National Immunization Conference

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Vaccine Management Business Improvement Project

• National Immunization Conference
• Dallas, TX
• April 1, 2009
• Ad Hoc Part 1 715 845 AM

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Agenda

• VMBIP Overview Kim Lane
• Centralized Distribution Jeanne Santoli
• Pediatric Stockpile Jeanne Santoli
• VMBIP Communications Julie Orta
• Grantee/Provider Efficiency CQI Julie Orta
• Economic Order Quantity Julie Orta
• Questions Answers Open Discussion

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VMBIP Overview
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VMBIP overview

• Today, I will be answering the following
  questions
• Why did VMBIP get started?
• What is VMBIP?
• What has been accomplished and what is left to
  do?
• How is VMBIP getting done?

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VMBIP was influenced by many factors

• VMBIP comprehensive review of how public vaccine
  is managed
• The first top-to-bottom study conducted since
  inception of VFC in 1994 many existing
  processes established decades ago
• Several factors drove need for the assessment
• Public health expectations following 9/11
• Vaccine shortage monitoring
• Implementation of a national pediatric stockpile
  and accounting changes
• System limitations to support vaccine funding
  allocations to grantees and DA-vaccine funding
  changes
• Outdated legacy systems (VACMAN supported via
  FoxPro)
• Need to ensure a stable infrastructure for
  decades to come

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2003 VMBIP Business Case Findings
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VMBIPs vision continues to guide us in all of
our decisions

• Establish a world class logistics system in
  support of the public-sector vaccine management
  activities
• VTrckS will process orders in real time
• Adopt commercial industry best practices, create
  efficiencies, and bring more transparency to
  vaccine management
• Deliver the expected levels of service and
  responsiveness to providers, while minimizing
  total supply chain costs
• Processes should be convenient, scalable, and
  flexible
• Ensure appropriate program and financial controls

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VMBIP Benefits To Date

• Improved shortage management capabilities
• Increased visibility into national public-sector
  supply
• Eliminated multiple DA-vaccine funding rounds via
  grant awards
• Supported emergency response vaccine requests
• Able to project national vaccine demand based on
  actual data
• Funds management efficiencies

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VMBIP has financed itself with the savings
realized to-date

• 496M in one-time vaccine savings
• 220M Inventory Reduction - 176M for VFC and
  44M for 317
• 276M Funds Management Transition (VFC vaccine)
• 317 vaccine savings targeted for the Adult
  Hepatitis B Initiative
• Centralized Vaccine Distribution Savings
• Cost per dose savings of 0.09 for centralized
  distribution after benefits

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VMBIP is a multi-year initiative
Key Activities
Baseline current process and develop new model
Centralized Distribution
Centralized Distribution Implementation (June
2008)
VTrckS Provider Order Pilot
Centralized Ordering Implementation
Ordering
Continue process improvements CQI (e.g., EOQ)
Transition grantees to New Funds Management Model
Internal Efficiencies
Stockpile Pilot
Rescoping Pilot
Transition of product
Stockpile
2005
2006
2007
2008
2009
2010
2011
2013
2012
2003-2004
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VMBIPs size and importance require Program,
Business and IT Support
Coordinating Center for Infectious Diseases (CCID)
State/Local Immunization Programs
Financial Management Office (FMO)
Procurement and Grants Office (PGO)
Information Technology Services Office (ITSO)
Coordinating Center for Health Information and
Service (CCHIS)
Management Information Systems Office (MISO)
Providers
SAP
Northrop Grumman
McKesson Specialty
Booz Allen Hamilton McKing
CDC Internal Divisions External
Stakeholders Contractors
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A governance model supports all aspects of VMBIP
and VFC funding
VMBIP Governance Model
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Next Steps

• Realization of centralized distribution benefits
• Data and data analysis (e.g., new vaccine uptake)
• Process improvements
• CQI initiatives (EOQ, etc.)
• Continue enhancing the VMBIP governance model
  with advanced budget planning and process
  improvements
• Funds management/legislative/contractual changes
• VTrckS development and implementation
• Communications and marketing
• Organizational change management
• Training

