CASE STUDY
Renal replacement therapy
ar
CASE STUDY
Layar
Applying lean principles to continuous renal replacement therapy processes C. Brett Benfield, Philip Brummond, Andrew Lucarotti, Maria Villarreal, Adam Goodwin, Rob Wonnacott, Cheryl Talley, and Michael Heung
S
triving to achieve a process without non-value-added time, monetary waste, and product waste has been a long-standing tradition in manufacturing, but the healthcare industry has been slow to adopt these principles.1,2 Recently, health systems in the United States have started adopting the lean principles used in manufacturing to identify waste and develop processes to eliminate it.3 However, few studies have examined the impact of lean principles on healthcare delivery. Among the early adopters of lean processes in healthcare, the Charité University Hospital in Berlin, Germany, used lean tools to reduce an 11step workflow to 5 steps.4 Beth Israel Deaconess Medical Center broke a 64-step workflow into its individual parts to make each as efficient as possible.5 Both studies used value-stream mapping to identify areas of nonvalue-added waste in their processes and created interventions to eliminate waste. However, neither institution
Purpose. The application of lean principles to continuous renal replacement therapy (CRRT) processes in an academic medical center is described. Summary. A manual audit over six consecutive weeks revealed that 133 5-L bags of CRRT solution were discarded after being dispensed from pharmacy but before clinical use. Lean principles were used to examine the workflow for CRRT preparation and develop and implement an intervention. An educational program was developed to encourage and enhance direct communication between nursing and pharmacy about changes in a patient’s condition or CRRT order. It was through this education program that the reordering workflow shifted from nurses to pharmacy technicians. The primary outcome was the number of CRRT solution bags delivered in the preintervention and postintervention periods. Nurses and pharmacy technicians were surveyed
used metrics to objectively identify improvements resulting from the interventions. This case study describes
C. Brett Benfield, Pharm.D., is Postgraduate Year 1 Ambulatory Administrative Resident, Fairview Pharmacy Services, Minneapolis, MN; at the time of writing he was Student Pharmacist, University of Michigan College of Pharmacy (UMCP), Ann Arbor. Philip Brummond, Pharm.D., M.S., is Director of Pharmacy, Froedtert Hospital, Milwaukee, WI; at the time of writing he was Pharmacy Assistant Director, University of Michigan Health System (UMHS), Ann Arbor. Andrew Lucarotti, Pharm.D., is Pharmacist–Generalist UMHS, and Adjunct Clinical Instructor, UMCP. Maria Villarreal, CPhT, is Certified Pharmacy Technician; Adam Goodwin, CPhT,
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to determine their satisfaction with the workflow change. After implementation of lean principles, the mean number of CRRT solution bags dispensed per day of CRRT decreased substantially. Respondents’ overall satisfaction with the CRRT solution preparation process increased during the postintervention period, and the satisfaction scores for each individual component of the workflow after implementation of lean principles. The decreased solution waste resulted in projected annual cost savings exceeding $70,000 in product alone. Conclusion. The use of lean principles to identify medication waste in the CRRT workflow and implementation of an intervention to shift the workload from intensive care unit nurses to pharmacy technicians led to reduced CRRT solution waste, improved efficiency of CRRT workflow, and increased satisfaction among staff. Am J Health-Syst Pharm. 2015; 72:218-23
the use of lean principles to redesign workflow and reduce waste in a large academic medical center.
