r skiff healthcare synopsis

Richard Skiff – Synopses of Healthcare Projects

SYNOPSES OF SELECTED

PROJECTS IN HEALTHCARE

HEALTHCARE


STEPS TO IMPROVEMENT

• Acknowledge that there are problems

• Understand the cause(s) of the problem

• Solve the problem

• Sustain the solutionThe real challenge!

Harder

Hard

Easy


WHO IS THE CUSTOMER?

The customer is anyone whose evaluation of your services has an impact on your ability to continue to

deliver those services.


WHAT IS A PROBLEM?

A Problem (or opportunity)

is Something

that is Different than what it

Should Be.


ED PROBLEM

AVERAGE LENGTH OF

STAY

EMERGENCY DEPARTMENT IMPROVEMENT

5© 2013


6

Background Information

• Southeastern US Hospital• 81 Bed Emergency Department

– 26 Bed Major Unit (ESI levels 1-2)– 32 Bed Minor Unit(s) (ESI levels 3-5)– 12 Bed Major/Minor Transition– 10 Bed Behavioral Health Unit– 1 SANE room.

• 100,000 visits per year

Richard Skiff – Synopsis of Healthcare Projects

Door to provider Average LOS

Overall Quality of Care % Excellent

Door to Provider vs. LWBS

30

60

90

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Average Door to Provider

Better

Average Length of Stay

120

180

240

300

360


Min

ute

s

Average Length of Stay

Better

Overall Quality % Exc

0%

20%

40%

60%

80%

100%


% E

xcel

len

t

Overall Quality % Exc

Better

LWBS

0.0%

1.0%

2.0%

3.0%

4.0%

1 2 3 4 5 6 7 8 9 10 11 12

LWBS

Better

LWBS

Improve Key ED Metrics



59Holding

54 Green

Waiting

Room

50

49 48

51

47

Suture

46

Suture

EMS

Office

44 43

3534

42

39 Eyes

30 32 33

36

45

Suture

41

40

37

38

31

2928

58

57

56

55

53 52

Nurse

Station

RR

Radiology

Provider

Area RR

Pyxis Nurse’s

Station

Supply

Prep

and

Pyxis

RR

RR Soiled LinenTriage and Lab

PA

Discharge

“Green” Zone

3 Rooms

11 am to 11 pm

1 PA, 2 RN,

1 Tech, 1 MUS

“Yellow Intake”

3 Rooms

3 pm to 11 pm

1 MD, 2 RN, 1 Tech

“Yellow Zone”

24 Rooms

Open 24 hours

Staffing Varies Throughout Day

Phase 1: Minor Treatment Zones


FMC ED: Intake Average Length of Stay (ALOS)

60

90

120

150

180

210

240

270

300

Oct-08

Nov-08

Dec-08

Jan-

09

Feb-0

9

Mar

-09

Apr-0

9

May

-09

Jun-

09

Jul-0

9

Aug-0

9

Sep-0

9

Oct-09

Nov-09

Dec-09

Jan-

10

Feb-1

0

Mar

-10

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Inta

ke

AL

OS

(m

in)

Baseline: Mean = 240 min

Trial: Mean = 155 min

Intake Implemented: Mean = 170 min

Savings of 70 minutes per

patient

Savings of 70 minutes per patient by going through Intake Process vs.

Yellow Zone

Expand the demonstrated effectiveness of Phase I


59

54 Green

Waiting

Room

50

49 48

51

47

Suture

46

Suture

EMS

Office

44 43

3534

42

39 Eyes

30 32 33

36

45

Suture

41

40

37

38

31

2928

58

57

56

55

53 52

Phase 2

Nurse

Station

RR

Radiology

Provider

Area RR

Pyxis PACS,

Secretary

Supply

Prep

and

Pyxis

RR


PA

Team Intake 2

4 Rooms

3 pm to 11 pm

“Yellow Zone”

15 Rooms

Open 24 hours

Staffing Varies Throughout Day

Close 1 assignment to reallocate

staff for expanded

Team Intake

Team Intake 1

4 Rooms

11 am to 11 pm

“Supertrack”

3 Rooms; 1 pm to 10 pm


11

Phase 2 Improvements

• By focusing a provider (PA or MD), 2 Nurses, and a tech to a “pod” (a set of treatment rooms in close proximity), we found a significant improvement in the ability to focus on patients and patient flow, and therefore reducing the “Average Length of Stay” and “Left Without Being Seen” rates.

• We incrementally expanded this concept throughout the minor treatment zone, making adjustments as needed in each phase.

• The success was so significant that this process was expanded to include the entire minor treatment zone.


59

54 Green

Waiting

Room

50

49 48

51

47

Suture

46

Suture

EMS

Office

44

OB?

43

3534

42

39 Eyes

30 32 33

36 D/C; Flex

45

Suture

41

40

37 D/C; Flex

38 D/C; Flex

31

2928

58

57

56

55

53 52

Nurse

Station

RR

Radiology

Provider

Area RR

PyxisPACS,

MUS (2)

Supply

Prep

and

Pyxis

RR


PA

Intake Holding: Open 24/7 Pod A Open 1:00 pm to 6:00 am Pod B Open 9:00 am to 11:00 pm

Pod C Open 11:00 am to 11:00 pm

Pod D Open 24/7

There is a “Float” PA from 3:00 pm to 8:00 pm

1 pm – 10 pm PA

10 pm – 6 am PA

9 am – 5 pm PA

3 pm – 11 pm PA2 hr overlap 3 pm to 5 pm

11 am – 3 pm PA

3 pm – 11 pm MD

Flex Room

Flex Room Flex

Room

Shared by all pods

Flex Room

Shared by all pods

No more Supertrack – incorporated into intake pods

Main Lobby / Waiting Room

7 am – 4 pm PA

4 pm – 12 am PA

11 pm – 7 am PA1 hr overlap 11pm to 12 am

Phase 3


Pre-Implementation Simulation

• Patient data from a high volume day was analyzed to “simulate” running all of the Minor Zone as an Intake Process:

– Total ED Patients 315– Minor Zone Patients 209– BH Patients Arriving 23

• Note: No patient treatment times were shortened. Efficiencies were gained in through improving patient flow. Patient names are fictitious.


