the results of this review indicated a single vendor for all three technologies that would allow us to reach our expected goals. With this process under our belt, the ultimate contract negotiation was conducted and finalized in March 2011.
Looking Ahead to the Transition
In collaboration with our selected vendor, we developed a project plan with key chronological milestones to be completed over the next eight months beginning in July 2011. These steps include the replacement of ADCs with new ones, the implementation of the anesthesia dispensing system, the deployment of additional dispensing cabinets (ie, auxiliary and tower units) to support the point-of-care distribution model, and finally, the installation of two carousel units in the central pharmacy.
Concomitant to developing the project plan, we also met with our facilities management group to plan facility changes necessary to accommodate the additional ADCs on patient care units as well as the anesthesia dispensing system in surgical services. We performed a thorough walkthrough of the facility and worked together on a modification plan that would fit with our overall project plan. This plan was communicated to each affected clinical manager for feedback and fortunately, only very minor modifications were made to the plan. Once finalized, the facility modification plan was enacted and completed through April and May 2011, prior to arrival of the new technology elements.
Preempting Workflow Changes
Breaking down our distribution model and rebuilding from scratch was an exciting prospect and now that we are engaged in the project, we want to be as prepared as possible once the physical changes have been made. In order to brace for this, we organized another team of pharmacists, nurses, and performance improvement engineers to develop a future-state workflow for the new point-of-care decentralized distribution system. We incorporated lean and six sigma tools into this exercise and the group began by mapping out our existing processes and identifying process steps that either worked well or needed improvement. Further development of CTQ indicators helped guide the team and we created an ideal workflow based on the positive attributes of the current state and the CTQ indicators. From the ideal state, the team determined what was possible with the point-of-care technology and created a future state process (see Figure 2). As it stands now, the future-state process should serve as the work standard when the point-of-care medication distribution system is fully implemented at the end of the first quarter of 2012.
Viewing a Project from the Middle
Changing our medication distribution system from a centralized model to a point-of-care model is a large, sweeping change that will significantly impact pharmacy and patient care services. Due in large part to the level of background analysis we collectively performed leading up to this project, we expect the ultimate change to bring about the benefits we could only attempt to shoehorn into our previous model. The addition of new, streamlined technology will also better prepare us for the future. While a great deal of effort is required from several departments to successfully transform a medication distribution model, in the end, a more efficient system molded around our most up-to-date workflow should lead us toward our never-ending goal to persistently increase patient safety and improve the manner in which our collective staff members interact.
Dr. Dennis Killian graduated from the University of Maryland-Baltimore School of Pharmacy, obtaining a PharmD in 1999 and a PhD in Pharmaceutical Sciences in 2001. He is the director of pharmacy services at Peninsula Regional Medical Center where he has been employed since 2005. Dr. Killian also serves as an associate professor of pharmaceutical sciences at the University of Maryland Eastern Shore School of Pharmacy.
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