is Certified Pharmacy Technician; Rob Wonnacott, RN, is Critical Care Nurse; Cheryl Talley, RN, is Critical Care Nurse; and Michael Heung, M.D., M.S., is Medical Director, Inpatient Dialysis Programs, Department of Medicine, Division of Nephrology, UMHS. Address correspondence to Dr. Benfield ([email protected]). The authors have declared no potential conflicts of interest. Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0201-0218. DOI 10.2146/ajhp140257
CASE STUDY
Background The University of Michigan Health System has 941 inpatient beds, including nearly 100 intensive care unit (ICU) beds. The health system provides approximately 2500 patient-days of continuous renal replacement therapy (CRRT) annually. CRRT is delivered as a multidisciplinary collaborative: nephrology nurses initiate therapy, ICU nurses provide maintenance therapy, and pharmacy services prepare and deliver CRRT solutions. Commercial CRRT solutions are routinely adjusted with electrolytes such as potassium and phosphorus additives to achieve prescribed concentrations. As a result of this manipulation in an immediate-use area and as an infection-control measure, CRRT solutions must be used within 12 hours of preparation before they are considered to be expired. Problem CRRT is a complicated and costly therapy requiring careful coordination and cooperation among multiple disciplines and services, including ICU nurses, nephrology nurses, physicians, pharmacists, and pharmacy technicians. With the multiple steps associated with this workflow, there is potential for significant waste related to inefficiencies or breakdowns in communication. As part of a quality-improvement program, the waste of unused CRRT solutions in the health system was identified as a target area for improvement. Lean principles were used to identify the causes of inefficiency and formulate interventions to reduce waste in the CRRT program. Analysis and resolution Lean process. Before the implementation of lean principles to CRRT, a provider would place the initial order for CRRT, which generated a pharmacy order for the preparation of the solution. The nursing staff ordered subsequent
replacement bags directly from the pharmacy as needed. In anticipation of the required lead-time for pharmacy preparation and delivery, nurses routinely ordered solutions in advance, storing solution bags at the bedside until needed. With interruptions in therapy or changes to CRRT orders, the excess bags at the bedside were sometimes wasted. The appropriate stakeholders in the CRRT workflow were identified and formed a focus group for workflow review. In the first meeting, a value-stream map was created, which provided an overview of the workflow to identify areas of nonvalue-added waste (Figure 1). For two weeks, members of the focus group observed the workflow, aided by the value-stream map, to ensure that each step and the times associated with each step were appropriate. At the next meeting, a problemsolving tool, known as an “A3,” was created to identify areas of focus in order to reduce the identified waste. After exploring a number of different options, the stakeholder group recommended implementing an intervention focused on the workflow for reordering CRRT solutions. CRRT solution reordering was shifted from ICU nurses to pharmacy technicians in order to emphasize the principle of just-in-time delivery. With help from the health system’s information technology team, a report from the electronic medical record was designed to identify the flow rates used for each patient receiving CRRT. Pharmacy technicians were responsible for generating this report at the beginning of each shift and determining when additional bags would be needed for each patient. The goal was to deliver solutions within two hours of the anticipated need. To ensure accuracy, the pharmacy technician responsible for making hourly deliveries performed a bedside check to screen for any CRRT solution rate changes since the generation of the report.
Renal replacement therapy
Changes were communicated to the technician responsible for managing the CRRT solutions, and any necessary adjustments to the delivery time were made. The technicians responsible for CRRT maintained a logging system to record the delivery time of the last CRRT solution and the estimated time of the anticipated need, thereby maintaining continuity between shifts and team members. As part of the intervention, an educational program was developed to encourage and enhance direct communication between nursing and pharmacy about changes in a patient’s condition or CRRT order. All staff were educated in person and in writing as to the specifics of the new workflow. It was through this education program that the reordering workflow shifted from nurses to pharmacy technicians. Of note, this intervention used only existing personnel at no additional cost to the health system. Data collection. Data were collected from February 2012 through September 2013, with the intervention applied in April 2013. Initially, the unused CRRT solution bags were returned to the pharmacy, and the data were manually recorded. However, this was labor-intensive, and many wasted solution bags were not accounted for because they were disposed of at the ICU bedside instead of being returned to the pharmacy. Subsequently, the data switched from a prospective collection of the bags to a retrospective review of the dispensing of CRRT solution bags per therapy day. A monthly report of distribution data for the CRRT solutions was generated and analyzed for the number of bags dispensed each month. The total hours of therapy received by each patient (identified by medical record numbers) and the total number of therapy hours per month (divided by 24 to find the number of therapy days) were compared with the number of solution bags dispensed during that month.