Simulation Results – Minor Zone

Actual Simulation Savings

Average Length of Stay(BH Patients

included)

373 min 326 min 46 min

Average Length of Stay (BH Patients excluded)

241 min 190 min 51 min

Average Arrival to Room 91 min 49 min 42 min

Average Time in Treatment Room

N/A 52 min

Maximum # of Patients in Main Lobby Waiting Room

About 24 14

Left Without Being Seen 9 patients 5 patients (estimated)

Richard Skiff – Synopsis of Healthcare ProjectsMain Waiting Room

59

54 Green

Waiting

Room

50

49 48

51

47

46

EMS

44 43

3534

42

39 Eyes

30 32 33

36

45

41

40

37

38

31

2928

58

57

56

55

53 52

Nurse

Station

RR

Radiology

Provider

Area RR

Pyxis PACS,

Secretary

Supply

Prep

and

Pyxis

RR


Kyles 26

Bennett 36

Lester

Lamar 21

Jennings 98

Bell 39

Kirksey 28

Beck 47 Buford

Bass 104

Blake 28

Baker 119

Bean 69

Jones 62

Beeson 41

Boyd

Burns

CLOSED

Helms

Weathers

Green

WatsonSi

nks

Dan

iels

Spin

ks

Ala

bast

er

Arc

hiba

ld

Dill

ard

Pete

rs

Min

ton

Hendrick Jefferson

HarrisAndrade Gillespie

Gen

try

Fox

Stewart

Sum

mer

s

Alle

n

Ston

e

Gri

er

Jess

upPurvis

Bullins

Wall

Boyd

Brewer

Nelson

Calloway

Baxter 16:00

King 29

At 16:00, 18 patients in Waiting Room with average wait time of 58 minutes to that

point

Billings 32 Johnson 84 Bergman 36 Brady

DISCHARGE

Actual Current Process

Hob

son

138

From Triage

PA


Main Waiting Room

59

54 Green

Waiting

Room

50

49 48

51

47

Suture

46

Suture

EMS

44

OB?

43

3534

42

39 Eyes

30 32 33

36

45

Suture

41

40

37

38

31

2928

58

57

56

55

53 52

Min

ton

Gre

en

Stone

Bro

dy

Allen

Daniels

Watson

Beane

Jenn

ings

Spin

ks

Gill

espi

e

Bass

Archibald

Hob

son

John

son

Wea

ther

sB

eck

King 29

Nurse

Station

RR

Radiology

Provider

Area RR

Pyxis PACS,

Secretary

Supply

Prep

and

Pyxis

RR


PA

Intake Holding

Lam

ar 2

1

Fox

Bee

son

41

Bill

ings

32

Kyl

es 2

6

Ben

nett

36

Ber

gman

36

Bla

ke 2

8

Kir

ksey

28

Jess

up

Jone

s

Bax

ter

Bell

Ala

bast

er

HelmsB

aker

Summers

Stewart

Bow

ers

16:0016:0116:0216:0316:0416:0516:0616:0716:0816:0916:1016:1116:1216:1316:1416:1516:1616:1716:1816:1916:2016:2116:2216:2316:2416:2516:2616:2716:2816:2916:30

At 16:00, 9 patients in Waiting Room with average wait time of 31 minutes to that

point

Simulated New Process

Hendrick BH Jefferson BH

Harris BH

From Triage DISCHARGE


HOSPITAL PROBLEM:

NURSING STAFF TIME WASTED

DOING “HUNTING AND

GATHERING”

NURSE EFFECTIVNESS

17© 2013


18

What is “Hunting and Gathering?”

Anytime a member of the Nursing Staff has to go someplace other than his/her immediate area to get something to provide care to the patient.

– Physical hunting and gathering of equipment, supplies, and equipment.

– Waiting for information/people/resources that are not where they are needed when they are needed.

*In this study, only Nurse hunting and gathering was measured. Hunting and Gathering should also include all other care givers, including Providers and CNAs.


19

Current State

TCAB Overall ScopeC

onte

xt D

iagr

am

Admit Patient to

Unit

Implement Care and Treatment

Complete Patient

Discharge

Patient Enters

Patient Departs

Care Planning

Med Administration

Hunting and Gathering is present in all aspects of Nursing Care.

Admission/Discharge

Med AdministrationCare PlanningHunting and Gathering

Complete Health History

Evaluate Patient

Response

Patient Assessment

Itterative Cycle

Scope of Hunting and Gathering


Time Spent Hunting and Gathering

20

Minutes per 12 hr. Nursing Shift Spent.....

Hunting and Gathering

25%; 3 hr 1 min

See Separate Chart

Bothpaper and computer charting19%; 2 hr 14 min

Med scanning from cart 9%; 1 hr

Shift/Nurse reporting

6%; 44 min

General nursing duties in patient's room and

administration of meds

35%; 4 hr 10 min

Misc7%; 51

min

Hunting and Gathering is about 25% of a Nurse’s day

These are only relatively small

snapshots of time, and results are

for high level/directional

use only


What are they spending time hunting?

21

Percent of Total Nurse time spent Hunting and Gathering for………..

Equipment 5.4%

Supplies 3.8%

Wait for Equip/Pyxis

2.6%

Info 1.1%

Get Meds from Pyxis 8%

Med not

in 1st Pyxis

1.5%

Patient Amenity

2.4%

Hunting and Gathering is 25% of

total RN time


22

Methods and Procedures

Provide own d/c transport GG

Transport ancillary (Radiology, Dialysis, Transfers) GGWasted med witness GG

Insulin Witness GG

Documentation GG

Duplicate Forms GG

Floor Stock Electronic Equipment (Dynamaps, Pulse Ox, etc.) GG

Floor Stock Non-Electronic Equipment (Wheelchairs, Recliners, walkers, etc..) GG

Equipment Failures – look for working equip GG, W

Take home equipment

Discharge orders WPyxis Discrepancy

Charts GG

Med info from pt. for pharmacy GG

Providers GG

Co-workers GG

Home meds GG

Policies GG

Radiology Results GG

Supplies &

Amenities

Respiratory Therapy Supplies GG

Search Multiple Pyxis GG

Linens GG

Nourishment GG

Coffee, Snacks, Personal Care items GG

Dressings GG

Load Med Cart GG

Stock Outs GG

Medications

IV Fluids GG

Checking for missing meds to be delivered from pharmacy GG

Insulin GG

Home Meds GG

Non stocked Narcotics GG, W

Blood GG

Ancillary Services

Lab W

Focus Area

X-Ray W

E.V.S. – Housekeeping W

Food Trays W

HUNTING AND GATHERINGGG = Go Get

W = Waiting

“Fishbone” diagram for reasons why nurses spent time

hunting and gathering

InformationEquipment


…..Floor Stock Electronic Equipment? (Dynamaps, PulsOx, Scanners, Med Carts, Phones, Bladder Scanners)

Hunting and Gathering: Why do we hunt for……W

hy?

Specific Task Item

Why

?W

hy?

Why

?W

hy?

Why

?

