SCANHvBCC 2018/19 Second-Place Submission by Rotman School of Management

SCAN Health Virtual Business Case Competition 2018/2019

Canadian Blood Services: “Vein-to-Vein” Traceability to Achieve Value Round Two Presentation Team: OPlus Jonathan Kong Amee Choksi

Contents 1) Problem Statement 2) The Proposed Solution a) CBS Data Warehouse 2.0 b) Donor Supply Marketing Strategy

3) Strategic Action Plan a) Stakeholder Identification b) Change Management c) KPI evaluation d) Timeline 4) Feasibility of Implementation a) Financials b) Qualitative Benefits

Problem Statement Problem Statement How does Canadian Blood Services (CBS) use technology to improve the traceability and use of its blood products in an effort to reduce product wastage and patient risk, thus ensuring accurate supply chain forecasting?

Result of 5-Why Root Cause Analysis • Lack of automated link between CBS and hospital blood inventory system • Lack of value derived by donors to donate

Design Objectives • Low cost • Scalable • Feasible

Key Focus Areas

Proposed Solution

CBS Blood Product Demand Side Barcode scanner inside hospital blood inventory rooms

Promote blood donations through HLS connection with Health Care Professionals

Vein to vein traceability through patient file tracking with OCR

CBS Warehouse 2.0

Keys to Success

CBS Blood Product Supply Side

2-way communication between hospitals and CBS

Donor Supply Marketing Strategy

Concept of shared value

Technological expertise

Proposed Solution CBS Blood Product Demand Side Barcode scanner inside hospital blood inventory rooms

Vein to vein traceability through patient file tracking with OCR

CBS Warehouse 2.0 Key Performance Indicators - Hospital adoption - Decreased scrap - CBS staff time saving - Elimination of the use of expired product

CBS Blood Product Supply Side Promote blood donations through HLS connection with Health Care Professionals Donor Supply Marketing Strategy Key Performance Indicators - Increased blood bank donations - Lower fluctuation in blood bank levels

CBS Warehouse 2.0 – Overview Goal of Demand Side Solution Create a real-time link of blood product usage at hospitals allowing for automatic product replenishment and full vein to vein traceability

Strengths 1. Fast inventory issuing and transportation network 2. Strong HLS network

Constraints 1. LIS is a medical device classified under the FDA 2. Regulations and Standards

• Used to trace the utilized blood product to the patient

OCR Technology

• Used in the hospital blood product inventory rooms to provide real time data to CBS

Removable Labels

Barcode Scanner

CBS Warehouse 2.0 – Technology • Used to interpret medical record information from the hospital transfusion cases

CBS Warehouse 2.0 – Use Case 1: LIS, paper record

New hardware or software that will be implemented as a part of the solution

New process actions that must be integrated into the hospital workflow for transfusion patients

CBS Warehouse 2.0 – Use Case 2: LIS, electronic record

New hardware or software that will be implemented as a part of the solution

New process actions that must be integrated into the hospital workflow for transfusion patients

CBS Warehouse 2.0 – Use Case 3: no LIS, paper record

New hardware or software that will be implemented as a part of the solution

New process actions that must be integrated into the hospital workflow for transfusion patients

Proposed Solution CBS Blood Product Demand Side Barcode scanner inside hospital blood inventory rooms

Vein to vein traceability through patient file tracking with OCR

CBS Warehouse 2.0 Key Performance Indicators - Hospital adoption - Decreased scrap - CBS staff time saving - Elimination of the use of expired product

CBS Blood Product Supply Side Promote blood donations through HLS connection with Health Care Professionals Donor Supply Marketing Strategy Key Performance Indicators - Increased blood bank donations - Lower fluctuation in blood bank levels

Donor Supply Marketing Strategy – Overview Goal of Supply Side Solution Decrease volatility in blood bank levels and ensure a sustainable supply of blood products from donors

Strength Strong outreach resources

Constraint Krever Commission

Donor Supply Marketing Strategy “Active recruitment in the hospital environment by Canadian Blood Services is currently done on a very limited scale (4 hospitals) and focused primarily on expectant mothers” – Rick Prinzen, Chief Supply Chain Officer and Vice-President, Donor Relations

Donor Supply Marketing Strategy Focus on the "informed" public with a personal connection

HCP raises awareness of blood products utilized

Patient family members are more inclined

Replenishment of blood bank

Donor Supply Marketing Strategy

Someone made a difference in your life today. You have the ability to do the same. Please donate at your nearest blood donation site.

