Demand Management Project

Transcription

1 Demand Management Project New Zealand Blood Service Three years ago, hospital manager Dr Pearce asked his staff why their use of blood products was so much higher than their neighbouring district yet their populations were similar. Debating the possible reasons with his peers was fruitless because he reckoned without proper data they could only speculate. Those lively debates did not solve the problem of overstocking blood products that expired faster than they could be used. Nor did they ensure he had enough stock for the lesser-used blood products for his patients. It disturbed him knowing a patient might suffer because they did not have the tools to properly manage their hospital s blood stock. It also disturbed him that this precious gift of blood was sometimes being wasted. However, that was three years ago. Today, Dr Pearce manages his stocks of blood products using new software tools. He can report on blood stocks and reduce wastage; track patients, their blood transfusions and their surgeries; and even compare his hospital s blood use with national performances and international guidelines. Introduction to the project The New Zealand Blood Service (NZBS) Demand Management Project team includes (from left): Jonathan Webb, Information Project Manager; Carolyn Jeffrey, Information Project Analyst; Dr Peter Flanagan. The New Zealand Blood Service (NZBS) Demand Management Project assists managers to understand where blood products are used. It identifies areas for improving efficiency in use and cost, and helps managers to make better decisions about the use of blood transfusions for patient care. Since 1998, the NZBS has progressively introduced a vein-to-vein blood management system called Progesa, an information management software tool. Progesa provides information in a continuum, from the blood donor through to the recipient of the blood. It is now installed in every District Health Board blood bank. It manages national and local blood stocks, and controls the testing and selection of blood products for patients. It tracks blood products so clinicians always know where blood is. However, Progesa has limited analysis and reporting functions. For example, it does not store information on clinical diagnosis, data about the surgery, or where a patient specifically lives as opposed to where they are treated. So, the NZBS developed a data warehouse that extracts data from Progesa and other systems. The Demand Management Project was launched in April It manages data during the

2 collection, testing, processing and supply of blood and blood products. It provides data on transfusion practices to hospital clinicians and identifies trends. Differences in trends over time, and by district, can be identified and clinicians can assess factors to understand the reasons for the differences. For audit purposes, the Demand Management Project can also show patterns of transfusions that can be compared with clinical international practices and standards. About the organisation The NZBS was established in 1998 to ensure the supply of safe blood products. It is responsible for developing an integrated national blood transfusion process, from the collection of blood from volunteer donors, to the transfusion of blood products within hospitals known as a veinto-vein transfusion service. What were the needs? The NZBS needed to provide information about blood products that, combined with effective clinical audits, would assist with two important concerns: the increasing cost of blood products the possible inappropriate use of blood products. Blood transfusion costs were increasing both in New Zealand and overseas. Managing blood and blood product stocks in hospitals and other locations was a dislocated activity. Blood was being wasted and it was possible that transfusions were occurring inconsistently throughout the country. Medical literature suggested that sometimes the use of blood and blood products was inappropriate. NZBS s Dr Peter Flanagan explains, Twenty or 30 years ago, before we knew of complications about transmitting blood, we viewed blood as a panacea a cure-all. Since then, HIV transmission, hepatitis C and other complications have meant that clinicians needed to be aware that whilst blood could benefit a patient there needed to be more acknowledgement of the risks given the complications we now know about today. Benefits have to override risk, he says. We have tended to use blood more liberally than appropriate. In an audit, clinicians could find that some transfusions could have been avoided and less risky treatments, or no intervention, might have been more appropriate. We needed a more critical approach that would be in the greater interest of patients, says Dr Flanagan. How are the needs met? The Demand Management Project provides reports to District Health Boards at several levels, including chief medical advisors, hospital transfusion committees, blood bank scientists and DHB managers. The information assists moves to standardise practice and to improve the use of blood products. Impacts of the project Improved visibility of blood product use so that District Health Boards can influence and manage the demands. For example, the Demand Management Project began in the 2004/05 financial year. Prior to this, the annual demand for red cell components had been growing at approximately 2 percent per year. In 2005/06, red cell demand fell by 2 percent. The project enables some District Health Boards to explain high use of blood product by showing a corresponding high level of inter-district flow; that is, the movement of people who live in neighbouring districts into the DHB area where they receive blood. The data shows that inter-district flow can be responsible for a particular District Health Board s high blood