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We have eleven VMBIP workstreams that are
frequently monitored
VMBIP Executive Sponsor Kimberly Lane
Communications
Project Management Office
Organizational Change Management
Stockpile Storage
Centralized Distribution
Internal Efficiencies
VTrckS
Continuous Quality Improvement
Stockpile Support
Centralized Distribution Support
VTrckS Blueprint
VTrckS Provider Order Pilot
Funds Mgmt Replenishment
VMBIP Contact Center
Data Warehouse
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VMBIP project and change management support

• Project Management Office (PMO)
• The PMO is a business group/office that defines
  and maintains standard operating procedures,
  provides guidance, evaluates metrics and supplies
  project management to the overall program
• Develop an integrated master schedule
• Develop and implement project performance
  measures (e.g., reduction in depots and quantify
  reduction in order timeline with VTrckS)
• Organizational Change Management (OCM)
• OCM is the implementation of a systematic
  approach to accelerate adoption and acceptance of
  a new process and/or system
• Analyze VTrckS requirements to review the degree
  of change to the stakeholders processes
• Plan VTrckS Provider Order Pilot training
  deployment activities

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Todays ad hoc sessions will cover a majority of
the 11 workstreams
VMBIP Executive Sponsor Kim Lane
Communications Julie Orta
Project Management Office
Organizational Change Management
Stockpile Storage
Centralized Distribution
Internal Efficiencies
VTrckS
VTrckS Blueprint Janet Kelly
Continuous Quality Improvement GPE/EOQ Julie Orta
Stockpile Support Jeanne Santoli
Centralized Distribution Support Jeanne Santoli
VTrckS Provider Order Pilot John Visser
Funds Mgmt Replenishment
VMBIP Contact Center Julie Orta
VACMAN Karron Singleton
Data Warehouse Joe McDowell
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Centralized Distribution
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Centralized Distribution Background

• Transition began in February 2007 and was
  completed in June 2008
• Benefits
• Decrease in the overall size of the inventory
• Increase in federal visibility to vaccine
• Vaccine insured prior to/during distribution
• Points of Contact
• Sally Somerfeldt
• Helen Kuykendall
• Lisa Galloway
• Jeanne Santoli

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Where are we now? (1 of 2)

• The centralized distribution contract is in its
  third year
• CDC completed a modification of the distribution
  contract in early March 2009
• Key areas of this modification include
• Shipping timelines and method
• Liability procedures/customer service
• Additional/refined data and reporting components

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Where are we now? (2 of 2)

• There are two key areas that CDC will focus on
  in the coming months
• Implementation of contract changes defined in the
  recent contract modification
• Continued efforts to assess and improve quality
  of ongoing operations
• Problem log from Michigan

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Shipping Timelines and Methods
Overnight shipping on routine/priority/flu
vaccine orders

• 3-5 shipping days delivered in 4-10 business
  days

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Liability (1 of 2)

• Initial Contract
• Grantees are required to contact customer service
  within two hours of provider receipt of vaccine
  when temperature excursion/vaccine viability is
  in question
• Problems reported outside of this two hour period
  become CDC liability
• This narrow time window resulted in increased
  liability for CDC

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Liability (2 of 2)

• Recently Modified Contract
• Liability procedures still involve two hour
  window, but increased flexibility because
  customer service will handle calls directly from
  providers related to vaccine viability/temperature
  excursions
• McKesson protocols ensure grantees will be aware
  of these provider calls
• Grantees will have a role in requesting
  manufacturer advice about vaccine viability as
  part of this new liability procedure

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Over-shipments/Over-orders

• Recently Modified Contract
• Grantees opting to keep/redistribute
  over-shipments must place additional vaccine
  orders to cover the cost
• If grantees do not opt to keep/redistribute
  over-shipments, formal procedures have been
  developed for retrieval
• McKesson responsible for documenting/retrieving
  over-shipments/mis-shipments
• Grantees responsible for documenting/shipping
  unintended over-orders

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Centralized Distribution - Customer Service

• Recently Modified Contract
• Enhanced customer service to support provider
  liability calls
• Use of a customer service tool to allow for
• Monitoring of call types and resolutions
• Measurement of customer service performance
• Improved calculation of order quality metric

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Data/Reporting Enhancements

• Continue to improve data quality of existing
  reports
• Formalize, improve shipping log
• Daily inventory updates
• Improvements in order status information
• Working to address missing shipment status
  updates (including order cancellation)

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Speaking of Cancelled Orders . . .

