Achieving Lean in Long-Term Care Facility Medication Management

This white paper examines ways in which lean principles can benefit LTC facilities and pharmacies, more specifically as they relate to the critical role of medication management as part of an overall program for LTC facilities to compete and thrive in a new era. 

Executive Summary

Long-term care (LTC) is a segment of senior care that is undergoing many unique challenges. Declining occupancy rates, changing reimbursement models and an insufficient number of nurses to meet growing demand sit at the center of these challenges. According to the Bureau of Labor Statistics, by 2022 there will be over one million unfilled nursing positions. Nurses face their own pressures due to tighter discharge networks based on quality scores, budget constraints, increased governmental oversight and higher acuity residents requiring immediate access to medications.

While other segments within the continuum of care have been quicker to embrace systematic improvements to modernize their operational environments, technology adoption has been slow with long-term care providers as they work to manage numerous staffing and reimbursement challenges. Sweeping changes made by the Centers for Medicare & Medicaid Services (CMS) to reimbursement models have created a complex layer of challenges as value-based care models replace traditional volume-based models with a strong focus on outcomes. LTC facilities must also deal with increased performance pressure through the CMS scale star rating system. Finally, LTC facilities must position themselves to attract investors as well as acute care referral partnerships. To do so will require systematic improvements as well as conducting a long overdue automation of tedious manual, time intensive processes.

One set of processes that negatively impacts efficiency and puts added stress on LTC nursing staff is that of medication management and “passing”, the process of organizing, sorting and administering medications to ensure that each resident is given the correct medication in a timely manner. It is a highly specialized process that must be conducted by a licensed nurse or a certified nurse’s assistant (CNA). Medications passing requires a great degree of tedious, time consuming piecework and is, therefore, highly stressful and prone to human error which, in turn, leads to waste. Each year billions of dollars can be attributed to medications waste.2 Furthermore, errors made by nurses and CNAs in medications preparation and dispensation can lead to receiving a deficiency citation after a CMS survey is conducted. Errors also expose LTC facilities to the risk of injury, death, and, subsequently, potential lawsuits.

Fortunately, technologies, such as in-facility packaging and dispensing systems, have emerged to automate the process of medication management. Traditionally, however, LTC facilities have been slow to adopt these new technologies, often due to established management styles that may limit innovation. The result has been a continuing lack of efficiency, medications waste and a revolving door of nurses, CNAs and other key team members.

Recognizing automation as key to meeting the challenges that lie ahead, however, many forward-thinking LTC facilities are increasingly turning to “lean” management principles. Lean focuses on eliminating waste and increasing efficiencies so that all work performed is adding value and serving the needs of the customers. It carves out a set of processes that, collectively, are geared to arm an organization with a means to establish and sustain optimum operational efficiencies and put more concentration on quality measures and growth. Lean also paves the way for technologies, such as in-facility medication dispensing systems, that are increasingly being adopted by LTC pharmacies and associated LTC facilities as a new model for optimizing efficiencies to minimize waste and enable nurses to put a greater focus on residents and improving outcomes.

The 5 Principles of Lean

These five principles of lean, together help to form a closed loop of continuous process improvement that helps eliminate waste and maximize efficiencies. The principles are as follows: 

Principle 1: Identify customers and define value

Who are your customers? For LTC pharmacies, the customer is the LTC facility, and those responsible for medications management and dispensation. For the LTC facility, the customers are those individuals who are either directly involved in medications management or are impacted by it. This would include nurses, CNAs, physicians and, most importantly, the residents whose health depends upon receiving accurate and timely medications. 

The term “value” refers to the worth assigned to the services that the pharmacy provides to the LTC facility and that the facility, in turn, provides to those who manage the medications and the residents who receive them. The value equation, in healthcare terms, can be expressed as follows:

For LTC facilities the term “value” takes on added significance in light of the new CMS Patient Driven Payment Model (“PDPM”), which has adjusted the Medicare reimbursement model towards value-based care, moving away from quantity (time-based) to quality outcomes-based reimbursement. 