Not Returned to

Proper Location

Left in room

In Use by

another

No designated

place for equipment

Improper use

Hoarded

Called to another

task

Frequent use by

this patient

No time to return

to location

No Time to charge

Multiple storage places

Equipment shared by

multiple units

Not enough storage places

Past normal

life

No PM Program

Overuse

No replacement

plan

Not Charged

(Dead Battery

Bad cords

No Preventative Maintenance

No place to plug in

Not enough for each unit

Plan to use for

next Patient

Broken

Off unit (Borrowed or appropriated

)

Too far to walk

to return

Unknown charge

time

No charging schedule

Not plugged

in

See A

ANeeded for use

No Accountability

Lack of training

5 Why Analysis

23

Took focus areas noted in the fishbone diagram, and generated a “5 Why”

analysis to address issues.


24

…...Floor Stock Electronic Equipment? (Dynamaps, PulsOx, Scanners, Med Carts, Phones, Bladder Scanners)

Hunting and Gathering: Why do we hunt for……W

hy?

Why

?W

hy?

Why

?W

hy?

Why

?

Unfixable and not

communicated

Gave back to wrong

unit

Sent to Engineering

and not returned

Waiting for Repair

Never sent for repair

Not enough equipment

Floor Stock Electronic Equipment (Dynamaps, PulsOx, Scanners, Med Carts, Phones, Bladder Scanners)

Staff doesn’t

enter the request

No clear method for

engineering to communicate

back to the unit the status

No way to track

No defined return path

Waiting on parts

Don’t know how

Process too cumbersome

No replacement process – not

communicate to person that can

order

No Process or Bad

Process

Borrowed and not returned

Another unit

doesn’t have the

equip they need

No or poor

tracking system

Ineffective sign out system

No defined labeling system that is

permanent

Equipment poorly

labled so not

returned

Hoarding

No easy access to equipment

Ability to order equip

is too compli-cated

Not enough

ordered or purchased

Financial Constraints

Don’t know how many we have

When comes in

not delivered

to unit

No inventory guideline

Takes a long time to come

after ordered

Don’t have ownership

and a process

Specific Task Item


…...Non-Electronic Floor Stock? (Carts, Wheelchairs, Walkers, IV Poles, Bedside Commodes, Recliners, etc.)

Hunting and Gathering: Why do we hunt for…… W

hy?

Wh

y?W

hy?

Wh

y?W

hy?

Wh

y?

People left equipment in other area (i.e.

discharge)

Not enough equipment

No ownership

In a hurry

Went someplace else and when

came back equipment was

gone

No Accountability

Removed from room

In use with another patient

When Unit closed and equipment removed and

taken elsewhere

EVS does Discharge clean and removes

equipment

Borrowed for another

patient

Variable process and equipment needs for each

unit

Inventory issue

Broken

Missing parts

Thrown away

No Security or ability to lock unit.

Specific Task Item

25


HOSPITAL PROBLEM

New Hospital Opening – Are

We Ready?

NURSE EFFECTIVNESS

26© 2013


NEW HOSPITAL OPENING

• A new system 60 bed hospital was slated to open in approximately 70 days.

• Worked with start-up team to determine process needs/gaps prior to hospital opening.


Emergency

Direct Admit

Procedures (In /Out Patient)

Walk-ins

Regional PhysicianOffices

Discharge into

Community

INPUTS VALUE STREAMS OUTPUTS

Three Main Hospital Value Streams


High Level Value Streams


From MD OfficesFrom EmergencyFrom Inpatient

Pre Arrival Information

Registration Pre Cert, etc

Patient Info

NameDOBDemographicsInsurance

Clinical Information

Procedure/InfusionLength of ProcedureAllergiesSpecial NeedsOrder for ConsentRegular Orders

Pre-Anesthesia VisitMedical History and PhysicalPre-op Teaching/instructions If face to face; RN will notify pt.

Provider InformationSurgeon/MD; Does Patient need a PAV?

Schedule Patient

Enter into PICIS

Patient Arrival Arrival at Front Desk

Escort to Surgical Services

Greeter entry into Smartrak

Escort to ACU

Update Smartrak

Patient Arrival

Developed Key Quality Characteristics for each value stream.

Each stream had three main steps:

• Patient Arrival

• Patient Treatment

• Patient Departure

Surgical Services Value Stream


Perform Surgery

Pre-Op

Complete Assessment

Pre-Procedure verification

Outside Ancillary Tests Completed and Charted

Signed Consents

Site Marked

Prep Patient

Activate RDY button when Pt. is completely ready

Operating Room

RN go to ACU/Preop to meet/greeet patient

Transport Patient to OR

Update Smartrak - Circ RN

MD-Surgeon - Sign and mark

Anesthesia - Interview blocks

Perform Sugery

Upon Completion, Call ACU/PACU when close to transporting patient (RNA or RN)

How do Ancillary Services communicate / hand-off to Surgery?- Radiology- Pathology- Labs- Respiratory- Pharmacy- ICU- Wound

Patient Treatment

The key steps in each process were determined, and then processes needed to accomplish that task were identified.

Then they were evaluated for “readiness to open”

Green = Ready to Go

Yellow = Needs some refining

Red = Needs a lot of work


PACUReceive Patient and Report from OR / ORNA

Patient Recovery

Update in Smartrak

Hand off to Next Level of Care

Bed Control

ACU

ICU

Med Surg

How do Ancillary Services communicate / hand-off to Surgery?- Radiology- Labs- Respiratory- Pharmacy- Wound Care

ACU

Patient Report from OR / CRNA / PACU

Patient Recovery

Food and Nutrition

Update in Smartrack

Discharge to Community

Communicate Discharge Reports and Instructions Provider/Nurse Ask Me Three Written and Verbal

Vital Signs

Referrals Insure Feedback and Follow-up

Movement of Patient

Exit Transportation

Meds/Prescriptions

Patient Departure

These “maps” were jointly developed and rated by the functional department, clinical personnel, administration, related ancillary services, etc.

From there, the functional areas were able to focus on “Gaps” prior to the opening of the hospital.


PROBLEM:

Uncertainty on the time

effectiveness of Ultrasound Technicians

ULTRASOUND TIME EFFECTIVENESS

33© 2013


34

TIME STUDY PROTOCOL

• Methodology:

Followed one sonographer for an entire shift, logging the time spent doing his/her normal tasks. Times shown are only for one sonographer, and do not reflect activities of others in the department at the time.

SHIFT # of Patients # of Exams

Day 8 10

Day 8 8

Evening 8 8

Evening 9 9


Page 1

Radiology – Ultrasound “Scheduling” ProcessU

nit

Se

cre

tary

Order comes in via Printer

Put order in Future Basket

Is order for today?

Go to computer and print out Outpatient schedule

Near end of shift, fill out Day Log. Add to day

Log if already started.

Place patient requests and Day log into future basket

At beginning of day shift, pull requests from future basket

Is patient a Portable, ED, or Outpatient?

