6Bar Coding: It’s Hard to Kill a Hippo
Margaret Keller, Beverly Oneida, and Gale McCarty
For years, the quality improvement committee (QIC) at University Hospital had beencollecting incident reports documenting errors in patient ID, medication administra-tion, and specimen collection. QIC became interested in the possibility of utilizing barcode technology to enhance patient care by decreasing these types of errors. Afterfailing in an effort 2 years earlier, a bar coding project team was built consisting of rep-resentatives from admitting, pharmacy, clinical labs, clinical engineering, medical centercomputing (MCC), hospital procurement, operations improvement, quality improve-ment, and health unit coordination. The project was defined and divided into threephases for ease of implementation and cost control. The team decided to start with theleast expensive and least controversial project, replacement of the “B-plates.” Theseplates are the embossed, credit card–like plates used to stamp patient ID informationon all hospital and major procedure documentation and on ID bracelets. The Address-ograph typeface embossing machines used to make the patient ID blue plates were known as “hippos,” because of their resemblance to the open mouth of a hippopotamus.”
Valentine’s Day 2001
“One step forward and two steps back . . . ,” mused the usually optimistic Janet Erwin,director of value analysis and operations improvement, who was beginning to worryabout the timeline she had set for implementation of phase I of her bar coding project.As the strains of her singing Valentine faded and the February 14 meeting began inearnest, she reviewed the phase 1 goal: replacement of the B-plate system of inpatientID with bar coding technology in order to provide accurate and legible patient IDinformation at the time a patient presents to the health system for admission or forextended periods of care. The requirements for the bar coding project are:
• Use patient ID technology to support bar code and/or radiofrequency applicationsto enhance patient safety and to increase staff efficiency
• Limit noise production on patient care units• Eliminate hand writing of patient ID• Use technology that supports a secure patient ID band system based on patient age• Eliminate the need to replace patient ID bands when a patient transfers from unit
to unit
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• Produce printed patient information on patient ID bands and patient ID labelsincluding the patient’s full name, medical record number, gender, account number,and date of birth.
Subsequent phases of the project were envisioned to include medication and lab spec-imen/collection tracking (phase II); equipment, personnel, and patient tracking; andmother/baby ID (phase III).
Janet had been brought into the project early in 1999 and had worked hard to deter-mine the problems with the current system as well as a technology solution. The entireproject had been initiated not only in response to dissatisfaction with the current B-plate system but also because of an overall desire to eliminate errors in patient ID,medication administration, and specimen collection. Bar coding had been used in thelab for 15 years, and in the pharmacy for 5 years, so the technology base was familiarto end users. Janet felt there was no support in the medical center for keeping thecurrent B-plate system, so replacing it with more advanced technology seemed to bea good initial project for the QIC. The discussion today centered on phase I of the totalpatient ID initiative and whether a solution should be developed in-house or pursuedwith a third-party vendor. The MCC division was reluctant to support in-house development.
The View from MCC
The quietly commanding voice of Carl Cusak, chief information officer, resonated frombehind his desktop, laptop, and personal digital assistant (PDA), all on active screens,as he summarized the reasons why he needed to call “time out” on the bar code projectand “regroup” to a prior point in the planning process. “Most projects involvingadvanced technology and informatics at University Hospital begin with fervor, energyand commitment, but often fail because pertinent points in process development areassumed or overlooked,” he noted. Carl spoke with the authority of his experience.
The lack of MCC involvement meant that technical requirements had never beendefined, including details such as standards for data input, hardware infrastructurerequirements, or a charter document stating the purpose, scope, timeline, or productdevelopment requirements. In addition, software specifications and interface require-ments were lacking. Carl also felt that little attention was being paid to the substruc-ture and interface problems inherent in bar coding, i.e., the capability of the bar codereader to read the code on a patient’s wrist band. The use of radiofrequency technol-ogy and the use of hardware such as PDAs into which the bar code could be uploadedvia a software program, allowing real-time ID of patients and tracking, were consid-ered, but the benefits and drawbacks were not well researched. Backup strategies forunanticipated breakdowns in the system also had not been defined.
Carl complemented some of the long-standing individuals involved with the bar codeproject, such as Janet, for their commitment and effort. He noted that bar coding hadlong been used for applications in the pharmacy, the operating room, central supply,and the lab. Despite these varied uses of bar coding at University Hospital, however,no standards had evolved among these bar coding efforts. Carl admitted that MCCshould have taken ownership of these disparate bar coding projects earlier and shouldhave become the major shareholder in bar coding development. However, MCC personnel changes and priority mandates had kept it from assigning the necessaryresources to the project.