Together, we are Canada’s lifeline

Download the GiveBlood app to book an appointment at your closest clinic today blood.ca

1 888 2DONATE

Implementation: Strategic Action Plan Goal of Action Plan To ensure initial adoption and long term sustainability of our solution

Critical success factors

Stakeholder identification

Change management

Key performance indicators (KPIs)

Stakeholder identification Goal Identify affected stakeholders who can drive the solution STAKEHOLDERS

CBS VALUE CAPTURE

CBS Management and Board of Directors

Experience, expertise and existing relationships/network with hospitals and HCPs throughout Canada

Government

Source of funding. Government support also augments CBS’s credibility

Hospitals and HCPs

Frontline drivers of desired change. They are also well-placed agents that CBS can leverage for the recruitment of donors

Patient families

The families of patients being treated at the hospital are in the most ideal position to donate blood in an effort to “replenish the blood supply"

Existing donors

Donor loyalty can ensure the sustainability of blood supply

Public

Generation of new donors through word of mouth marketing

Value add for stakeholders Goal To gain commitment from stakeholders by leveraging their value capture STAKEHOLDERS

STAKEHOLDER VALUE CAPTURE

CBS Management and Board of Directors

Ability to forecast the supply, demand and transfer of blood products between hospitals, thus reducing overall wastage, better control on the flow of blood products and inventory management

Government

Advancements towards digitization of healthcare processes in Canada, thus strengthening and integrating the healthcare system

Hospitals and HCPs

Reduced risk in patient care processes, ease of access of patient records due to digitization, efficiencies in work flow processes for the requisition of blood products

Patient families

Having benefited from successful transfusion of blood products, patient families have an opportunity to “give back” to the community

Existing donors and public

Continued feeling of making an impact in someone’s life

Change Management Goal Keep stakeholders involved throughout the process to ensure commitment to the solution and thus change adoption STAKEHOLDERS

METHODS OF ENGAGEMENT

CBS Management and Board of Directors

Face-to-face consultations (conferences, teleconferences and one-on-one), roundtable discussions, newsletters

Government

Periodic meetings with updates on progress and impact of efficiency in processes

Hospitals and HCPs

Provide a support system through the HLS for technical and workflow change. Provision of training for hospital staff

Patients

One-on-one engagement with patients and their families through HCP’s

Donors

Relationship and loyalty building through the GiveBlood App, newsletters and social media

Public

Public dialogues, webinars, radio, website: create momentum and a 2-way dialogue on the challenges of blood supply, and experiences of the public thus creating collaborations with the community

KPI Monitoring – CBS Warehouse 2.0 Goal To gauge the utilization and success of the solution KPI

Description

Monitoring

Hospital adoption

Frequency of the usage of the system within hospitals

-

Continuous feedback from HCPs monthly Number of times the product is scanned by the scanner in the blood product inventory room and the incoming patient files to the OCR system

Decreased Scrap

Decreased blood product scrapped due to expiry date disposition

-

Reduction in quantity of blood product wastage Increase re-distribution of product among hospitals Decreased number of urgent order placements

Reduce risk of blood products to patient care

Use of expired and/or incorrect blood product in transfusion cases

-

Observed decrease in blood product transfusion cases with expired product through digitization of vein to vein traceability Observed decrease in blood product transfusion cases with incorrect blood product

-

KPI Monitoring – Donor Supply Marketing Strategy Goal To gauge the utilization and success of the solution KPI

Description

Monitoring

Increased blood bank donations

HCP referrals increases the probability that the informed public will go donate blood