3 product use, but also that actual residents of that district health board are no more likely to receive blood products than any other DHB. Financially, District Health Boards can plan for a high level of transfusions. Data is used to establish priorities for the NZBS s national clinical audit initiative. This focuses on blood products that show significant increases in demand. The combination of reports, and the results of structured clinical audits, can reassure DHB managers that increases in demand relates to appropriate use of blood products. Members from the Auckland community donate their blood to those in need. The Demand Management Project assists in effectively utilising blood from various donors. This critical approach appeals to the great needs in patients. Recent analyses on red cell expiry rates shows wastage occurs as the products expire after just 35 days overstocking means some of it has to be thrown out. Also, stock levels of the rarer Group O Rh(D) negative red cells, used for emergencies when blood types of patients is not known, need to be better managed by using data to determine how much blood should be kept in each location. The aim is to ease the pressure on collecting blood, and at the same time, ensure hospitals can respond to emergencies. Clinicians can now look at large numbers of patients and at the appropriateness of transfusions. They can select guidelines or standards from international literature, agree the standards, and review their practices against them. They can eliminate risks, focus on certain categories of patients, track patients and units of blood and increase the confidence that patients are getting the special treatment they need. What unique contribution is made to the community? District Health Boards can plan and manage their blood product stocks better and monitor the appropriateness of transfusions against national and international standards. Clinicians can now make informed decisions at a management level, and have clinical audits to improve their care. Patients can be more confident that their needs are being tracked and special care delivered. Donors benefit from reduced demand on blood collection because the health sector can make sure it is collecting the right volumes of blood, recognising the gift of donation. What value is added to the organisation? The availability of high-quality data enhances the relationships between the NZBS and the wider health sector. This results in numerous opportunities for NZBS to assist District Health Boards in their work, says Dr Flanagan. In addition, they have increased their level of expertise from developing the tool in-house.

4 What technology is used? The Demand Management Project is a data warehouse that extracts data from a number of systems including: the NZBS Progesa system the NZBS Epicor financial system the Ministry of Health s National Health Index register multiple hospital patient management system. The first stage in the Demand Management Project was based on sales of blood products to district health boards. The source is the NZBS finance system Epicor. Data is extracted via an OBDC (Open Database Connectivity) connection to an MS Access database. A series of queries creates MS Excel spreadsheet reports that are then ed to District Health Boards. Excel was selected because it is available to all District Health Boards. The next phase was to provide blood product use reports by clinical specialty. The NZBS Progesa system records issues of blood products to patients, including the prescribing doctor, allowing a specialty to be identified for each blood product issue. An ODBC connection from Progesa supplies data to an MS Access database. Information about each doctor to their specialty is supplied from District Health Boards. Specialty reports are created in MS Excel spreadsheets that include a report interrogation function to allow managers to analyse to lower levels of data. The project can also identify inter-district flows, where patients from outside the DHB are issued with blood. Patient location information is supplied by the Ministry of Health systems. Initially, MS Access was chosen for its familiarity and ease of use. However, as the scope and complexity of the project has grown, the limitations have become apparent. So, the next phase is to move to a commercial data warehouse product called WhereScape; a data warehouse lifecycle management software for design, construction and operation of data warehouses, data marts, business intelligence environments and decision-support systems. How information and technology management serves the project The Demand Management Project was initiated and managed within NZBS. It has a small team responsible for technical development, and clinical advice is provided by the wider NZBS team. They visited District Health Boards during development of the project to assess their needs, get feedback on reports, and to identify improvements. Initially, the project began with a small scope but it has evolved over time, says information project manager Jonathan Webb. The reporting was basic at first but the demands and expectations have grown. NZBS will soon move to a formal data warehouse environment to cope with more complex external reports. The project used MS Office products because District Health Boards all have the application software to open these files. The NZBS has ensured that no other dedicated additional hardware or software is required.

