DMAIC Optimization of the Sterile Compounding Program per

DMAIC Optimization of the Sterile Compounding Program per Joint Commissions Standards A 3 REPORT LT Sebastian Garcia, Pharmacist/Lead Belt/Process Owner; Mr. Shawn Dewey, NME/M 5 CLSSMBB; LCDR Tillman, Champion; Dr. Todman, QM/RM Navy Medicine East Regional Quality Collaborative. SPIDR ID: PIO-26672 1 a. BACKGROUND (DEFINE) SG Alignment: READINESS 2. CURRENT STATE (MEASURE) Sterile compounding allows pharmacies to provide custom medication to their patients produced by highly-trained staff. Failure in both the quality and compliance of numerous training requirements increases the risk of creating faulty medications which may not function as expected or even cause patient harm. 1 b. PROBLEM OPPORTUNITY STATEMENT (DEFINE) Between Jan 2016 and Dec 2017, the Pharmacy Department determined the Sterile Compounding (SC) Training Compliance Rate Baseline, a composition of the following 5 requirements, was below the Joint Commission requirement of 100% compliance: a) Media Fill Test - 0% b) Finger-tipped Testing - 0% c) Didactic Testing – 0% d) Staff Observed Compounding – 10% (2016), 100% (2017) e) Competency Upload - 0% 3. TARGET STATE (DEFINE/MEASURE) 4. PRIORITIZED ROOT CAUSES (ANALYZE) Immediate corrective action to achieve 100% Compliance rate in all 5 Metrics with robust SUSTAINMENT. 6. COUNTERMEASURES (IMPROVE) All Improvement Strategies are based on Work Flow Changes only vice requiring Financial outlays. Solution Prioritization is in full alignment to the Root Cause Prioritization. SC Program Optimization by: • Establishment of a robust SC program • SC standardization • Effective knowledge capture and turnover 6. COUNTERMEASURES (IMPROVE) 5. PRIORITIZED COUNTERMEASURES (IMPROVE) 7. PROCESS PERFORMANCE RESULTS (CONTROL) 8. SUSTAINMENT (CONTROL) • Automatic Training Reminders • New Staff fully Trained • Project Data Posted on Command Share. Drive • Annual Department Wide Training Audit • Command Oversite through the SEAT Department • AS OF 03 FEB 2020, 100% Training Completed World-Class Care…Anytime, Anywhere