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Am J Health-Syst Pharm—Vol 72 Feb 1, 2015
Renal replacement therapy
ar
CASE STUDY
Layar
Applying lean principles to continuous renal replacement therapy processes C. Brett Benfield, Philip Brummond, Andrew Lucarotti, Maria Villarreal, Adam Goodwin, Rob Wonnacott, Cheryl Talley, and Michael Heung
S
triving to achieve a process without non-value-added time, monetary waste, and product waste has been a long-standing tradition in manufacturing, but the healthcare industry has been slow to adopt these principles.1,2 Recently, health systems in the United States have started adopting the lean principles used in manufacturing to identify waste and develop processes to eliminate it.3 However, few studies have examined the impact of lean principles on healthcare delivery. Among the early adopters of lean processes in healthcare, the Charité University Hospital in Berlin, Germany, used lean tools to reduce an 11step workflow to 5 steps.4 Beth Israel Deaconess Medical Center broke a 64-step workflow into its individual parts to make each as efficient as possible.5 Both studies used value-stream mapping to identify areas of nonvalue-added waste in their processes and created interventions to eliminate waste. However, neither institution
Purpose. The application of lean principles to continuous renal replacement therapy (CRRT) processes in an academic medical center is described. Summary. A manual audit over six consecutive weeks revealed that 133 5-L bags of CRRT solution were discarded after being dispensed from pharmacy but before clinical use. Lean principles were used to examine the workflow for CRRT preparation and develop and implement an intervention. An educational program was developed to encourage and enhance direct communication between nursing and pharmacy about changes in a patient’s condition or CRRT order. It was through this education program that the reordering workflow shifted from nurses to pharmacy technicians. The primary outcome was the number of CRRT solution bags delivered in the preintervention and postintervention periods. Nurses and pharmacy technicians were surveyed
used metrics to objectively identify improvements resulting from the interventions. This case study describes
C. Brett Benfield, Pharm.D., is Postgraduate Year 1 Ambulatory Administrative Resident, Fairview Pharmacy Services, Minneapolis, MN; at the time of writing he was Student Pharmacist, University of Michigan College of Pharmacy (UMCP), Ann Arbor. Philip Brummond, Pharm.D., M.S., is Director of Pharmacy, Froedtert Hospital, Milwaukee, WI; at the time of writing he was Pharmacy Assistant Director, University of Michigan Health System (UMHS), Ann Arbor. Andrew Lucarotti, Pharm.D., is Pharmacist–Generalist UMHS, and Adjunct Clinical Instructor, UMCP. Maria Villarreal, CPhT, is Certified Pharmacy Technician; Adam Goodwin, CPhT,
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to determine their satisfaction with the workflow change. After implementation of lean principles, the mean number of CRRT solution bags dispensed per day of CRRT decreased substantially. Respondents’ overall satisfaction with the CRRT solution preparation process increased during the postintervention period, and the satisfaction scores for each individual component of the workflow after implementation of lean principles. The decreased solution waste resulted in projected annual cost savings exceeding $70,000 in product alone. Conclusion. The use of lean principles to identify medication waste in the CRRT workflow and implementation of an intervention to shift the workload from intensive care unit nurses to pharmacy technicians led to reduced CRRT solution waste, improved efficiency of CRRT workflow, and increased satisfaction among staff. Am J Health-Syst Pharm. 2015; 72:218-23
the use of lean principles to redesign workflow and reduce waste in a large academic medical center.