The move to value-based care represents a significant shift for LTC facilities. Making a successful transition will be critical for those wishing to grow and sustain their organizations. This is not only important for reimbursement compliance purposes, but also to grow acute provider referral networks of providers who seek partners who are operating successfully within the new, value-driven model. 

Principle 2: Map the value stream

Any program geared towards process improvement must first examine the efficacy of the processes and mechanisms already in place to deliver care. Lean refers to this as “current state mapping” which is used to assess where performance gaps and other operational issues lie and how they may be negatively impacting the efficiency and quality of services provided. Mapping is an integral part of the foundation necessary to apply lean principles. 

The LTC facility environment, however, is dynamic which means that, in addition to standard “textbook” steps, nurses must regularly take additional steps to adjust for interruptions and unanticipated situations. These might include being called away to address an emergency, re-checking medications where an error is suspected or searching for misplaced medications. Including all steps in the mapping process is important to properly benchmark performance, both against history as well as that of industry peers. It will also help LTC pharmacies identify the key performance indicators (KPIs) that they can use to properly calculate a Return on Investment “ROI”. 

Principle 3: Create efficient workflow and eliminate waste

This principle could be considered the cornerstone of the lean methodology. The process of streamlining operational efficiencies and eliminating wasteful activities that take up valuable employee time is central to creating a highly effective organization. For LTC pharmacies, asking questions such as “Does this step help us deliver greater value to LTC facility staff?” or, for LTC facilities, “What tasks allow nurses to deliver a positive resident experience?” will help all participants in the medication management processes to clarify where workflow improvements can potentially shorten the path to a more favorable outcome. 

The medication management process is ideally positioned to benefit from the application of Principle 3 in that each step of the process must be evaluated and categorized as “creates value”, “does not create value but is necessary” or “creates no value”, which is thereby identified as waste. The process then undergoes further refinement to eliminate or reduce wasteful steps, working towards what is termed a “Future or Ideal State Process”. 

Principle 4: Respond to customer pull

The “pull” processes of push/pull methodology of meeting demand relate to those processes that respond on demand to resident needs. “Push” processes anticipate resident needs by making educated “guesses” about which medications and/or services might be needed and queuing them up in advance to meet demand. The pull component is critical in medication management, as no resident should be required to wait for needed medications. The push component, having the right amount of medications available at all times, is especially important for first dose administration as well as PRN or STAT medication needs. Questions should be asked, such as, “What medications do our residents need at what time and frequency?”, “How can we ensure dose accuracy?” and “How are we managing our inventory?”

The challenge for medication management is to balance push/pull to ensure that processes are properly aligned to deliver value within the context of the major demand driver; the need for timely delivery of required medications. Many LTC facilities are turning to in-facility medications dispensaries, which enable instant access to medications stored on site. This reduces the guesswork and subsequent reactive deliveries associated with traditional pharmacy-to-LTC facility medication provisions.

Principle 5: Pursue perfection through continuous improvement

The concept of continuous improvement is key to lean management. All processes must be continuously analyzed and evaluated to ensure that non-value steps aren’t inadvertently added that may knock an entire process off track and negatively impact performance. 

The philosophy of continuous improvement helps LTC facilities ensure that ongoing monitoring of their medication management processes continues to be an active part of the value chain and that any processes that begin to show signs of degradation are quickly brought up to the desired quality levels. 

A continuous improvement model also demonstrates a commitment to the nursing staff that their time is valuable and that steps are being taken, on an ongoing basis, to minimize time-consuming, redundant tasks that prevent them from providing quality care to residents. 

The Role of Automation in Achieving Lean in Long-Term Care

Once lean management principles have been deployed by an LTC facility, they become ideally suited to automation. Organizations can drive higher accuracy and time savings by automating certain processes that previously took valuable employee time. Automation can also save a facility thousands to millions of dollars over time.

Over the years, technologies serving the medical industry have gained inroads into automating various pieces of the process of medication management. These include hub and spoke pharmacy arrangements, as well as pre-packaged medication blister cards. However, these methods still require considerable manual effort, leading to significant and costly medications waste. 

One of the most advanced breakthroughs in the last five years has been the in-facility packaging and dispensing system model...

Read the full white paper here!