Richard Blackwell Project Director, Process Quality Cermak Health Services
<ul><li>Background on Cermak Health Services </li></ul><ul><li>Motivation for process improvement </li></ul><ul><li>Proces...
<ul><li>Part of the Cook County, Illinois Health & Hospitals System </li></ul><ul><li>Located in the Cook County Jail </li...
<ul><li>Skyrocketing prison population, 1970s-2005  </li></ul><ul><li>2,212,475  incarcerated in USA at end 2003 </li></ul...
<ul><li>Over 33% of all inmates reported some physical or mental disability. </li></ul><ul><li>About  25% of jail inmates ...
<ul><li>Largely driven by two forces </li></ul><ul><ul><li>Lawsuits by inmates ( Estelle v. Gamble,  1976 ) </li></ul></ul...
<ul><li>HIV/AIDS </li></ul><ul><li>TB </li></ul><ul><li>STDs </li></ul><ul><li>Hepatitis B & C </li></ul><ul><li>Other com...
<ul><li>Cook County Health and Hospitals System </li></ul><ul><ul><li>Created in 2007 to split governance off from the Coo...
<ul><li>Starts with Six Sigma as a structured problem-solving approach </li></ul><ul><ul><li>Methods: DMAIC, Lean, etc. </...
<ul><li>>20% of detainees receive medication, with many receiving more than 1 </li></ul><ul><li>Patients are dispersed </l...
<ul><li>New Rx are generated by several sources </li></ul><ul><li>All Rx flow to the Pharmacy for verification, recording,...
<ul><li>Current process is fragmented,  </li></ul><ul><li>and lacks controls </li></ul><ul><li>Security concerns (it’s a j...
 
<ul><li>Patient Data Management System replaces the manual process </li></ul><ul><ul><li>Physician Order Entry : Patient e...
<ul><li>Automate to ensure “5 Rights” </li></ul><ul><ul><li>Identify patient via bar-coded wristband </li></ul></ul><ul><u...
<ul><li>Process analysis teams and Root Cause Analysis/FMEA to identify process requirements </li></ul><ul><li>Challenges ...
<ul><li>The Attractions </li></ul><ul><li>The Problems </li></ul><ul><li>The mission </li></ul><ul><li>Commitment to the m...
<ul><li>Your Personal Approach </li></ul><ul><li>Project Techniques </li></ul><ul><li>Patience and tenacity </li></ul><ul>...
<ul><li>Basic Industrial Engineering </li></ul><ul><ul><li>Process analysis and documentation </li></ul></ul><ul><ul><li>P...
<ul><li>“ Change management  is a structured approach to transitioning individuals, teams, and organizations from a curren...
<ul><li>Establish a Change Management Committee </li></ul><ul><ul><li>All stakeholders, internal & external </li></ul></ul...
Richard Blackwell [email_address]
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IIE June Conference R Blackwell

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Presentation to 2010 annual conference in Cancun

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  • The new asylums/ jails as mental institutions
  • 1976 Supreme Court recognized the constitutional right to health care. Estelle vs. Gamble “We therefore conclude that deliberate indifference to serious medical needs of prisoners constitutes the unnecessary and wanton infliction of pain proscribed by the 8 th amendment.” Rights established by the Supreme Court include Right of access to care Right to professional medical judgment AMA and APHA reviewed conditions in prisons and jails NCCHC developed minimum standards for health care services NCCHC accreditation process
  • So began correctional health – a public health opportunity
  • IIE June Conference R Blackwell

