J Med Syst (2014) 38:22 DOI 10.1007/s10916-014-0022-4

RESEARCH ARTICLE

Impact of Technological Innovation on a Nursing Home Performance and on the Medication-use Process Safety Chantal Baril & Viviane Gascon & Christel Brouillette

Received: 26 September 2013 / Accepted: 4 March 2014 / Published online: 14 March 2014 # Springer Science+Business Media New York 2014

Abstract Despite the fact that since 1985 the government of Québec increased by 5.75 % on average the amount of money spent on healthcare per year, little improvement was noted. It is obvious that an optimal use of resources is essential to reduce waiting times and provide safer and faster services to patients. The use of new technology can contribute to improve the healthcare system efficiency. Our study aims to assess the impact of a medication distribution technology on 1) the performance of a health and social services center’s pharmacy, 2) the performance of one care unit in a nursing home and on 3) the medication-use process safety. To measure performance we were inspired by the Lean approach. The results show that medication distribution technology is considered as an effective way to significantly detect medication errors, to allow nurses to focus more on patients and pharmacy to react more rapidly to changes in patient medications. Keywords Medication distribution technology . Hospital pharmacy . Technology implementation . Lean approach . Performance

Introduction In recent years, the healthcare system in the province of Québec has been the subject of much criticism related, among C. Baril (*) : C. Brouillette Industrial Engineering Department, Université du Québec à Trois-Rivières, 3351boul. des Forges, Trois-Rivières, Canada e-mail: [email protected] V. Gascon Management Science Department, Université du Québec à Trois-Rivières, 3351boul. des Forges, Trois-Rivières, Canada

others, to congestion of emergency rooms, long waiting time for a surgery and difficulty to get a family doctor. People often think that simply putting more money and resources in the healthcare system will improve the situation. Despite the fact that since 1985 the government of Québec increased by 5.75 % on average the amount of money spent on healthcare per year [1], little improvement was noted. Health and social services in the province of Québec count more than 280 000 workers with a budget of $ 28 billion representing almost 45 % of the Québec Government spending [2]. It is obvious that an optimal use of resources is essential to reduce waiting times and provide safer and faster services to patients. The use of new technology can contribute to improve the healthcare system efficiency. New ways to provide social services and healthcare to patients must be developed by considering continuous improvement approaches based on Lean Manufacturing [3] or Six Sigma [4]. In recent years, the province of Québec has had to deal with major labor shortages in hospital’s pharmacy due to unattractive working conditions, lower remuneration than in private pharmacies and an additional training of two years to work in a hospital. This situation is not unique to Québec. Indeed shortages in pharmacists are noticed across Canada and in the United States. Consequently we are witnessing a general movement in hospitals towards better support to these professionals, including the modernization of their current working tools. In 2007, the Ministry of Health and Social Services of Québec put in place instructions requiring that their health services local networks and hospitals become equipped with medication distribution technology by 2012. The province of Québec is divided into 95 local health services networks. Each

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of these local health services networks includes a facility called the health and social services center (HSSC), nursing homes, and for most of them at least one hospital. The HSSC is the basis of the local health services network, since it provides services accessibility, continuity and quality of care to its local population. The objective of these new instructions was to improve quality of care by substantially reducing the number of medical and medication errors, increase personnel productivity [5] and indirectly make hospitals more attractive to pharmacists. The medication distribution technology advocated by the HSSCs in Québec combines an automated packaging device for the pharmacy and mobile medication dispensing carts (MDCs) for care units. Computerization and automation of the medication-use process are generally considered as a mean to substantially reduce the number of medication errors and ensure that nursing staff can devote more time to patients. A recent study of Association des hôpitaux du Québec [6] concludes that: “A medication-use process not organized and supported by technology is unsafe and unproductive: prescription non-reviewed by the pharmacist; duplication of paper and computer tools for the medication management by pharmacist, nurse and doctor; many manipulations of drugs in crowded work areas, many unnecessary movements, etc. ”. This paper presents how these technological devices were implemented in a local health services network in the province of Québec which includes a HSSC, a hospital and six nursing homes. The HSSC and one of the nursing homes are located in the same establishment. The five other nursing homes are separate institutions and are spread over an area of 10 square kilometers. Our study aims to assess the impact of this technological innovation on 1) the performance of the HSSC’s pharmacy, 2) the performance of one care unit in a nursing home and on 3) the medication-use process safety. To measure performance we were inspired by the Lean approach. This paper is organized as follows. First, a literature review on the impact of a secured medication-use process, automated dispensing systems and mobile medication dispensing carts on medication errors and efficiency is presented. The use of Lean approaches in pharmacies is also reviewed. Second, the methodological framework is explained, the case study is described and the research hypothesis and variables are summarized. Finally, results and conclusions are discussed.

