A patient-centered framework for health systems engineering in gastroenterology: improving inpatient colonoscopy bowel preparation.

BACKGROUND: Inpatient colonoscopy bowel preparation (ICBP) is frequently inadequate and can lead to adverse events, delayed or repeated procedures, and negative patient outcomes. Guidelines to overcome the complex factors in this setting are not well established. Our aims were to use health systems engineering principles to comprehensively evaluate the ICBP process, create an ICBP protocol, increase adequate ICBP, and decrease length of stay. Our goal was to provide adaptable tools for other institutions and procedural specialties. METHODS: Patients admitted to our tertiary care academic hospital that underwent inpatient colonoscopy between July 3, 2017 to June 8, 2018 were included. Our multi-disciplinary team created a protocol employing health systems engineering techniques (i.e., process mapping, cause-effect diagrams, and plan-do-study-act cycles). We collected demographic and colonoscopy data. Our outcome measures were adequate preparation and length of stay. We compared pre-intervention (120 ICBP) vs. post-intervention (129 ICBP) outcomes using generalized linear regression models. Our new ICBP protocol included: split-dose 6-L polyethylene glycol-electrolyte solution, a gastroenterology electronic note template, and an education plan for patients, nurses, and physicians. RESULTS: The percent of adequate ICBPs significantly increased with the intervention from 61% pre-intervention to 74% post-intervention (adjusted odds ratio of 1.87, p value = 0.023). The median length of stay decreased by approximately 25%, from 4 days pre-intervention to 3 days post-intervention (p value = 0.11). CONCLUSIONS: By addressing issues at patient, provider, and system levels with health systems engineering principles, we addressed patient safety and quality of care provided by improving rates of adequate ICBP.

Expansion of inpatient clinical pharmacy services through reallocation of pharmacists.

PURPOSE: The redesign of an inpatient pharmacy practice model through reallocation of pharmacy resources in order to expand clinical services is described. METHODS: A pharmacy practice model change was implemented at a nonprofit academic medical center to meet the increasing demand for direct patient care services. In order to accomplish this change, the following steps were completed: reevaluation of daily tasks and responsibilities, reallocation of remaining tasks to the most appropriate pharmacy staff member, determination of the ideal number of positions needed to complete each task, and reorganization of the model into a collection of teams. Data were collected in both the preimplementation and postimplementation periods to assess the impact of the model change on operational workflow and clinical service expansion. RESULTS: The mean ± S.D. times to order verification were 17 ± 52 minutes during the preimplementation period and 21 ± 70 minutes in the postimplementation period (p < 0.001). During the 3 months before and after implementation of the model change, the mean number of medication reconciliations performed increased from 114 to 144. After implementation of the model change, total interventions increased 194%. Notably, there was a 736% increase in the number of interventions focused on facilitating safe discharge. CONCLUSION: A pharmacy practice model change was successfully implemented by reallocating existing pharmacist and technician roles and increasing incorporation of pharmacy residents and students. This change led to an expansion of direct patient care coordination services without negatively affecting the operational responsibilities of the pharmacy or the need to hire additional staff.