Sarah Bush Lincoln is a rural regional health system located
in Mattoon in East Central Illinois that received the state’s
highest performance honors from Illinois Performance
Excellence (ILPEx) in 2011. The financially strong and
innovative hospital has 128 beds and provides a full range
of ambulatory services including a Regional Cancer Center,
Center for Interventional Pain, Diagnostic and
Rehabilitation Services, Advanced Wound Center and a
Heart Center in partnership with nationally renowned
Prairie Heart Institute of Illinois.
Additionally, it has primary care clinics in nine area
communities, as well as two Walk-In clinics and
employs 125 physicians and mid-level providers. The
organization employs nearly 2,000 people and was
recently named a HealthStrong hospital, placing it
among the top 15 percent of high performing
hospitals nationwide.
Cancer Center Rapid Improvement EventProject Charter
• Problem Statement:
• High patient volumes (Increase of average daily
chemo infusions by 56% over 2 year period)
• No change in process as service expanded over
previous years
• Chemotherapy orders written and faxed over a 3 to
4 hour time frame
• Increased potential for significant or dangerous
medication errors
• Increased patient wait time
Focus AreaPatient Arrives  Chemo Delivered
Impact on CustomerIncreased wait times, Potential for dangerous errors,
Staff frustration, Confusion in communication
Major factors of variationMultiple orders faxed simultaneously, lab wait times,
reporting of values, timeliness for physician to see
patients, flexible patient arrival times.
AssumptionsNeed less congestion within the process,
ACCURACY is the most important outcome.
ConstraintsSpace, staff, supplies, complex process, EHR system
does not support Oncology
Key MetricsTime from door to chemo
Med Error Rate- near misses
Timeliness of chemo administration
Staff frustration and confusion
Time Frame = 30 days
Team MembersCancer Center Director
Pharmacy Director
Pharmacists
Pharmacy Tech
Cancer Center RN’s
Cancer Center secretary
Lab Manager
Process Facilitators
Ad Hoc members- Admitting staff, IS staff, Oncologists
Physician OrderChemotherapy
Staffing
• Cancer Center staff
• 5 RN’s, 1 Nurse assistant
• Pharmacy
• All oncology incorporated into daily
workflow. Staff rotation.
• No proactive interaction between Pharmacy and
Oncology staff.
Chemo Near Misses
• 112 Near Misses/22 days (5 near misses per day)
• Typically missing BSA or dose calculation questions
Drug Waste $$$
• Total value of drug waste= ~$160,000 per year
• Process for consistently billing for waste not fully
developed or implemented.
• No consistent method to audit payments for
services
OPPORTUNITIES IDENTIFIED (16)
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Scheduling of Patient visits
Laboratory scheduling
Bedside Registration
Nurse Navigator
“Team Approach” (Nurse and Physician rounding together)
Patient demographics and information obtained during lab pre-work
Point of Care lab equipment
Inter-Disciplinary huddle daily
Laptop or tablet for physicians to view lab values
Electronic order entry by physicians
Addition of Pyxis machine to Cancer Center
Specialized Pharmacist and Pharmacy Technician for Oncology
Oncology Software system for order management
Reduction in the use of “Stat” lab orders
Lab results pushed to mobile device
Standardization of solutions- utilizing pre-mixes when possible
Actions tabled or delayed (6/16)
• Bedside Registration
• Inadequate space to accommodate technology in current
environment
• Nurse Navigator
• Position is currently under evaluation
• Point of Care lab equipment
• Improvements in scheduling reduced the need for specialized
equipment
• Laptop or tablet for physicians to view lab values
• Computers (wall modules) available in each exam room.
• Oncology Software system for order management
• Request to Administration for upgrade- approved and scheduled for
FY15
• Lab results pushed to mobile device
• Improvements in lab scheduling reduced the need for mobile device
alerts
Action Items Implemented (10/16)
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Scheduling of Patient visits
Laboratory scheduling
“Team Approach” (Nurse and Physician rounding together)
• Improved communication = Improved patient flow
Patient demographics and information obtained during lab pre-work
• Vital Signs, weights, and Medication lists obtained when patients arrive for lab-work.
Inter-Disciplinary huddle daily
• Pharmacy, Nursing, Clerical staff, and Physicians (when possible)
• Discussions regarding “What went well today, Opportunities, and future patients”
Electronic order entry by physicians
• Order sets created for “pre-meds” and IV’s
Addition of Pyxis machine to Cancer Center
Specialized Pharmacist and Pharmacy Technician for Oncology
Reduction in the use of “Stat” lab orders
• Everything is Stat = Nothing is Stat
Standardization of solutions- utilizing pre-mixes when possible
• Stock pre-mixes and IV’s in Pyxis
Cancer Center Scheduling Changes
Scheduling
Monday - Thursday
Friday
4 pts / RN
= 12 -16 Chemo Pts
10 Labs (Day prior and Nadir's)= 10 labs
5 pts / Doc followups = 10-12 followups
5 follow-up labs
= 5 followup labs
1pt / Doc Consults
= 2 Consults
Chemo capacity = 48/week
Current level = 42/week
(14% increase in capacity)
"Like Chemos"
Monday
Tuesday
Abraxane
Wednesday
Erbitux/Alimta
8-10 followups
infusions
injections
transfusions
low risk chemo
Noon
"Lab only's" (RN-allday)
Port Flush's (RN-allday)
Thursday
Avastin
Friday
Pharmacy- Oncology Center Changes
• Addition of 1.0 FTE- Oncology Technician
• Responsibilities
• Chemotherapy IV admixture
• Daily rounding in Cancer Center
• Standardization of work procedures- Standard Work Instructions
• Daily review of drug charges and order entry
• Tracking of drug utilization and drug waste
• Dedicated Oncology Pharmacist (reallocation of existing staff)
• Responsible for all Oncology patient order processing, review, and IV
admixture checking
• Daily Rounding in Cancer Center
• Dedicated Oncology Workspace
• Isolated area for Oncology Pharmacist and Technician
• Communication- dedicated Fax, Phone, Computer, Pharmacy Window
OUTCOMES:
• Patient Wait times- decreased by 25%
• Medication Error Opportunity Reduction- 65%
• Before: 112 Near Misses/22 days (5.1 near misses/ day)
• After: 36 Near Misses/20 days (1.8 near misses/day)
• Chemotherapy Patient Capacity Increase of 14%
• Increase from 42 to 48 patients per week
• Drug Waste Reduction
• $150,000 immediately
• Combination of waste reduction and billing improvements
• Improved Revenue
• $60,000 annual billing error discovery- Aloxi appropriate j-code
units
• Patient eligibility screening- $$$
• Pyxis capture of all floorstock charges- ~$20,000/year
OUTCOMES:
• Staff • Decreased frustration considerably. New model is more efficient
• Better communication
• Interdisciplinary involvement
• Patient Outcomes•
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More fluid process
Less waiting (25%)
96% Patient satisfaction score
Less opportunity for Medication Errors (65% reduction)- potentially
devastating errors
• Health Center• Revenue- Increased capacity (14%), decreased waste ($150,000), improved
revenue/billing processes
• Responsive to Employee concerns  employee satisfaction
The Future:
• New free standing Cancer Center
• New Electronic Health Record system
• Nurse Navigator system (under
construction)
QUESTIONS?
Michael Craig R.Ph.| Director of Pharmacy
Sarah Bush Lincoln Health System| www.sarahbush.org
(217) 258-2520| mcraig@sblhs.org