is Certified Pharmacy Technician; Rob Wonnacott, RN, is Critical Care Nurse; Cheryl Talley, RN, is Critical Care Nurse; and Michael Heung, M.D., M.S., is Medical Director, Inpatient Dialysis Programs, Department of Medicine, Division of Nephrology, UMHS. Address correspondence to Dr. Benfield ([email protected]). The authors have declared no potential conflicts of interest. Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0201-0218. DOI 10.2146/ajhp140257
CASE STUDY
Background The University of Michigan Health System has 941 inpatient beds, including nearly 100 intensive care unit (ICU) beds. The health system provides approximately 2500 patient-days of continuous renal replacement therapy (CRRT) annually. CRRT is delivered as a multidisciplinary collaborative: nephrology nurses initiate therapy, ICU nurses provide maintenance therapy, and pharmacy services prepare and deliver CRRT solutions. Commercial CRRT solutions are routinely adjusted with electrolytes such as potassium and phosphorus additives to achieve prescribed concentrations. As a result of this manipulation in an immediate-use area and as an infection-control measure, CRRT solutions must be used within 12 hours of preparation before they are considered to be expired. Problem CRRT is a complicated and costly therapy requiring careful coordination and cooperation among multiple disciplines and services, including ICU nurses, nephrology nurses, physicians, pharmacists, and pharmacy technicians. With the multiple steps associated with this workflow, there is potential for significant waste related to inefficiencies or breakdowns in communication. As part of a quality-improvement program, the waste of unused CRRT solutions in the health system was identified as a target area for improvement. Lean principles were used to identify the causes of inefficiency and formulate interventions to reduce waste in the CRRT program. Analysis and resolution Lean process. Before the implementation of lean principles to CRRT, a provider would place the initial order for CRRT, which generated a pharmacy order for the preparation of the solution. The nursing staff ordered subsequent
replacement bags directly from the pharmacy as needed. In anticipation of the required lead-time for pharmacy preparation and delivery, nurses routinely ordered solutions in advance, storing solution bags at the bedside until needed. With interruptions in therapy or changes to CRRT orders, the excess bags at the bedside were sometimes wasted. The appropriate stakeholders in the CRRT workflow were identified and formed a focus group for workflow review. In the first meeting, a value-stream map was created, which provided an overview of the workflow to identify areas of nonvalue-added waste (Figure 1). For two weeks, members of the focus group observed the workflow, aided by the value-stream map, to ensure that each step and the times associated with each step were appropriate. At the next meeting, a problemsolving tool, known as an “A3,” was created to identify areas of focus in order to reduce the identified waste. After exploring a number of different options, the stakeholder group recommended implementing an intervention focused on the workflow for reordering CRRT solutions. CRRT solution reordering was shifted from ICU nurses to pharmacy technicians in order to emphasize the principle of just-in-time delivery. With help from the health system’s information technology team, a report from the electronic medical record was designed to identify the flow rates used for each patient receiving CRRT. Pharmacy technicians were responsible for generating this report at the beginning of each shift and determining when additional bags would be needed for each patient. The goal was to deliver solutions within two hours of the anticipated need. To ensure accuracy, the pharmacy technician responsible for making hourly deliveries performed a bedside check to screen for any CRRT solution rate changes since the generation of the report.
Renal replacement therapy
Changes were communicated to the technician responsible for managing the CRRT solutions, and any necessary adjustments to the delivery time were made. The technicians responsible for CRRT maintained a logging system to record the delivery time of the last CRRT solution and the estimated time of the anticipated need, thereby maintaining continuity between shifts and team members. As part of the intervention, an educational program was developed to encourage and enhance direct communication between nursing and pharmacy about changes in a patient’s condition or CRRT order. All staff were educated in person and in writing as to the specifics of the new workflow. It was through this education program that the reordering workflow shifted from nurses to pharmacy technicians. Of note, this intervention used only existing personnel at no additional cost to the health system. Data collection. Data were collected from February 2012 through September 2013, with the intervention applied in April 2013. Initially, the unused CRRT solution bags were returned to the pharmacy, and the data were manually recorded. However, this was labor-intensive, and many wasted solution bags were not accounted for because they were disposed of at the ICU bedside instead of being returned to the pharmacy. Subsequently, the data switched from a prospective collection of the bags to a retrospective review of the dispensing of CRRT solution bags per therapy day. A monthly report of distribution data for the CRRT solutions was generated and analyzed for the number of bags dispensed each month. The total hours of therapy received by each patient (identified by medical record numbers) and the total number of therapy hours per month (divided by 24 to find the number of therapy days) were compared with the number of solution bags dispensed during that month.
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