    1. 1. Richard Blackwell Project Director, Process Quality Cermak Health Services
    2. 2. <ul><li>Background on Cermak Health Services </li></ul><ul><li>Motivation for process improvement </li></ul><ul><li>Process improvement in a jail – mistake proofing and automating the administration of medications </li></ul><ul><li>Implementation issues </li></ul><ul><li>What works, and what doesn’t </li></ul><ul><li>Change Management </li></ul>
    3. 3. <ul><li>Part of the Cook County, Illinois Health & Hospitals System </li></ul><ul><li>Located in the Cook County Jail </li></ul><ul><li>Provides comprehensive health care for the largest single-site correctional healthcare facility in the US </li></ul><ul><ul><li>Provides comprehensive care for ~10,000 detainees </li></ul></ul><ul><ul><li>150,000 sq ft in 129 bed infirmary plus satellite facilities within the jail; 100 acre campus </li></ul></ul>
    4. 4. <ul><li>Skyrocketing prison population, 1970s-2005 </li></ul><ul><li>2,212,475 incarcerated in USA at end 2003 </li></ul><ul><li>Over 10 million detainees released annually from prison and jails to community </li></ul><ul><li>Approximately 4 million under age 30 </li></ul><ul><li>Potential reservoir of infectious disease for the community and site for intervention </li></ul><ul><li>Source: www.sentencingproject.org/pdfs/1044.pdf accessed 10/5/05, and Prisoners in 2003 , Bureau of Justice Bulletin, NCJ 205335, Nov. 2004. </li></ul>
    5. 5. <ul><li>Over 33% of all inmates reported some physical or mental disability. </li></ul><ul><li>About 25% of jail inmates report they had been treated at some time for a mental or emotional problem. </li></ul><ul><li>Clinical studies suggest that 6 to 15 percent of persons in county jails have severe mental illness. </li></ul><ul><li>A large proportion are homeless. </li></ul>
    6. 6. <ul><li>Largely driven by two forces </li></ul><ul><ul><li>Lawsuits by inmates ( Estelle v. Gamble, 1976 ) </li></ul></ul><ul><ul><li>Lawsuits by employees (MDR-TB New York) </li></ul></ul><ul><li>Emerging discipline </li></ul><ul><ul><li>National Commission on Correctional Health Care </li></ul></ul><ul><ul><li>Public health interactions – CDC, HRSA </li></ul></ul><ul><ul><li>ACP ASIM, SGIM, APA, ICAAC, CROI </li></ul></ul>
    7. 7. <ul><li>HIV/AIDS </li></ul><ul><li>TB </li></ul><ul><li>STDs </li></ul><ul><li>Hepatitis B & C </li></ul><ul><li>Other communicable diseases (MRSA) </li></ul><ul><li>Foodborne outbreaks </li></ul><ul><li>Mental health </li></ul><ul><li>Violence prevention </li></ul><ul><li>Substance abuse </li></ul><ul><li>Chronic diseases – hypertension, heart disease, diabetes, asthma </li></ul>
    8. 8. <ul><li>Cook County Health and Hospitals System </li></ul><ul><ul><li>Created in 2007 to split governance off from the Cook County Board of Commissioners </li></ul></ul><ul><ul><li>Has installed a new management team at CHS & is providing the necessary financial support </li></ul></ul><ul><li>Cermak under pressure to improve patient services </li></ul><ul><ul><li>Lost accreditation (National Commission for Correctional Health Care) in 2007 </li></ul></ul><ul><ul><li>2008 Department of Justice investigation led to a Consent Decree and Court monitors </li></ul></ul><ul><ul><li>Patient safety incidents have occurred </li></ul></ul><ul><ul><li>Class action and private lawsuits </li></ul></ul>
    9. 9. <ul><li>Starts with Six Sigma as a structured problem-solving approach </li></ul><ul><ul><li>Methods: DMAIC, Lean, etc. </li></ul></ul><ul><ul><li>Tools: Process/problem & statistical analysis </li></ul></ul><ul><ul><li>Teams: develop buy-in by involving stakeholders in development of solutions </li></ul></ul><ul><li>Uses Quality Management System </li></ul><ul><li>certification as a goal and a club </li></ul><ul><li>to drive organizational change </li></ul>
    10. 10. <ul><li>>20% of detainees receive medication, with many receiving more than 1 </li></ul><ul><li>Patients are dispersed </li></ul><ul><ul><li>129-bed Infirmary for acute care </li></ul></ul><ul><ul><li>3 step-down intermediate care units </li></ul></ul><ul><ul><li>General population is in 247 small living units (~50 per unit) in 17 stand-alone Divisions </li></ul></ul><ul><li>A court has determined that detainees are to receive all prescribed meds within 24 hours of prescription </li></ul>
    11. 11. <ul><li>New Rx are generated by several sources </li></ul><ul><li>All Rx flow to the Pharmacy for verification, recording, and dispensing </li></ul><ul><li>Each patient has a medication profile that is available via a paper Medications Administration Record (MAR) </li></ul><ul><ul><li>The official record that determines how Nursing administers all medications </li></ul></ul><ul><ul><li>Printed at the beginning of the month </li></ul></ul><ul><ul><li>Updated for changes during the month </li></ul></ul>