• Timing of cancellation is critical - once orders
  have already moved beyond a certain point,
  cancelling is not guaranteed
• Best to call customer service about cancelled
  orders
• Grantees should advise providers not to refuse an
  order they thought was supposed to be cancelled
  contact state program instead
• Refused orders result in wasted vaccine (CDC
  liability)

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Improving Safety of Vaccine Returns to McKesson
(1 of 3)
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Improving Safety of Vaccine Returns to McKesson
(2 of 3)
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Improving Safety of Vaccine Returns to McKesson
(3 of 3)

• Approximately a dozen incidents since July 2008
• Used syringes as well as unused vaccine drawn up
  into syringes
• Extremely dangerous practice that violates needle
  safety guidelines
• Centralized distribution staff are placed at risk

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CDC Flyer in Vaccine Shipments
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How is your feedback incorporated?

• Recent contract modification requests reflect
  input/suggestions/problems raised by grantees
• Close collaboration with POB Project Officers
• Provide regular updates at weekly staff meeting
• Address problems/issues brought to POB Project
  Officers by grantees
• Biweekly calls with AIM Distribution Working Group

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Pediatric Vaccine Stockpile
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Background

• Stockpile program began in 1983
• VFC legislation (1993) authorized CDC to use VFC
  funds for stockpile purchases
• Approach Manufacturer-managed storage and
  rotation stockpiles
• Strategy
• Initial Fully implemented routine vaccines with
  a single manufacturer
• Current All vaccines, addressing both disease
  outbreaks and supply disruptions

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Where are we now? (1 of 2)

• Transition of a portion of the stockpiles to
  McKesson
• Pilot currently underway, includes several
  vaccines at both depots
• Transition plan for additional doses is currently
  under development
• Accessing vaccines/borrowing
• Impact on expiry
• Re-examination of the optimal target size
• Six-month national usage versus six-month federal
  contract

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Where are we now? (2 of 2)
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Where are we going?

• Ensure public-sector vaccine availability to help
  safeguard against national emergency or temporary
  vaccine shortage
• Continue to build and maintain/transfer pediatric
  stockpiles at manufacturers and McKesson depots
• Reduce costs for storage and rotation and allow
  manufacturers to recognize revenue for stockpile
  deliveries to McKesson

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Communications
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Communications Background

• Supports VMBIP team to communicate clearly and
  consistently to all stakeholders, including
• grantees
• providers
• Our goal is to improve the flow and clarity of
  VMBIP information
• Points of Contact
• Julie Orta and Brad Prescott
• Your POB Project Officer

CDC general public
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Communications Whats in it for me?

• Benefits to grantees, providers CDC
• Increased understanding of VMBIP scope and
  benefits
• Timely communication of VMBIP updates
• Transparent communication
• Assistance with communications to stakeholders
• Consistency of message

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Communications - Where are we now?

• E-newsletter with key updates
• Grantee Advisory Committee (GAC) conference
  calls/meetings
• VMBIP website (www.cdc.gov/vaccines/programs/vmbip
  )
• VFC/AFIX quarterly conference calls

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Communications - Where are we going?

• Improve communication based on your feedback
• Join AIM General Membership calls
• Increase focus on VMBIP core concepts
• Create tangible communications tools such as
• VMBIP website as go-to resource
• Communications plan
• Frequently asked questions (FAQs)
• Flyers
• Evaluate effectiveness of communication tools

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Communications - How is your feedback
incorporated?