No

Attach blank “yellow sheet” (Hand off

communication tool) to every inpatient

request.

Call proper unit and ask for Patient’s RN; Fill out questions on

Yellow Sheet

No

Yes

Is patient in

ED ?Put request in ED Slot

Put request in Portable

Slot

Is Request for a Portable unit?

Put in 2nd slot in rack

When a Sonographer, room,

and machine are available, send for

patient

Transporter picks up request

Put front sheet in proper slot – to keep track of

what patients have been sent for

Is patient to come

to radiology unit?

Add order to Day Sheet

“A”

To AYes

No

Yes

Yes

Put request in Outpatient

slot

Is it an ED request?

Is the portable request Stat?

Place request in

“Ready Patient” slot

Put request in Portable Slot

Yes

No

Put request in ED Slot

No

Will procedure

need a labwork check?

Print off Labwork

sheet

Is labwork complete?

Call RN and order

labwork

Continue to check with RN until labwork is

complete

YesYes

No

Yes

No

No

No

To ED Process Page 2

To Outpatient Process Page 2

To “Portable” Process Page 2

To Outpatient Process Page 2

To B

“B”

Hospital Ultrasound Scheduling Process


Page 2

Radiology – Ultrasound “Scheduling” Process

Out

patie

nt P

roce

ss“P

orta

bles

” P

roce

ssE

D P

roce

ss From ED Page 1

From “Outpatient”

Page 1

From “Portable”

Page 1

Wait for call from ED to say that

patient is ready for exam

Take paperwork from ED slot, write

“R” on the top of the sheet, and place it in

the first open “Ready Patient” slot

Next available Sonographer

retrieves paper, gets portable machine, and goes to ED

Sonographer performs exam

Are there more

exams in ED?Return to

departmentNo

Yes

US Supervisor pulls all “Portable” exam paperwork out of

“Portables” slot and place in “Ready

Patient” slot

Next available Sonographer

retrieves chart, gets portable machine,

and goes to Patient location

Sonographer performs exam

Return to department

Scheduled Outpatient

comes to US Department

US department processes

paperwork and puts in next “Ready

Patient” slot

Sonographer gets paperwork

and patient, takes to room

Sonographer performs exam or procedure

Put completed paperwork in

stack of completed exams

Unit secretary takes batches of

paperwork to Medical Records (once or twice a

month)

Ultrasound Scheduling Process (cont.)


Sonographer Process

Son

ogra

pher

Check US “ready”

rack

Is there an ED

Exam ?

Go to ED Ultrasound

room

Is there “Portable”

Exam

Is there an “in department” exam

or procedure?

Get paperwork from printer

Check T-system for

room, relevant info

Get equipment

ready

Go to Pt Room

Perform exam

Is there another ED

Exam ?

Return to US Dept

Return to ED

US Room

Enter results of exam into computer

Yes

No

No

Yes

Do these first

Are there any

Transcranial exams?

Check Medical

records for previous exams

No

Yes

Perform exam

Go to Pt Room

Get equipment

ready

Is there another Exam

in batch?

Yes

Enter exam results into computer system

Did images transfer from

Portable?

Push images to computer

File paperwork

No

Yes

NoDoes

work-flow allow Portables

now?

Yes Yes

No

Check with supervisor for

priority

No

Return to US Dept

Go to charting computer,

begin charting process

Is patient here?

Send transport to get patient

Do Mandantory Education, Department

housekeeping, restocking, professional

development

Check Medical

records for previous exams

Grab chart

Check yellow sheet

for issues

Perform exam or

procedure

Yes Yes File paperwork

NoNo

A

To A

Go to charting computer,

begin charting process

Individual Sonographer Process


Ultrasound Time Study: Combined Shifts

44.5%

10.7% 10.5%

8.1%6.3%

3.8% 3.0% 2.7% 2.5% 2.4% 2.3%1.0%

3.3%

0%

10%

20%

30%

40%

50%

14:3

4:44

3:30

:45

3:25

:45

2:39

:46

2:03

:15

1:14

:00

0:58

:15

0:52

:30

0:49

:45

0:47

:00

0:44

:45

0:19

:30

1:05

:45

In room Dow ntime- No

Patients

ComputerCharting

Travel Lunch Misc prep Delay ScanBehind

Paperw ork MiscAdmin

Dow ntime

ChartReview

MiscDow ntime

Other

% o

f T

ime

Ultrasound Time Study: In Room Time - Combined Shifts

65.6%

9.9% 9.3%

5.1%3.6%

2.3% 2.0% 1.9%0.3%

0%

10%

20%

30%

40%

50%

60%

70%

9:33

:45

1:27

:00

1:21

:15

0:44

:29

0:31

:30

0:20

:15

0:17

:45

0:16

:15

0:03

:58

Examination Post ExamClean-up

Pre-Exam Prep Room Prep Paperw ork Chart Check Computer Delay Delay Other

% o

f T

ime

Possible Opportunity

Found that the ultrasound department actually had a very high percent of

their time actively working with patients. Some improvements could be made at end of shift procedures

scheduling.

Time Study Results


Opportunity: Waiting for Patients

Why is a Sonographer Waiting for Patients?– Waiting for Transportation – Why?– End of a Shift - Why?– Waiting for Labs - Why?– No exam/procedure requests– Other


PROBLEM:

What are some of the issues

affecting Nuclear

Medicine?

NUCLEAR MEDICINE PROCESS STUDY

40© 2013


Nuclear Medicine Process Study

• Observed Nuclear Medicine and PET for four shifts, including nights and weekends.

• Collected responses from the “magic wand*” sheets, as well as from conversations with staff.

* Staff were asked the question: “If you could wave a magic wand and change three things in your area, what would they be?


Process Improvement

The Nuclear Medicine and PET Groups were continually making changes to improve their department. As one technologist said, “...every two or three weeks we’re trying something different to try to make things better.”

This is exactly what we need to encourage – people who actually do the work having input and making changes to improve the delivery of value to the customer.


Nuclear Medicine: Breakdown of ProceduresJune 13 - December 9, 2010

Inpatient, 50.4%

Outpatient, 32.2%

Emergency, 17.4%

PET Procedures - Requesting "Unit"

Inpatient, 248, 16%

Outpatient, 1286, 84%

Who is Requesting Procedures?


Procedures Issues

• CCK and Lasix; RN vs. Technologist injections

• Outpatients with Ports, getting an RN in a timely manner

• Cardiolytes, getting a PA in a timely manner. One cardiology practice has recently cut PA positions – now have to wait for an MD to monitor.


Scheduling Ideas / Issues

• Mail appointment times and instructions to outpatients.