    12. 12. <ul><li>Current process is fragmented, </li></ul><ul><li>and lacks controls </li></ul><ul><li>Security concerns (it’s a jail!) </li></ul><ul><li>Number of patients per nurse </li></ul><ul><li>Detainees move around </li></ul><ul><ul><li>Transferred at short notice, or may be in Court or school at meds admin time </li></ul></ul><ul><li>Meds distribution methods vary </li></ul><ul><ul><li>Dose by dose administration of TB, HIV, psychotropics, and controlled substances </li></ul></ul><ul><ul><li>7-day self-packs (Blister Packs) when appropriate </li></ul></ul>
    13. 14. <ul><li>Patient Data Management System replaces the manual process </li></ul><ul><ul><li>Physician Order Entry : Patient encounter data (including Rx) entered directly by physician or nurse into the patient’s medication profile </li></ul></ul><ul><ul><li>PharmNet : used by Pharmacy to record and track dispensing and inventory </li></ul></ul><ul><ul><li>Scheduling : maintains & manages patient encounters </li></ul></ul><ul><ul><li>eMAR : electronic patient record contains all data (text and scanned) generated by patient encounters and medications </li></ul></ul>
    14. 15. <ul><li>Automate to ensure “5 Rights” </li></ul><ul><ul><li>Identify patient via bar-coded wristband </li></ul></ul><ul><ul><li>Pull up patient’s med profile from PDMS </li></ul></ul><ul><ul><li>Confirm medications to be administered with bar code </li></ul></ul><ul><ul><li>Confirm administration event to PDMS </li></ul></ul><ul><ul><li>Record vitals, problems, special conditions </li></ul></ul><ul><li>To be implemented with Wireless </li></ul><ul><li>handheld devices </li></ul><ul><li>Right patient </li></ul><ul><li>Right time </li></ul><ul><li>Right drug </li></ul><ul><li>Right dose </li></ul><ul><li>Right route </li></ul>
    15. 16. <ul><li>Process analysis teams and Root Cause Analysis/FMEA to identify process requirements </li></ul><ul><li>Challenges encountered so far </li></ul><ul><ul><li>Lack of experience </li></ul></ul><ul><ul><li>Organizational “Silos” </li></ul></ul><ul><ul><li>History & personalities </li></ul></ul><ul><ul><li>Resources </li></ul></ul><ul><ul><li>Vendor management </li></ul></ul><ul><ul><li>Project management </li></ul></ul>
    16. 17. <ul><li>The Attractions </li></ul><ul><li>The Problems </li></ul><ul><li>The mission </li></ul><ul><li>Commitment to the mission by key managers </li></ul><ul><li>Exposure to real problems faced by others not much like you </li></ul><ul><li>Opportunity to apply standard solutions in new ways </li></ul><ul><li>Low hanging fruit </li></ul><ul><li>Immediate impact </li></ul><ul><li>Resources </li></ul><ul><ul><li>No slack capacity </li></ul></ul><ul><ul><li>Naïve management </li></ul></ul><ul><ul><li>Facilities </li></ul></ul><ul><ul><li>Archaic processes & tools </li></ul></ul><ul><li>Workforce </li></ul><ul><ul><li>Entrenched, Unionized </li></ul></ul><ul><ul><li>Cynical </li></ul></ul><ul><ul><li>Aging </li></ul></ul><ul><li>Purchasing constraints </li></ul><ul><li>Inertia, confusion, poor information </li></ul><ul><li>Politics </li></ul>
    17. 18. <ul><li>Your Personal Approach </li></ul><ul><li>Project Techniques </li></ul><ul><li>Patience and tenacity </li></ul><ul><li>Flexibility & willingness to compromise </li></ul><ul><li>Respect for diversity </li></ul><ul><li>A good sense of humor </li></ul><ul><li>Thick skin </li></ul><ul><li>LISTEN </li></ul><ul><li>Plan & coordinate </li></ul><ul><li>SIMPLIFY </li></ul><ul><li>Coach; don’t dictate </li></ul><ul><li>Be ready to make mid-course corrections </li></ul><ul><li>SIMPLIFY </li></ul>
    18. 19. <ul><li>Basic Industrial Engineering </li></ul><ul><ul><li>Process analysis and documentation </li></ul></ul><ul><ul><li>Process simplification </li></ul></ul><ul><ul><li>Cost analysis and reduction </li></ul></ul><ul><ul><li>Cost justification (e.g. ROI) </li></ul></ul><ul><ul><li>Mistake-proofing </li></ul></ul><ul><li>Exposure to IT processes, especially requirements definition </li></ul><ul><li>Project management </li></ul><ul><li>Change management </li></ul>
    19. 20. <ul><li>“ Change management is a structured approach to transitioning individuals, teams, and organizations from a current state to a desired future state. Change management (or change control) is the process during which the changes of a system are implemented in a controlled manner by following a pre-defined framework/model with, to some extent, reasonable modifications.” - (Wikipedia) </li></ul><ul><li>Avoid overwhelming the organization </li></ul><ul><li>Co-ordinate disparate & sometimes conflicting efforts </li></ul><ul><li>Help the organization evolve </li></ul>
    20. 21. <ul><li>Establish a Change Management Committee </li></ul><ul><ul><li>All stakeholders, internal & external </li></ul></ul><ul><ul><li>Commitment by Sr. Management </li></ul></ul><ul><ul><li>Schedule & drive required meetings </li></ul></ul><ul><ul><li>Setup Corrective Action tracking tools </li></ul></ul><ul><li>Train & develop the team </li></ul><ul><ul><li>Communications </li></ul></ul><ul><ul><li>Planning process change efforts </li></ul></ul><ul><ul><li>Dealing with conflict </li></ul></ul><ul><ul><li>Tracking and closing Corrective Actions </li></ul></ul><ul><li>CMC is a permanent commitment </li></ul>
    21. 22. Richard Blackwell [email_address]

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