-

Increased number of donors Increased number of return visits

Lower fluctuation in blood bank levels

The volatility of the blood bank levels should be subdued due to active replenishment by patient families

-

Observed fluctuation in blood product levels

Timeline

Now

Funding approved (Jan 2019)

2 months

Start Engaging with Ministry officials regarding project and submit budget (Nov 2018) Secure funding Obtain, secure approval, and train staff of 9 hospitals for pilot Hire required IT staff Finalize supply deals, procure equipment, install equipment

Full Scale implementation (Jan 2021)

End pilot (Mar 2020)

9 months 6 months

(Phase 1)

Start Pilot (Jun 2019)

Work with hospitals to gather feedback on system Daily monitoring of data received Ongoing support as required Site visits Ongoing system modifications

6 months 2 months

(Phase 2)

All changes and validations complete (Jun 2020) Evaluation of results and effectiveness Evaluation of integration Evaluation of feedback Final changes Final validations Update ministry

CBS to secure commitment from partnering hospitals Apply for additional funding to purchase HR & capital resources Employ HLS assistants Organize training sessions for HCP Site visits to monitor hospital status

Pilot project Purpose 1. Refine and modify the roll-out plan 2. Assist with the preparation of roll-out 3. Enhance likelihood of adoption in full scale roll-out

Features 1. 9 month project with 9 hospitals 2. 3 hospitals in each of the identified use cases

During the pilot 1. Track activities 2. 2-way feedback 3. Record adjustments 4. Provide IT and in-person support to hospital staff and management

Post Pilot 1. Gauge HCP reaction and comfort with program 2. Confirm readiness for full scale 3. Run required validations on changes 4. Reassess allocation of time and resources in project timeline

Feasibility Feasibility of implementation

Financial

Phase 1: Pilot Project Phase 2: Full scale rollout plan

Qualitative

Phase 1: Financials for pilot project

Total expense up front $207,344

Total expense for 9 hospitals $15,011

Total expense for donor cards $32

CBS Expense $222,387

* Pilot Project carried out in Ontario

Note: Refer to Appendix 5.1, 5.2 & 5.3 for detailed calculations

Phase 1: Financials for pilot project

Total expense up front $207,344

Total expense for 9 hospitals $10,382

Total expense for donor cards $748

CBS Expense $222,387

Note: Refer to Appendix 5.1 for detailed calculations

Phase 1: Financials for pilot project

Total expense up front $207,344

Total expense for 9 hospitals $15,011

Total expense for donor cards $748

CBS Expense $222,387

Note: Refer to Appendix 5.2 for detailed calculations

Phase 1: Financials for pilot project

Total expense up front $207,344

Total expense for 9 hospitals $10,382

Total expense for donor cards $32

CBS Expense $222,387

Note: Refer to Appendix 5.3 for detailed calculations

Phase 2: Financials for roll out plan in Canada Assumption: All jurisdictions approve required funding

Cost to CBS

Cost to Hospital

Phase 2: Financials for roll out plan in Canada

Cost to CBS

Cost to Hospital

Phase 2: Financials for roll out plan in Canada

Cost to CBS

Cost to Hospital

1.

2.

3.

3 Use Cases Hospital with LIS, paper-based medical record Hospital with LIS, electronic medical record Hospital without LIS, paper-based medical record

Phase 2: Financials for roll out plan in Canada

Cost to CBS

Cost to Hospital

1.

2.

3.

3 Use Cases Hospital with LIS, paper-based medical record Hospital with LIS, electronic medical record Hospital without LIS, paper-based medical record

Phase 2: Financials for roll out plan in Canada

Cost to CBS

Cost to Hospital

1.

2.

3.

3 Use Cases Hospital with LIS, paper-based medical record Hospital with LIS, electronic medical record Hospital without LIS, paper-based medical record

Phase 2: Financials for roll out plan in Canada

Cost to CBS

Cost to Hospital

1.

2.

3.