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6. Bar Coding: It’s Hard to Kill a Hippo 67
“I can’t believe that the bar coding initiative could still become an in-house devel-opment project at this point!” said Chris Matt, a QIC member who could rememberwhen the idea of replacing the B-plates with bar code technology was brought up backin 1996. On the surface, the project seemed to be popular enough with anyone involvedwith direct patient care to ensure its success. MCC, however, had been so busy withother projects that the perceived lack of immediacy or of a high-level champion hadtabled the bar coding initiative in the past.
With an increased focus on all patient safety issues, especially those related to ID,the QIC continued to identify and evaluate examples of potential problems. It seemedthat once ID issues were examined, the scope of the concerns grew. Chris noted thatthe team went from a working goal of all patients having an ID wristband to that ofall patients having a correct ID wristband. It became evident that something had tochange to prevent a potential catastrophe. Processes tightened, but the basic difficul-ties surrounding the lack of clear, accurate, consistent patient ID were now in the spotlight.
On April 13, 2000, the request for proposal (RFP) was developed and distributed to certain third-party vendors for response. Chris was not happy to hear that phase Iof the project could still end up being accomplished in-house, despite the RFPresponses. If that was the decision, the project could have been completed a long timeago.
Needs of End Users
Charlotte Graham, inpatient admitting director, had been involved with the bar codingproject from the start. After all, her area would be affected the most by any change ininpatient ID. Over the years, she had heard the complaints about the current system.She knew well how costly the “hippos” were and how much maintenance they required,and she was aware of the poor quality of many of the imprints. She also realized thatthe B-plates often did not get to their destination in a timely fashion, as they were gen-erated in admitting and put in a central location for transportation to pick up. Evenafter pickup, the plates were taken to a sorting area and often awaited transport to theunits. Some plates never reached their destination and had to be regenerated. This wasespecially true for unplanned admissions that were brought directly to the floor or wereadmitted through a major procedure area. Charlotte realized that while mistakes couldnot be totally eliminated, there was a need to minimize the areas where mistakes couldbe made. She saw bar coding as a tried-and-true method of inventory control that could be easily adapted to track patients and match patients to their records, films, orspecimens.
Charlotte was disappointed to be back at the point of considering an in-house solu-tion to the problem. If the project was not contracted out to a third-party vendor, itwould need to be interfaced with the current admitting information system, which wasvery old and in need of being upgraded. The admitting information system was cur-rently used to maintain demographic, billing, and visit information on all patients seenat University Hospital. Charlotte also felt that the current admitting informationsystem could not support phases II and III of the project in the future.
In addition to Charlotte and her admitting staff, the front-line people, including unitcoordinators, nurses, doctors, therapists, etc., would be directly affected by a change inthe method of patient ID. One of their representatives on the project team was RisiKay, an administrative assistant with experience working on the inpatient units.
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Risi felt that despite the fact that most people would be happy to see the B-platesgone, a bar code system with labels would probably require a little more effort. Thiswould especially be true during off-shifts, when unit coordinators were not available,as someone would have to be able to generate additional patient ID labels as they wereneeded. Just who would be trained to use the new system had not been determined.Time was often in short supply in completing day-to-day patient care activities. Easeof use and an institutionwide consistency of flow would be critical.
The Decision and the Implementation Plan
While awaiting the final word from MCC, Janet mused, “I would be delighted if wecould do this project in-house, as long as we could meet goals and project deadlines.. . . It would be so much easier . . . it would help having MCC own this with us.”
On March 20, an update meeting was held. It was noted that MCC had successfullygenerated patient identified bar codes from the admitting information system and haddesigned a system that permitted additional patient ID labels to be printed on request.They had also been able to generate various font sizes that would be consistent withadult, pediatric, or neonate bandwidths. The RFP for phase I was then canceled. TheRFPs for phases II and III would remain open to enable University Hospital to betterevaluate the available technology solutions for future phases.
It had been a long time coming, but Janet enjoyed the feeling of satisfaction she wasexperiencing with a job well done. She finally had her project on the agenda of theinformation technology governance committee, and with their support she felt that itwould become a reality. “I am not going to dwell on the issue that this should havebeen happening all along, but hopefully the process that we have all had to go throughwill have a positive effect on other projects that go forward and require everyone tobe on the same page and same priority level.” Jane sat at her desk and smiled.
Questions
1. How could the MCC group have better worked with the end users on the bar codingproject?
2. Develop a plan for moving patient identification to phase II.3. What strategies could the QIC develop with the MCC to ensure future coopera-
tion?4. Was bar coding a good first project? Why? Why not?
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