• STAT orders to NucMed on 2nd and 3rd shift – how to know that they are there.

• PET Procedure printing after 3:00 pm• Possible use of pagers in Waiting room – to

let patients know when to come back


Location of Transports to/fromOther1.9%

Nuclear Med26.5%

PET12.3%

MRI35.0%

Rad/Onc24.3%

Over 60% of transports are done for other departments than NucMed

and PET

METHODOLOGY:

Compiled NucMed

Transporter Log

11/30/2010 – 12/10/2010

10 Days Total

Transporter Process Improvement


Individual Transporter Data

TransporterWorked Minutes

Total Trips

Average Trips per

Hour

Calculated Total

transporting Minutes

Calculated % of Time

Transporting

A 4599 100 1.3 2280 49.6%B 3720 81 1.3 1847 49.6%C 3600 61 1.0 1391 38.6%D 4230 83 1.2 1892 44.7%

Includes trips taken with another transporter

10 days X 8 Hrs, less PTO

Total Trips times 22.8 minutes per trip

The percent of time that a transporter was actively transporting ranged from 39 to 50 %


TransporterWorked Minutes

Total Trips

Average Trips per

Hour

Calculated Total

transporting Minutes

Calculated % of Time

Transporting

A 4599 100 1.3 2280 49.6%B 3720 81 1.3 1847 49.6%C 3600 61 1.0 1391 38.6%D 4230 83 1.2 1892 44.7%

Includes trips taken with

another transporter

10 days X 8 Hrs, less PTO

Total Trips times 22.8 minutes per trip

The percent of time that a transporter was actively transporting ranged from 39 to 50 %


PROBLEM

Individual hospital process variation

affected system wide ED Stroke Response

times

SYSTEM WIDE ED STROKE IMPROVEMENT

49© 2013


ED Stroke Project Methodology

• Observed and process mapped main hospital and four satellite hospital ED stroke processes

• Process Mapped each Hospital’s processes, and Gathered ED stroke response data

• Brought all hospitals together to review process maps

• Determined best practices system wide to improve ED Stroke response, and began implementation of those practices


Mean Median0

15

30

45

60

75

90

14.12

2

10.19

10

15.35

11

28.87

25

18.38

16

tPA Order to tPA Start

CT Read to tPA Order

CT Complete to CT Read

CT Order to CT Complete

Door to CT Order

Minutes

Main Hospital ED Code Stroke Data

Richard Skiff – Synopsis of Healthcare ProjectsMission System Wide ED Stroke Process: Current State Comparison

tPA Ordered

Patient Arrival

CT Scan CT Read

ME

MO

RIA

L

tPA Prepared

TransferProtocol

to Memorial

EMS Process

Patient Assess-

ment; CT

Ordered

AN

GE

LB

LUE

RID

GE

TR

AN

SY

LVA

NIA

McD

OW

ELL

EMS Assessment on Stretcher

MD Assess Pt. for Stroke in ED Room

Draw Blood if possible

Bring Telestroke Robot

Connect to Neurologist via Telestroke

RN Prepares tPAPlace patient

in room.

POV Assessment

??

“Clot Box” with Protocol and

Stroke supplies available

RN Standing orders allow for CT order

Lab samples taken

Bring Telestroke Robot

Connect to Neurologist via Telestroke

RN Prepares tPA

CT Scanners alert Radiology if > 20 min

w/o interpretation

Notify Dispatch with Name, DOB, and pt.

address

ED notifies MD, Radiology, and Lab.

Notify ED of inbound stroke

Dispatch contacts ED with preregistration

info and ETA

Register pt. at door if possible

POV: Notify CT and Lab; call Code

Stroke

Draw blood in room, if not

done yet

EKG, X-Ray if ordered by

MD

POV: Registration or Triage makes

first stroke assessment

POV: Registration or Triage makes

first stroke assessment; call

“Code Stroke”

EMS Arrival; put in ED

room

POV: Triage makes

first stroke assessment

ED notifies Radiology and

Lab

Notify ED, start IV

MD assess for stroke

Draw Blood

Quick Register Pt.

Connect to Neurologist via Telestroke when back in

room

tPA Ordered by Neurologist

RN Prepares tPA

RN administers

tPA

ED Alerts ED of incoming possible stroke, and ETA

Draws blood, if possible

Denotes Targeted Best Practice

Register pt. at door if possible

May also alert Telestroke

RN Standing orders allow for CT order

If clear “Rule In,” MD orders CT Scan and contacts MMH Neurology via phone for acceptance of transfer, without using

telestroke

If CT is busy, may do EKG

while patient is waiting for CT

If using Telestroke, bring robot to room. (sometimes while in CT, sometimes after back in

room.

Draw lab samples when back in ED room, if not

drawn before.

Decision to admit or transfer Pt to Memorial

RN Prepares tPA

RN administers

tPA

RN administers

tPA

RN administers

tPA

In house radiology available 8-5; after hours use Asheville Radiology. Consistently good

response times.

2 “boxes” of tPA ingredients kept in ED

Omnicell; 2 more in Pharmacy

POV: Registration or Triage recognizes stroke

symtoms

Assessment done at Triage or EMS stretcher

(Preferred) or in ED room

EMT assesses Pt.Start IV if possiblePerform CBG test

MAMA (only) can call Code Stroke

POV:PACE RN or Triage determines possible Stroke; either can call Code Stroke

EMS: Place patient in room Start NIH assessment Draw blood for lab Register Pt if not done before.

RN or Pharmacist Prepares tPA

Bedside

RN administers

tPA

2 CT Scans:Plain CT followed by an Angio CT with contrast

Begin moving Robot when Code Stroke is called, for all EDs except Memorial

tPA Given

STK-4 Criteria: Patients administered tPA within 60 minutes of presentation to ED (Patients admitted to hospital)

OP-23 Criteria: CT read within 45 minutes of presentation to ED: (Patients “discharged” from ED – i.e. transferred to another hospital)

Mai

n H

ospi

tal

Sate

llite

#1

Sate

llite

#2

Sate

llite

#3

Sate

lilte

#4


PROCESS APPROACH

• Value Stream Map of Materials Distribution• Process Map of Materials Ordering –

Transactional Processes• Process Map of Post Product Approval

Process


SDC to SPD O.R. Case Cycle Time8:55 am to 3:56 pm (421 min) Processing Time: 262 min“Value Added” Time: 172 minProcessing Ratio: 62.2%Value Added Ratio: 40.9%

Print, separate and prioritize by expected delivery time and location.

