A Kick Start to Medication Reconciliation

Safer Healthcare Now! Teleconference Tuesday, November 21, 2006

A Kick Start to Medication

ReconciliationDr. Hilary AdamsQuality Improvement Physician, Family Medicine Calgary Health

Region Judy Schoen

Pharmacy Patient Care Manager, Calgary Health Region


The team• Multidisciplinary• Champions/opinion leaders• QI support if possible• Don’t forget frontline staff!• Distinct group with common

focus (e.g. nursing unit, specific service etc)


Getting Started

• GSK from SHN• PDSA quality improvement

model• FOCUS

– Find an opportunity– Organize a team– Clarify current process– Understand variability– Sustain results


Why baseline data

• We don’t know what we don’t know

• Recognize size of problem• Get buy in early• Helps show improvement• Makes it a priority


Success Index: 56.9%

Mean # of Undocumented Discrepancies: 0.6/patient

Mean # of Unintentional Discrepancies: 1.7/patient

5

Baseline Measures


Current process and Variability

• Analyze current process for gaps and drops

• Understand variability• ? multiple locations for data


Past Process: Hospitalist History and

Physical Form

Incompletemed list

7


Past Process: Hospitalist History and

Physical Form

No med list

88


Past Process: Nursing Medication

History

No med list

9


• Variety of processes

• Unclear roles• Concerns

about duplication

• Rework in locating information in chart

Key Learnings

10


• Variety of processes

• Unclear roles• Concerns about

duplication• Rework in

locating information in chart

Team Vision:

• Standard approach• Clear roles• Single location for

home medication information in chart

• Collect Best Possible Medication History (BPMH) in 24 – 48 hours

11


Team Charter• Identify all team members• Purpose of project• Guiding principles• Scope and boundary• Goals and objectives• Ideas for change• Principles for working together• Roles and responsibilities


Challenges at the Onset

• No clear owner.No clear owner.

• Variety of processes. Variety of processes.

• Obtaining accurate medication Obtaining accurate medication

information.information.

• Limited clinical pharmacy resources.Limited clinical pharmacy resources.

• Physician / nursing buy-in.Physician / nursing buy-in.

• Difficulty in adopting new practices.Difficulty in adopting new practices.

• Lack of communication between Lack of communication between

interfaces.interfaces.

13


Critical Aspects• No duplication/melds with current

workflow

• Prompts/cues on forms (e.g. dose)

• Involvement of all disciplines

• Education

• Strong leadership

• Monitoring our progress

• Auditing the process, not individuals14


An Improved Process: What things may look like

• Standardized approach• Multidisciplinary• Clear roles.• Defined location for home

medication information in patient chart.

• Increased awareness of key questions to ask to illicit the BPMH.

15


An Improved Process: What things may look

like• Ease of use• Flexible• Does not result in

duplication• Clear communication• Close the loop• Prompts health care

providers to provide BPMH


Step 2: Pre-Admission Medication List

17


Step 3 & 4: Additions/Clarifications of Pre-Admission Medication List

18



Step 5: Physician Review

20


Challenges• Wellnet – not a complete record• “As directed” on Rx• Patient altering own

medications• Limited sources of information

outside of office hours• Transposing to PCIS (EMR)• Adapting learnings to the

community 21


Lessons learned• Understand variation in current

practice is critical• Multidisciplinary approach is

essential• Vision of final outcome critical• BPMH auditor must be separate to

the process• Clear definitions• Deal with one issue at a time• Small successes build momentum• Just do it! (when is it right enough?)


Gains

A nurse on Unit 62 received a phone call from a patient’s wife. She asked why her husband was on lasix. The nurse pulled the patients chart and referred to the BPMH form in which the MD had documented that lasix was to be ‘held’ due to dehydration. The nurse was able to efficiently respond to the patient’s wife.

23


Baseline Measures

Success Index: 56.9% at baseline to as high as 92.8%

Mean # of Undocumented Discrepancies: 0.6/patient to as few as 0.0

Mean # of Unintentional Discrepancies: 1.7/patient to as few as 0.4

24


Step 1: Patient Risk Assessment Tool

Step 1: Patient Risk Assessment Tool

25


Referrals to Pharmacy

26

Hospitalist Pharmacist Referrals

05

10152025303540

Hospitalists

Nurses

Pharmacists

Other


Success Index

Success Index

0

20

40

60

80

100

Aug.-Sep.,2005

Oct.12,

2005

Oct.25,

2005

Nov.16-17,2005

Dec. 8-15,

2005*

Dec. 8-15,

2005*

Jan. 17-18,

2006

Feb. 27- Mar.

8, 2006

Per

cen

t

Baseline (Dr.s only)

(n=24)

PDSA 1: Form 1

(Dr.s only)(n=7)

PDSA 2: Form 2(Dr.s only)(n=5)

PDSA 3: Form 3

(Dr.s only)(n=11)

PDSA 4: Form 3

(Dr.s only)(n=8)

Stretch Goal: 100%

Goal: 85%

PDSA 5: Form 3 (Dr.s & Nurses)(n=2)

* P DSA's took place during same timeframe

PDSA 6: Form 4 (Dr.s ,

Nurses & Pharmacists)

(n=4)



(n=9)


Undocumented Intentional Discrepancies

Mean # of Undocumented Intentional Discrepancies

0

0.5

1

1.5

2

2.5

Aug.-Sep.,2005

Oct. 12,2005

Oct. 25,2005

Nov.16/17,2005

Dec. 8-15,

2005

Dec. 8-15,

2005

Jan. 17-18,

2006

Feb. 27- Mar.

8, 2006

Mea

n #

of

Dis

crep

anci

es

Stretch Goal: 0.2

Goal: 0.3


(n=24)

PDSA 1: Form 1

(Dr.s only)(n=7)


PDSA 3: Form 3(Dr.s only)

PDSA 4: Form 3

(Dr.s only)(n=8)


PDSA 6: Form 4 (Dr.s , Nurses & Pharmacists)

(n=4)PDSA 7: Form 4 (Dr.s ,


(n=9)


Unintentional Discrepancies

Mean # of Unintentional Discrepancies

00.20.40.60.8

11.21.41.61.8

22.22.42.62.8

Aug.-Sep.,2005

Oct.12,

2005

Oct.25,

2005

Nov.16/17,2005

Dec. 8-15,

2005

Dec. 8-15,

2005

Jan. 17-18,

2006

Feb. 27- Mar.

8, 2006

Mea

n #

of

Dis

crep

anci

es

Stretch Goal: 0.4

Goal: 1.3


(n=24)

PDSA 1: Form 1

(Dr.s only)(n=7)


PDSA 3: Form 3(Dr.s only)

PDSA 4: Form 3

(Dr.s only)(n=8)




(n=4)



(n=9)

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A Kick Start to Medication Reconciliation

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