5 Critical factors and how they were managed There were three critical factors. In the concept phase, the NZBS had to ask how transparent the reporting would be, particularly where sensitive information might reveal areas of difference between District Health Boards. Would the NZBS provide reports, for example, that identified specific District Health Boards? The NZBS needed to get agreement from DHB Chief Executive Officers about how open the reporting would be. They agreed to have an open and honest reporting system that enabled DHBs to see results across all districts and nationally. This new data warehouse (Demand Management Project) assists in managing stocks of blood within the NZ Blood Service. Educating managers and clinicians about the quality of data and the degrees of perfection they could expect was a critical aspect of the project. As with most data collections, the data can be incomplete or inaccurate, due in the main, to human error. Managers look for trends at a high level, so they understand that a degree of error is acceptable because this does not impact on the trends. However, clinicians found this difficult to accept and their concerns had to be considered. Over time, there has been a greater acceptance and appreciation by clinicians about the value of the data as a tool for managing blood products and audits at a high level. The expectation for even more data and reporting has grown. Due to a limited capacity to respond to all requests, the NZBS has had to manage these expectations by prioritising the reporting requests of District Health Boards. At this time, it produces standard reports and only produces ad hoc reports if necessary. What lessons were learned? As time has passed, the reports have become more complex, with some now including dropdown tables with variables that the user can choose from. This has raised issues about context and interpretation. Users need to be conscious of the limitations of the data and be careful not to over-interpret it. Progesa is in every District Health Board but there are inconsistencies in the way the software is used. Staff may see the system differently to others. For example, if a blood component is discarded Progesa will ask for the reasons why using a set of classifications. Different staff use those classifications inconsistently, so training is necessary to increase consistency. What are the cost factors? The staff costs have been in-house and include one FTE (full-time equivalent staff member). The recurring annual costs are approximately $60 70,000. It is difficult to assess the impact in financial terms because its reach goes beyond the NZBS. However, the 2 percent reduction in red cell units issued to District Health Boards in 2005/06 would equate to an in-year saving of $400,000. The Demand Management Project is one of many contributors to this saving.

6 NZBS anticipates a further reduction in demand for red cells during the next few years, which will allow for a shift from whole blood collection to plasmapheresis the process in which the fluid part of the blood, called plasma, is removed from blood cells. The costs of the plasmapheresis are lower and enable increased plasma collection from within current resources. It also ensures that the NZBS can continue to meet the increasing demands for Intragam P, a preparation of human immunoglobulin for intravenous use, prepared from blood obtained from voluntary donors. The project has been of proven value to both District Health Boards and the NZBS because the data can be used to confidently predict the future demand for blood and blood products, and this assists with the budget process. Is the project transferable to other organisations? The project utilises features that are possibly unique to New Zealand, which would make the transferability outside of the country difficult. In New Zealand, all District Health Board blood banks use Progesa. This accounts for over 98 percent of the total blood products issued in the country. While many international blood services have a single blood management system, very few manage stocks within hospital blood banks. The use of a single patient identifier (NHI number) across the health sector is also unusual and provides a valuable unique identifier that has greatly assisted the success of this project. The approach is certainly transferable within the New Zealand context, especially where a single software product is being used throughout the health sector. Where to next? The Demand Management Project promotes active benchmarking across the sector, says Dr Flanagan. He believes it should be considered as part of an increasing level of support for District Health Boards. Future developments include further refining the product and, in particular, looking at areas of blood expiry and waste. A stronger audit programme is also part of a future drive to improve usage and appropriateness of blood product use. The project team Dr Peter Flanagan National Medical Director Peter.Flanagan@nzblood.co.nz Jonathan Webb Information Project Manager Jonathan.Webb@nzblood.co.nz Carolyn Jeffrey Information Project Analyst Carolyn Jeffrey.@nzblood.co.nz New Zealand Blood Service Private Bag , Epsom, Auckland National Office, 71 Great South Road, Epsom, Auckland The new data warehouse manages data collection during the collecting, processing and supply of blood and blood products in Auckland.