3 Use Cases Hospital with LIS, paper-based medical record Hospital with LIS, electronic medical record Hospital without LIS, paper-based medical record

Cost Benefits Analysis 7.6%

The full cost of the solution is 7.6% of the hospital product outdates in Canada in 2017/18

Note: Refer to Appendix 6.0 for detailed calculations

Qualitative feasibility of solution

Scalability

Transferability

Sustainability

Pilot program will identify any gaps in Pilot program will provide validation the implementation plan thus of impact to secure additional minimizing inefficiencies for the roll funding from the Ministry of Health out plan for Canada wide

Alignment with Canada’s long term goals of digitizing healthcare data, enabling hospitals to leapfrog to digitization

The pilot will also be conducted in 3 Majority of the roll out costs are one different kinds of settings to ensure time costs which will have been that effectiveness is tested and incurred during the pilot project, achieved thus allowing for ease of scaling

Compatibility with existing hospital infrastructure. The minimum costs, low maintenance and training will ensure long term sustainability for hospitals

Conclusion Low cost Upfront costs Low maintenance cost

Feasible Subject to government funding Value add for hospitals

Scalable Centralized data Replicable

Meeting Project Objectives

Thank you

Appendices

List of Appendices Appendix 1.0 – Root Cause Analysis Appendix 2.1 – Alternative Demand Solutions Appendix 2.2 – Alternative caveat to proposed solution Appendix 3.0 – Alternative Supply Solutions Appendix 4.0 – Foreseeable challenges Appendix 5.1 to 5.3 – Pilot Project Financials Appendix 6.0 – Cost Benefit Calculations

Appendix 1.0 – Root Cause Analysis Inaccurate CBS supply chain forecasting and lack of vein-to-vein traceability Monthly reporting of basic aggregate data from hospitals

Problem

Unstable supply of blood from donors

Why? #1

Lack of real-time reporting of hospital full blood product use to CBS

Donors do not meet eligibility criteria

One-time “spur of the moment” donors

Why? #2

Too much work by hospitals to report data in real time

Did “risk taking” activities (i.e. tattoos, piercings, alcohol)

People do not feel the need to return – they are aware but no action taken

Why? #3

Need to manually input all inventory levels into CBS portal

Life activity choice based on personal interests

Inconvenient to fit their busy schedules

Why? #4

No automated link between hospital LIS and CBS database

Intrinsic value

No incentive to shift appointments in calendar to accommodate

Why? #5

Appendix 2.1 – Alternative Demand Solutions The following table briefly summarizes the evaluation of the alternative solutions for the demand side problem Name of solution

Description

Reason not used

LIS Modification

Update current LIS system in hospital inventory rooms to directly upload data to a CBS centralized database

LIS is FDA regulated as a medical device; any changes to the LIS will require a 510k as this change is significant

Prolong blood product shelf life

Research into methods to prolong the shelf life of blood products

Very research intensive. Costs are not measurable, but likely high, and payback not guaranteed.

SAP

Integrate an SAP inventory management system to track blood products throughout the supply chain and automatically replenish orders

Very costly (upfront and ongoing) and steep learning curve. Will require high level of training across hospital and CBS staff

Appendix 2.2 – Alternative caveat to proposed solution The proposed solution will enable CBS to achieve its objective of having true “Vein-to-Vein” traceability. However, there are patient privacy laws that protect the use of patients’ medical information. CBS must be aware of such privacy laws, like the Personal Health Information Protection Act (2005) in Ontario. Each province and hospital have their own privacy guidelines with regards to the protection of their patients’ medical information.

Time will need to be spent discussing with hospital management in each jurisdiction to ensure that the tracking of patient files through OCR technology in a centralized database does not compromise any privacy contracts/regulations that are currently in place. In addition, advanced data protection measures, such as encryption, firewalls, and the use of VPN servers, must be taken in order to secure the sensitive information on the CBS database.

In the worst case scenario, where the tracking of patient files is not allowed, hospitals can indicate the “use case” when scanning the blood product with the specialized barcode scanner. The hospital staff will indicate where the blood product is being used on the touchscreen (i.e. choose one of three use locations: ER, inpatient, or outpatient). This will enable CBS to gather real time data regarding the general location of where the blood product is being used in the hospital. It will not be able to connect the “vein of donors to the vein of recipients” due to privacy laws. However, an improvement is still made as there is an added resolution of blood product traceability. This will help CBS create more detailed data reports.

