University of Colorado Hospital

Focus-PDCA
Performance Improvement Team Worksheet

Department: Outpatient Bone Marrow Transplant Date: 11/1/2013
Primary Contact Person: Lindsey McMenimen Extension: 80670

(F) Find a Process to Improve The medication refill process within the outpatient bone marrow
transplant unit has been identified as problematic by the BMT staff. With increasing patient loads,
scope of practice concerns, the amount of time required and lack of staff and patient education.
Medication refills have become a source of frustration for both staff and patients.

BMT is unique in that patients often interact with many different healthcare providers (Transplant
Nurse Coordinator, Clinic Nurses, Nurse Practitioners, Physicians and nurses in the Infusion
Center). Often times patients are unsure who exactly to request medication refills from . Often
times they ask many different sources, resulting in duplicaiton of efforts, confusion and delays.

Opportunity Statement - Our unit, Hematological Malignancies and Blood and Bone Marrow
Program has grown exponentially within the last 2 years. In the 2013 fiscal year we saw 1,124
more patients in our clinic than the previous year. With the increase in the patient volume the
need to address certain workflows has become a priority. One of those workflows is the
medication refill process.

Medication refills are a high volume clinical task. It has the potential to be problem prone for both
patients and staff if there is not a clear process. There is an opportunity to improve the medication
refill process for both staff and patients. I hope to improve efficiency and safety for the patients
and to improve staff satisfaction with the overall process.

Circle all that apply:
Dimension of Performance: Dimensions of health care performance are those definable,
preferably measurable, attributes of the system that are related to its functioning to maintain,
restore, or improve health care.

- Efficiency - Safety
- Staff Satisfaction - Effectiveness
- Patient Centeredness - Continuity

Prioritization:

- High Risk - High Impact on Performance
- High Volume - High Potential for Improvement
- Problem Prone - Supports Critical Success Factors
- Low Volume - Patient Safety

(O) Organize a team that knows the process:
List Team Members:

Lindsey McMenimen, BMT Charge RN
Jenni Tobin, BMT PharmD
Erin Stohner, BMT Practice Manager
Dr. Clayton Smith, BMT Medical Director

(C) Clarify the current knowledge
What do we know about the process?

1- Whoever gets a call, email, fax or request for a medication refill will personally address the
request.
2- Patients are calling multiple places for refill requests.
3- Patients have alack of knowledge on when, where and how to appropriately seek medication
refills.
4- Staff is spending multiple hours per week addressing medication refills.
5- There is not a centralized refill request system in place.
6- there is a lot of standard medications that patients are on for extended amounts of time.
7- Prior Authorizations can be very time consuming.
8- With recent events in the cancer center, scope of practice has become a concern.


(U) Understand sources of variation:
Why are we looking at this process? Why is the process not going the way planned?

Staff is very unsatisfied with the current process. It is confusion and time consuming. With the
patient growth our program has experienced, the current medication refill request system has
been challenging to maintain. The medication refill process has never been clear. With the recent
onboarding of many new staff members as well, it has become an all hands on deck approach. I
am looking to improve not only the quality of service we can provide to our patients, but also hope
to improve staff satisfaction by clarify the process, centralizing it and providing education and
guidance.

(S) Select the improvement:

1- Centralize the medication refill process by implementing a medication refill line.
2- Clarify scope of practice by creating a policy and procedure.

(P) Plan the improvement:

1-Sruvey staff regarding the current medication refill process.
2- Implement and medication refill line.
3- Provide staff and patient education.
4- Collect data on the refill line and its use.
5- Re-Survey staff regarding the new medication refill line/process.
6- Create a medication refill policy and procedure to address scope of practice concerns.

(D) Implement the improvement:

1- Establish a medication refill line.
2- Create fliers for patients regarding medication refills/refill line.
3- Educate staff on the new process.
4- Develop Policy and Procedure

(C) Check the results:

1- Collect Data on the use of the Medication Refill Line
2- Re-survey staff after the implementation of the intervention.
3- Make changes if necessary

(A) Act to hold the gain:

Continue to evaluate the process on an annual basis. Focus on patient education.


Repeat PDCA as needed and maintain documentation in your department.