• Feedback opportunities
• Grantee Advisory Committee
• Provider Advisory Committee
• VMBIP communications leads
• Your POB Project Officer
• How stakeholder feedback is used
• Tailor messages for each audience
• Evaluate effectiveness

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Grantee/Provider Efficiency (GPE) Continuous
Quality Improvement (CQI)
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Grantee/Provider Efficiency (GPE) CQI
Background (1 of 3)

• The GPE Continuous Quality Improvement (CQI)
  initiative
• Supports grantees and providers who want to
  improve vaccine ordering process
• Involves initial site visit to document current
  processes
• Involves follow up site visit to provide
  customized tools and methods and facilitate
  application

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GPE CQI Background (2 of 3)

• GPE CQI team responsibility
• Baseline analysis
• Customized tools and methods
• Tools and methods training
• Grantee responsibility
• Initiate request to CDC for GPE CQI
• Implement tools and methods
• Provide feedback on the experience
• Support the GPE CQI site visits
• VFC manager 25 time commitment
• Support staff 10 time commitment

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GPE CQI Background (3 of 3)

• Points of Contact
• Julie Orta
• Your POB Project Officer

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GPE CQI - Whats in it for me? (1 of 3)

• Benefit to grantee
• Improved order processing flow
• Improved processes that will complement VTrckS
  implementation
• Opportunity to apply best practices

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GPE CQI - Whats in it for me? (2 of 3)

• Benefit to grantee

Analysis of historical order volume
Analysis of historical call volume
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GPE CQI - Whats in it for me? (3 of 3)

• Benefit to provider
• Improved storage and handling methods
• Improved ability to determine doses needed
• Benefit to CDC
• Improved processes that will complement other
  VMBIP workstreams
• Improved vaccine order flow nationwide
• Benefit to all
• Smoothing the ordering spikes allows for more
  efficient movement of vaccine through the
  ordering and shipping cycle

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GPE CQI - Where are we now?
FM
GU
MH
AS
MP
PW
PR
VI
Completed - 4
Scheduled - 16
Requested but not scheduled - 8
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GPE CQI - How can you request support?

• Contact your POB Project Officer to schedule a
  conference call to discuss
• Detailed overview and expected benefits
• Level of effort required from grantee and
  provider staff
• Possible dates for GPE CQI activity

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Economic Order Quantity (EOQ)
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EOQ Background (1 of 2)

• Economic Order Quantity (EOQ) is an industry best
  practice that balances order size, order
  frequency, and storage and handling costs
• Assigns ordering tiers per provider based on
  annual volume of doses
• Grantees tailor ordering frequency for certain
  providers and situations

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EOQ Background (2 of 2)

• Reduces overall provider and grantee order
  processing workload
• Improves efficiency and savings
• Complements GPE CQI
• Points of Contact
• Julie Orta
• Your POB Project Officer

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EOQ - Ordering Tiers
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EOQ - Whats in it for me?

• Benefit to grantee
• Overall fewer orders to review/process
• Visibility into provider-level ordering data via
  CDC provided reports
• Benefit to provider
• For most providers, less time spent ordering
• Smooth out vaccine ordering spikes
• Benefit to CDC
• Greater predictability and fewer ordering
  spikes for the program
• Inventory management improvements

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EOQ Historical Order Information
Doses (M)
Memphis Distribution Center
Sacramento Distribution Center
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EOQ - Where are we now? (1 of 2)
Four pilot grantees
FM
GU
MH
AS
MP
PW
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PR
VI
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EOQ - Where are we now? (2 of 2)

• Site visits
• Provider-level data analysis
• Fact finding
• Strategy planning
• Tool and template review and revision
• Ongoing technical assistance
• Follow-up visits
• Monitor provider-level ordering data

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EOQ - How are we going to get there?

• CDC support for grantees
• VFC FA operations ordering funding in 2010 and
  2011
• Technical assistance, templates and tools,
  up-to-date provider-level ordering data
• Best practices and lessons learned to be shared
  nationwide
• Complement Grantee/Provider Efficiency CQI
• EOQ functionality in VTrckS

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EOQ - How is your feedback incorporated?

• Talk to EOQ team and your POB Project Officer
  about
• Feasibility of implementation
• Barriers to implementation
• Suggestions
• Your knowledge and experience help CDC adapt EOQ
  implementation strategy

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This document

• This document can be found on the CDC website at
• http//www.cdc.gov/vaccines/programs/vmbip/downloa
  ds/newsletters/2009/nic-vmbip-ad-hoc-pt1.ppt