Literature review The medication-use process The medication-use process consists of a series of successive steps performed by different professionals: the prescription is a medical procedure, dispensing a medication is a pharmaceutical action and administration of a medication is a nursing or

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medical act. The concept of “medication-use process” has become a standard in the province of Québec and abroad. Analysis of the medication-use process focusses either on hospitals of a whole region or country [7], or on a single hospital as a case study [8]. In both situations, the objectives remain to improve quality of services by reducing the number of medication errors and to improve the process efficiency. Having in mind the objectives of improving service quality and process efficiency, l’Association des hôpitaux du Québec [6] felt that each hospital should have a global vision of its medication-use process and undertake its revision. The medication-use process is more complex than it seems, with many activities and tools to support them, and requires equipment and information systems, many of which are interfaced. The structure of the medication-use process considered in this paper is presented in Fig. 1. Since the medication-use process consists of several steps, each step becomes a source of potential errors that can cause risks to the patient. Leape [9] has identified some sources of medication errors in the medication-use process. He found that 39 % of medication errors are associated with the medication prescription being illegible or incomplete. These prescriptions are transmitted to the pharmacy by various means (fax, scanner, pneumatic tube or by a person), where they are captured (12 % errors) in a software. Preparing and sending medications (11 % errors) require different information tools and technical equipment such as databases used to validate information and automated packaging devices used for packaging medication safely. Medications are then delivered to the care units (38 % errors), where they are stored in the cabinets before being administered to patients. Automated dispensing systems Automated dispensing systems are used in pharmacies to pack medications in unit doses before delivering them to care units. Packaging contains information on the medication and the patient and sometimes a printed bar code. These automated dispensing systems eliminate manual tasks associated with filling alveolate blisters and packaging medications. Already in 1998, automated dispensing systems with a bar code reader interfaced with the information system of the pharmacy were considered more efficient than humans to prepare and pack medications [10]. If delivery of medications is made daily and mobile carts are used, automated packaging lightens nurses’ work by reducing handling involved in preparing and administering medications. Past research involving the use of automated dispensing devices has shown improved medication use in medical and surgical care units with a positive impact on errors related to administration time, omissions, and greater efficacy of work activities [11–13]. Medication error rate decreased from 2.9 % to 0.6 % due to these devices according to Weaver et al. [14]

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Care units

Pharmacy

Care units

Manual prescriptions

Transcription in a software

Medication transfer to the dispensing carts

Delivery/fax of prescriptions to the pharmacy

Preparation of medications using an automated packaging device

Medication administration to patients

Fillingof delivery carts

Delivery of medications to care units

Fig. 1 Medication-use process in a HSSC

and from 0.84 % to 0.65 % according to Klein et al. [15]. Another pre-post evaluation shows a medication error rate of less than 1 % [16]. In general, it is recognized that the use of automated dispensing systems increase the pharmacist’s efficiency as shown in Cohen [16]. Cohen [16] mentions that a saving of 9.5 pharmacy hours/day had been noticed in the Montreal’s Jewish General Hospital after introducing the use of such a system. In a recent study [17] involving a pre-post intervention design comprising a control medical intensive care unit and a test medical intensive care unit, an automated dispensing system was implemented in one of the care units after a twomonth observation period. Data about 1,476 medications administered to 115 patients was collected. After the implementation of the automatic dispensing system researchers found a significant reduced percentage of total opportunities for error in the test unit compared with the control unit (13.5 % versus 18.6 %, respectively, p

Impact of technological innovation on a nursing home performance and on the medication-use process safety.

Despite the fact that since 1985 the government of Québec increased by 5.75 % on average the amount of money spent on healthcare per year, little impr...
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