Main Process: 7:00 am

Also prints every 30 minutes during the day

Unit calls, go to computer to look up

item

Cycle Time:

VA Time:

# of Units:

Yield:

Start Time:

End Time:

Distance:

Staff:1

Pull order

Cycle Time:

VA Time:

# of Units:

Yield:

Start Time:7:19am; 9:55 am

End Time:9:18am; 11:30 am

Distance:

Staff:

Place on cart or pallet to go to unit

Cycle Time:

VA Time:

# of Units:

Yield:

Start Time:

End Time:

Distance:

Staff:

Key in item – for inventory transfer

Process item

Cycle Time:

VA Time:

# of Units:

Yield:

Start Time:

End Time:

Distance:

Staff:

1) South Dock2) St Joseph3) Jasmine

ASC Delivered on 6:30 am truck

Also have van run at 12:30 for other locations, and throughout day for urgent items

Truck Delivers to Dock

Cycle Time: avg 25 min

VA Time:

# of Units:

Yield:

Start Time:

End Time:

Distance:

Staff:

3 Trucks each scheduled throughout the day:6:30 am8:30 am10:30 am12:30 pm2:30 pm

Load onto Truck

Cycle Time: 12 min

VA Time:

# of Units:

Yield:

Start Time:10:30 am

End Time: 10:42 am

Distance:

Staff:

Travel to first unit

Cycle Time: 6 min; 7 min

VA Time:

# of Units:

Yield:


End Time: 9:01 am; 10:55 am

Distance:

Staff:

Come to docks to get the materials for their assigned zones.

Sort into units as needed.

Similar process for virtually all nursing units in the hospital

Distribution techs get items for floors

Cycle Time: 20 min

VA Time:

# of Units:

Yield:

Start Time:

End Time:

Distance:

Staff:

Bring cart and any trash , excess items to dock.

Empty trash

Return to Dock


VA Time:

# of Units:

Yield:

Start Time:

End Time:

Distance:

Staff:

StockRelease OrderLook for holes/and excessCycle count as neededDo a “does it look right?” scan

Stock Omnicell

Cycle Time: 24; 38; 84 min

VA Time:

# of Units:

Yield:

Start Time:11:30; 9:01; 11:40

End Time:11:54; 9:39; 13:04

Distance:

Staff:

Non Stock and Misc.

No Weekends

Print, separate andpPrioritize by expected delivery time and location.

Main Process: 7:00 am

Also prints every 30 minutes during the day

Omnicell and Lawson Orders

Cycle Time: 12 min

VA Time:

# of Units:

Yield:

Start Time: 6:48 am

End Time: 7:00 am

Distance:

Staff:1

Separates into zones. May make several cart trips per order .

Picker pulls order

Cycle Time:119 min; 95 min

VA Time:

# of Units: 124; 175

Yield:


End Time:9:18am; 11:30 am

Distance:

Staff:

From inventory management system.

Issue produce out of inventory

Scan badge and pages to Access data base; productivity tool.

Process out of Inventory

Cycle Time:

VA Time:

# of Units:

Yield:

Start Time:

End Time:

Distance:

Staff:

Lawson or Omnicell Orders

Weekends use WH

Crew

Sort as they come off of truck into:PO – non stock ground and air

Misc PO

Add tracking label (Orange) to misc. PO. Items

Dock log items

Cycle Time:

VA Time:

# of Units:

Yield:

Start Time:

End Time:

Distance:

Staff:1

1) Refrigerated tissue, etc. – try to get on 10:30 truck2) The rest of the next day air3) Ground

Try to get 2 and 3 onto 12:30 truck

Prioritize

Cycle Time: 160 min

VA Time:

# of Units: 282

Yield:

Start Time:9:40 am

End Time: 12:00

Distance:

Staff: 5

Scan package to a particular pallet to a particular dock –Secondary Dock Log

Receive non-stock PO Items

Cycle Time:

VA Time:

# of Units:

Yield:

Start Time:

End Time:

Distance:

Staff:

Cath Lab and Special Procedures

No Weekends

South DockSt. Josephs DockJasmine Dock

Prestage for truck

Cycle Time: 4 min

VA Time:

# of Units:

Yield:

Start Time:

End Time:

Distance:

Staff:

Requisition items print 7:00 am Sort Check previous day’s schedule for excess and add-ons to requisitions.

Can get add-ons all through the day.

Print and sort items

Cycle Time:14.5 min; 19 min

# of Units:

Yield:

Start Time: 7:02 am; 1:51 pm

End Time: 7:16;30 am; 2:12 pm

Distance:

Staff:1

Place in toteRelease out of systemPut sticker on each tote

Pull supplies

Cycle Time: 20 min

VA Time:

# of Units:

Yield:

Start Time:7:25 am

End Time: 9:25 am

Distance:

Staff: 3

Put tote onto cart/pallet and wrap

Cycle Time: 5 min

VA Time:

# of Units:

Yield:

Start Time:8:35 am

End Time:8:30 am

Distance:

Staff:

SDC to SPD Delivery

Weekend SDC Crew

Sort.Separate print for Womans ORNeed to look in Cerner for special needs – ie latex free

Print cases for next day surgery

Cycle Time:30 min

VA Time:

# of Units:1557 line items

Yield:

Start Time: 8:55

End Time: 9:25

Distance:

Staff:1

8:30 – 10:30 CVOR, Vascular10:00 – others

Staged at 12:00 – 1:301;30 – get changes and add ons

Pick cases and put into tote; wrap

Cycle Time: 160 min

VA Time:

# of Units: 282

Yield:

Start Time:9:40 am

End Time: 12:00

Distance:

Staff: 3

Cancels and add-ons

Add/Delete Items

Cycle Time:8 min; 32 min

VA Time:

# of Units:

Yield:

Start Time:11:12 am 1:17 pm

End Time:11:20 am; 1:49 pm

Distance:

Staff:

SDC CasesPrint and pull add ons

Refresh schedule

Cycle Time:10 min

VA Time:

# of Units:

Yield:

Start Time:11:10

End Time:11:20

Distance:

Staff:1

Lawson or Omnicell Call Ins

(Urgent?)


Weekdays 3 crews;

Weekends 1 5 man crew

Non Stock PO; Misc

PO;

UPS and Fed Ex

No Weekend

SDC Requisition

Items

Weekday 5Weekend 1

Morning run; just receive items

Afternoon (delivered by distribution tech) – Sign off on delivery

Receive units

Cycle Time: 4 min

VA Time:

# of Units:

Yield:

Start Time: 1:34 pm;

End Time:1;38 pm

Distance:

Staff:1

6:00 am only

Retrieve from Dock

Cycle Time: 4 min

VA Time:

# of Units:

Yield:

Start Time: 5:42 am

End Time: 5:46 am

Distance:

Staff:

Must get signature for all items Except for call in or requisition template items.

