Watching Hands in the Cookie Jar: A Project for Improving Medication Charge Capture in the Operating Room
Introduction: With the high cost of healthcare in the United States, there have been attempts to identify waste (1). In our anesthesia department, vials or syringes of non-controlled medications are not checked out individually from a pharmacist. Rather, they are removed from a medication housing machine (BD Pyxis Anesthesia Station ED™) before and during a case based on an honor system. The provider logs into the Pyxis system and then has access to any medication in that reservoir. When an individual medication is removed, a button has to be pressed on a screen to register its removal. Anyone who has electronic access to the Pyxis system may log in and withdraw a medication, potentially without documenting the removal. Our current system tracks medication use based on those documented as being removed from the Pyxis, and thus if a medication has not been “checked out”, it will not be billed. Feedback and Audit is a tool that can be utilized to change provider behavior (3) and potentially decrease medication discrepancies. Below, we describe the results of implementing such a tool, evaluating change in behavior, and the cost savings of doing so.
Problem: For the calendar year of 2018, there were 20,421 cases performed with an estimated loss per case of $11.49. There is currently no incentive for correct practice, nor repercussion for failing to “check out” a medication from the Pyxis machine. Our pharmacy department follows these costs and losses, and has provided feedback to determine overall lost revenue.
Methodology: Using the electronic anesthesia record, all non-controlled medications that were documented as administered to the patient were analyzed, regardless of amount of medication that was administered. Any provider who was documented as a care provider on the chart was listed as a person that may have administered the drug. We included cases performed in the operating rooms of the main hospital, labor and delivery, BBRP (pediatric), and the Outpatient Surgical and Imaging Center (OSIS) for a total of 31 anesthetic sites. Exclusion criteria included emergency cases (ASA class “E”), controlled medications, as well as anesthetics provided in sites other than those listed above (e.g. SRMC or CCOR). Data was extracted using name-identified information. Using the average wholesale price (AWP) of the medications for the month of September 2019, we calculated the estimated lost revenue. We then calculated the mean percentage of medication dispensing discrepancy, and compared this with the habits of all anesthesia providers. Starting in January of 2019, this information was published on a slideshow that is displayed on an electronic announcement board in the anesthesiology break room, enabling providers to see how their practices compared with their peers’. After three months, there was a plateau in behavior. The residency director and director of the Advanced Practice Providers were then asked to send individual emails to the providers whose compliance was two standard deviations below the mean behavior in an attempt to improve compliance.
Results: For the calendar year of 2018, there were 20,421 cases performed in the above-mentioned operating rooms. The estimated loss per case was $11.49. For the months of November and December of 2018, there was an average provider baseline compliance rate of 77.76% for checking out medications. For the calendar year 2019, there were 21,290 cases performed in those operating rooms, with an estimated loss per case of $5.06. From November to December of 2019, there was an average provider compliance rate of 82.16%. This correlates to an improvement in dispensing practice of about 6%. Comparing calendar years 2018 and 2019, total cost savings was estimated at $127,000.
Discussion: It is estimated that the cost of United States healthcare approaches 18% gross domestic product, and up to 30% of this may be waste (2). In the field of anesthesiology, other institutions have looked at ways to reduce waste and overall expenditure (1), and have attempted to utilize a similar Feedback and Audit tool (5). Changing provider behavior can be difficult. Some of the most effective methods for changing behavior can also be the most effective (3). A Cochrane review looking at the effects on professional practice when using an Audit and Feedback system showed a median risk difference of 4.3% (4). Using an electronic slideshow with the published names of anesthesia providers and their compliance rates, we were able to demonstrate a similar improvement of dispensing practice of 4.4%, which correlated to a cost savings of $6.54 per case, averaged over 21,290 cases, and an estimated calendar-year cost savings of $127,000. It is interesting to note that this degree of improvement correlated with a cost savings of 38.9%. One possible explanation for the initial poor compliance rate of 77.76% is the design of the Pyxis system, and the need for multiple steps to register removal of a medication. This problem would best be addressed from a machine that was designed to follow expected provider behavior and workflow naturally. Limitations of this analysis include unintentional exclusion of certain medications that are commonly utilized, as well as including medications that are not stored in the Pyxis dispenser. Limitations to this review include sustainability, as one institution that utilized an Audit and Feedback tool demonstrated a downward trend in compliance in the post-intervention time frame (5).
- Rinehardt E, Sivarajan M. Costs and wastes in anesthesia care. Current Opinion in Anaesthesiology. 2002;25(2):221-225
- Chrank W, Rogstad T, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. Journal of the American Medical Association. 2019;322(15):1501-1509
- Trowbridge R, Weingarten S. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Chapter 54. Educational Techniques Used in Changing Provider Behavior. https://archive.ahrq.gov/clinic/ptsafety/chap54.htm
- Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, O'Brien MA, Johansen M, Grimshaw J, Oxman AD. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2012, Issue 6.
- Bowdle T, Jelacic S, Nair B, et al. Improve Anesthesia Provider Compliance with a Barcode-Based Drug Safety System. Anesthesia and Analgesia. 2019:129(2)418-425.
Luce, Casey; Connie Huynh; Tim Petersen; Jack Srouji; and Christ Arndt. "Watching Hands in the Cookie Jar: A Project for Improving Medication Charge Capture in the Operating Room." (2020). https://digitalrepository.unm.edu/hsc_qips/32
Presented at the University of New Mexico Health Science 2020 Annual Quality Improvement and Patient Safety Symposium