Appendix 3.0- Alternative Supply Solutions The following table briefly summarizes the evaluation of the alternative solutions for the supply side problem Name of solution

Description

Reason not used

Blood points raffle through GiveBlood app

“Blood points” or raffle ballots would be allocated for every donation given to CBS. Higher marginal points would be given as the number of repeat visits increases.

Users can also be rewarded blood points for word of mouth marketing with successful referral donations. At the end of every 6 months, a raffle draw would be held.

This solution spends a controlled amount of money and impact to blood bank is easily measured.

Krever commission does not allow any monetary renumeration for blood product donations. Even if the monetary prize is replaced by a physical item, such as a TV, this does not align with the suggested “precautionary” risk averse approach.

Incentive to donate blood prior to piercings, tattoos, etc.

This solution involves putting advertisements or offering monetary discounts on tattoos (or example) in hopes of getting people to donate prior to getting a tattoo (which would render them ineligible to donate for a period of time).

Krever commission does not allow any monetary renumeration for blood product donations.

In addition, the monetary investment cannot be measured.

Partnerships with companies

Partnerships with popular companies such as Starbucks or urban coffee shops would allow CBS to add another marketing channel to its donor outreach program. In addition, it may help accomplish CSR goal set out by targeted companies

The effectiveness is not measurable. A relatively large amount of money will need to be spent on CBS outreach staff to coordinate marketing campaigns and material, in which the return is not very high.

Appendix 4.0 – Foreseeable challenges The Strategic Action Plan addresses implementation and mitigation of the below risks/challenges: 1. CBS in-house capacity ○ HLS staff will face increased responsibilities in encouraging each hospital within the provinces to implement this solution. For successful realization of the outcome, the HLS staff will also have to continuously monitor the adopting hospitals and provide timely support and training throughout the implementation process. CBS will need to ensure that it develops its in-house capacity in order to accomodate for additional training support.

2. Approval of additional funding ○ Successful implementation is contingent upon the approval of the CBS’s application in each provincial jurisdiction. These additional funds are critical to support the initiation of the project.

3. Protection of sensitive patient information ○ Although CBS would like to achieve vein-to-vein traceability, hospitals may be resistant to implement the proposed solution in order to protect and avoid any breach with sharing of sensitive patient information. HLS staff will need to spend time with hospital management and share the long-term cost benefits analysis to describe the long-term advantages the solution will have for the hospital. If privacy is a major barrier, refer to Appendix 2.2 – Alternative caveat to proposed solution.

4. Change management within hospitals ○ Implementing a change in the workflow process may be challenging, as it does not account for behavioral resistance to change that would be expected from the staff. Extensive training and ongoing support will be required at every affected hospital staff level by outlining the value added behind the initiative as well as the benefits that result if the change is successfully implemented.

5. Data storage and protection/backups ○ CBS will increase its liability by withholding the large volume of sensitive patient information. It will need to ensure that the data is well backed up and securely protected with the use of Virtual Private Networks (VPN), firewalls, and data encryption.

6. Overestimation of hospital blood product inventory levels ○ For blood samples that are returned to inventory due to a failed transfusion, the lack of a process that can weigh the balance of the blood product used may result in misleading data of the amount of remaining blood product in inventory. This could result in inaccurate demand forecasting and the discrepancy can be amplified with every additional returned blood product.

Appendix 5.1 – Pilot Project Financials Cost to CBS

Appendix 5.2 – Pilot Project Financials Cost to hospital (covered by CBS during the pilot project)

Appendix 5.3 – Pilot Project Financials Cost to CBS

To get to the 2,131 donor card quantity, we used the supporting excel file in the case to guide the numbers.

Appendix 6.0 – Cost Benefit Calculations � Outdate rates taken only from hospitals. Did not include CBS outdates � To calculate “Total cost of product outdate�:

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