May require multiple trips

Deliver items to units


VA Time:

# of Units:

Yield:

Start Time:8:59 am;

End Time:10:34 am

Distance:

Staff:

By destination; plan route

Sort at Dock

Cycle Time: 53 min

VA Time:

# of Units:

Yield:

Start Time: 9:15

End Time: 10:08

Distance:

Staff:

PM delivery, match delivered items to orders.Print receipts for next daySort and Stock

Unpack and Stock Items in proper

location


VA Time:

# of Units:

Yield:

Start Time 5:46 am, 1:38 pm

End Time: 6:12 am; 2:10 pm

Distance:

Staff: 1

Unload; Scan when delivered to SPD,

Cycle Time: 22 min

VA Time:

# of Units: 28 totes

Yield:

Start Time:3:34 pm

End Time: 3:56 pm

Distance:

Staff:

Truck Driver delivers SPD totes to SPD

Cycle Time: 3 min

VA Time:

# of Units:

Yield:

Start Time:

End Time:

Distance:

Staff:

Totes from previous day’s surgery

Return Empty totes to truck

Cycle Time: VA Time:

# of Units:

Yield:

Start Time:

End Time:

Distance:

Staff:

November 2012 study:

21% of all items returned$250,000 value of items returned

SDC Returns

Cycle Time: 34 min, 20 min

VA Time:

# of Units: 7 totes; 7 totes

Yield:

Start Time:

End Time:

Distance:

Staff:

Non Value Added (NVA)

Value Added with some NVA

Value Added (VA)


Lawson or Omnicell Call Ins (Urgent)

Non-Stock P.O.s and UPS / Fed Ex

OR Requisition Items

OR Cases

Materials Distribution: Current State Map


Non-Stock and Misc.

Cath Lab / Surgical Procedures

SDC to SPD to OR Deliveries

Richard Skiff – Synopsis of Healthcare ProjectsSupply Chain Processes: Current State Map

OR Emergency

Totes

Forms

Omnicell

Lawson Template

Set-up

Item is scanned out of Omnicell

Is itemPatient

Chargeable?

Decrements On Hand Quantity

NoOmnicell hits a Re-order point

Omnicell creates an electronic

Requisition file: “This is what I

need”

Lawson routes P.O. to a Buyer

Force a “Job” in Lawson

Lawson creates a P.O. for non-

stock item

Query to Omnicell: “How are you in stock

level?”

Is it a Stock

Item?

Decrements On Hand Quantity

account

Creates record of Patient and

Item

At 5:00 am; Omnicell transfers

information into Medipac

Medipac creates a patient bill

Yes

Cycle Count Correction of

Stock Amounts in Omnicell

during stocking.

No

Yes

P.O. sits in Buyer queue as

“Unreleased”

Buyer reviews P.O.

Revision needed?

Buyer revises order (Quantity,

Price, other)

Release item in Lawson

No

Yes

Lawson looks at available stock

on hand

Is enough quantity?

Lawson creates a pick ticket in Warehouse for each Omnicell

Item is Picked (Mtls Distribution

VSM)

Lawson “Kills” Quantity, may

revise with lower Qty.

Lawson sends an email to

requestor about Qty change

Prints “Killed” items at bottom

of ticket

A Pseudo pick ticket prints at

“From” Warehouse

When received at “To” WH, does release of “In Transit Receipt”

and increments receiving WH

Yes

No

If only one item on P.O., Lawson will not print a pick

ticket.

Item has reached a Par or

below level in Warehouse

Lawson create a PO

for Item?

Sometimes Qty is to be transferred from

another warehouse

Pick items and ship

WH does “In Transit” receipt

release and Decrements “From” WH

No, Transfer

Warehouse Perpetual

Orders

Is Vendor set up

EDI?

Order goes to GHX (Clearing

House)

GHX sends order to Vendor

Vendor confirms order

Buyer gets On-line confirmation

Enough to fulfill order?

Yes No

Vendor set up

Autofax?

Lawson job looks for

released Autofax POs

Autofax order to Vendor

Email from Autofax to Vendor;

“I sent P.O.”, Confirms by Fax

Vendor feeds back expected

ship date

Yes

No

Lawson prints out order

Vendor Confirms order

Buyer calls or faxes vendor

No

Yes

Buyer gets back with requestor

Is revised ship

date OK?

Is there a substitute available

Requestor has to wait.

No No

Yes

Create a new P.O.

Yes

Lawson Template

Items

Unit orders via a

Lawson Template

Unit completes the order and

releases it

Requisition created in Lawson

Go through Lawson approval

process

Hand Held Orders (Open Stock)

Both Stock and Non

Stock items

Mtlscoordinator

orders item via Handheld (Lawson)

Transmits order to Mobile Supply Chain (MSCM)

Non Lawson Orders

(Specials and New

Items)

Unit sends ina requisition

form to purchaser

Paper/Faxed

Has this item been

ordered before?

Is Vendor Approved

Item Qty meet “Add to Lawson”

Criteria?

Doesitem need Product Review?

Can it be purchased someplace

else?

Will it be ordered again?

Feedback to requestor that

item needs to go through product review process

Product Review Process

Add Vendor to Lawson

Yes

No

Yes

No

Yes

Yes

No

NoYes

Yes IT Adds item to Lawson

Put into Template or Par

No

New Entity or Department to

be set up in Lawson

Go to Finance to create; Maps to “X” Cost Center

Is Cost Center set up in

Lawson?

Finance sends out email that “I’ve created

Cost Center and its Called Y”

Materials tries to determine if this cost center will

order stuff

If so, creates a requesting location in Lawson

Someone in this cost center

orders something

Materials asks “Who are you and what cost

center are you?”

Set up requesting

location for cost center.

Are you a “Requestor”

Are you authorized to order for this cost

center?

Send computer services

authorization form

When done, email sent back to Materials IT

Yes Yes

No No

Get authorization

and set up their profile

Is there a template set up?

No

YesReady to order

Dialog with unit for needs. Look to see if there is “someone like

you.”

Build Template

Yes

No

Equipment New Equipment Request

Is it Capital?(> $5K)

Capital Buyer gets OK to purchase

Clinical Equipment Approval Process

Lease or Use

Agreement Process

Rental Equipment

Process

Fill out request in Ascend Software

Doesit have Lawson

Number?

Is it on a Template?

No

No

Yes Bidding and Vendor

Approval Process

Is item over $25K

Pass MD Buyline?

Is it Biomed?

No

Yes

No

YesTo B

Yes Review through MD Buyline

Process

Place PO with vendor

Periodic status updates

between buyer and vendor

Receive Equipment in Ridgefield or

designated other location

Go through Biomed approval

process

Install Equipment

Yes Yes

No

Go back to department for

No

Requisition to Materials that

someone needs more of that

form

New form is created

someplace

Forms Approval Process

Does Lawson have Form

Template?

Requester goes to

Printshop Process

Yes To B

No

Prints out Spreadshe

et order form

OR orders replenishm

ent emergency

tote

Is there a tote ready?

Fax to SDC

Stage to put on next

truck for delivery

Build the tote

Yes

No

Vendor Ships Order

To A

A

To C

B

C

Need Follow-Up Process Map

Develop clear guidelines on what

needs to go through product review.

There is a new Product Review Process (Value

Analysis Process) instituted 2/6/13; but it has

not been fully vetted.

Floor Stock Patient Equipment Distribution

Process (exp – IV pumps, Dynamaps, etc.)

To B

Credit Card Purchase

Post Product Review

Transactional Processes.

Mapped 2/21/13

It does not appear that there is a Recall Process for products

or equipment

It does not appear that there is an

Equipment Review/Approval Process

Equipment

Non- Lawson (Special) Orders

Lawson Template Set-Up

Lawson Template Items

Hand Held Orders (Open Stock)

Warehouse Perpetual Orders

Omnicell Orders

Forms

OR Emergency Totes

Transactional Ordering Process Map


Post Value Analysis (Product Approval Process Map)

Need to define this process

Creates Excel Spreadsheet with

information and sends to DatabaseSpecialst II.

100% Manual Entry

An item has been approved Value

Analysis (i.e. Product Approval) and is to be

made ready for purchase.

Is it a Surgical Material?

Contract person generates letter

of approval

Send a letter of approval to Team Lead,

Materials, and Vendor.

No. Comes out of Clinical Materials Product Review

E

Assumes that the New Process (2/6/2013) is

in place

Yes

Contract Administrator

sends information to

Data Base Specialist:

Contains: Vendor Product Number Description Unit of Measure

Buy Distribute

Pricing Par Levels

Adds Ship to Location

Stock/Non-Stock/Facility

Check for Duplicates in

Lawson

Assign Lawson

Number to Item(s)

Upload to Lawson“Lawson

Build”

DB I Add: Type Cost Department CDM (Charge Master #) Markup Price Scale

(Price to Patient: “Extended Price”

DB II sends Excel file back to:

DB I Contracts

A

B

Contracts uploads file to

Access

DB IOpen “Item Class

Template” in Cerner

Copy and Paste Item Number (Lawson) and

Class into Template

.CSV

Save resulting file in .CSV format

File in C:Drive “Item Master Active”

Go to Explorer menu in Cerner;

click“Execute Query

Output Item Master”

After Class, repeat for Location and Locator; each

location must be done separately

Open Access, Delete current “Item Master Active File”

Import New .CSV file into Access.

1) “Item Master Active”2) Create Backup File

Run Query in Access- produces file.

Compares Lawson Item Master to Cerner

Item Master –Produces new items.

Cerner file exported to “Prod Weekly”

Excel File New items need to

build in Cerner

Pull vendor Price File (Access) and match to Lawson Build

File

Output file with: Lawson Number Vendor Item Number Price Unit of Measure Description

Export back to Excel

Go into Lawson; Create Vendor

Agreement Header

Is File over 50 Items?

Send to DB II to Auto Upload

Key in ManuallyNo

Yes

Copy and paste “Prod Weekly” file into Cerner Items Upload File .CSV

Cerner Item Master Template

In Cerner, go to “Materials

Management Upload Manager”

After A, B, C, loops, this is the last step in this loop

Cerner exists to have clinical documentation and make items patient chargable

Contract person activates “Release” function in Lawson

Item can now be purchased

Import .CSV fileCommit

Check for Errors.

If after “A” loop, then do not do an error

check.Go to “B”.

After “B” loop, go to “C”

C

Are there any errors?

Create and send Change Upload File (Excel) to

DB II

Manually correct errors in Cerner

Yes

Manually make corrections in Lawson

Item built in Item Master

A

Wait for Cerner Ops

Jobs10:00 am; 1:00 pm

Cerner Ops Job populates

Pricing Tool

No

Manually to into each item number and item location,

click “Group Complete.” (Pricing tool application)

Open Explorer menu in Cerner

Run “Pricing Tool Data” file

Exit Cerner. Save as

Excel file in Pricing Tool

Reports

Open Access.Import Pricing Tool

File and the File from the Build.

B

Run Access Query to

compare the two files.

Query produces combined Excel file:

“Query Upload.date”

Export file to “Upload Files

for Donna”

Go into Excel and open the

file

Manipulate file to add: Supply (copy and

paste) Different Header Add bill code Add price schedule

cost and mark up.

Save as .CSV in “Upload Files for Donna.”

Email to “Donna” -(Cerner Person)

Cerner uploads to Pricing Tool

Load into “Item Entry System (Access)

Lawson Number Approver Store Location Vendor Number,

etc. Chargeable?

New Item?Is it a

Cerner Item?

No, it’s a replacement

Send to DB II

Upload to Lawson

Yes

No

Lawson creates file

(Still Access)

Contract Person(s)

manually review file to determine items needing

action

Approver: Go to Vendor.Email:

Mfg Code Usage

Vendor notifies Mission their ETA to ship

stock

Set up contract

Approver sometimes has

to “nudge” contract person

by email

Send email to Surgical Materials manager

Surgical materials manager

determines: Usage Locations

Communicate change to

various locations

Notify DB I to make change in

Cerner

Notify DB II to make change in

Lawson

DBI adds additional mfg to

Cerner

Manually change price in Pricing Tool (if needed)

Release Contract

Enters Order Process at Unit:

Omnicell Lawson Template Special Orders Etc.

Communicate to Users that “Item is available to order.”

The timing of this communication is critical – to balance ordering with when it will be

available from vendor.

Yes

FUTURE STATE

Item is approved (2/6/13 Process)

Clear message from Value Advisor to

Execute

Information arrives from Vendor in Mission Excel

Template

DB I adds Mission Specific information

Lawson and Cerner dialog and put out a

final product

Look for duplicate: Descriptions Manufacturing Item

Numbers

Manual fix

Generate exception report for conflicts.

Fix manually

Buyer Message Item comes in with

Differences from P.O.

InvoiceReceiving

Found that this process takes over 30 steps, and involves 17 file format changes!


• Neptune Recall

• WOW Cart Overheating

• Propofol Syringe in Patient Room

• Propofol Syringe in NTICU

• OR Vacuum Reduction

• Direct Admit Flu Exposure

• Surgical Sight Specific Infection

• Phenobarbital Detox

• NICU Freezer Failure

• Vancomycin Extra Dosage

• Cardiologist Office Wrong Echocardiogram

• Trocar Injury

• Physician Office Complaint

Patient Safety Events:Root Cause Analyses Facilitated

r skiff healthcare synopsis

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