Transcript Pharmacy Integrated Model

Best Practice Power Hour
Medication Reconciliation:
Pharmacy Integrated
Model
Steve A. Carlson, RPh
Sara E. Grove, Pharm.D.
Northeast Georgia Health System (NGHS)
Gainesville, Georgia
NGHS
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Private, not-for-profit, community
Accredited by DNV
557 inpatient beds
261 skilled nursing beds
Serves almost 700,000 people in more
than 13 northeast Georgia counties
Patients Served
 Inpatients
 Outpatients
 Surgeries
 Outpatient
 Inpatients
 Emergency Visits
 Deliveries
30,364
238,542
10,801
7,466
99,456
4,087
Department of Pharmacy
 32.04 Pharmacists (including management)
 6 Clinical Pharmacy Specialists
 Cardiology
 Critical Care
 Internal Medicine
 Oncology
 Women & Children’s Health
 Emergency Medicine
 41 Technicians (3:1 ratio in GA)
 Unit-Based Pharmacy Technicians
 Cardiology
 Critical Care
 Internal Medicine
 Oncology
 Women & Children’s Health
 Emergency Medicine (2)
* Reflects staffing only at the medical center
Providing Exceptional
Service
 Customer Service is a major focus of
the facility
 Patient
 Staff
 Developed a Unit-Base Pharmacy
Technician Model
Unit-Based Pharmacy
Technician (UBT) Program
 Established in February 2007
 Initially 4 Pairs of Technicians
 Goals
 Optimize Distribution
 Establish Direct Communication
 Provide Focused Service
 Qualified Staff
 Certified Technicians
 Experienced Senior Staff
Review of Events
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January 2006: Nurse Managers Interviewed
March 2006: Base-Line Survey Conducted
May 2006: Results Presented
May 2006: Pilot on 2 Floors Conducted
July 2006: Proposal Presented & Approved
November 2006: Initial Deployment
February 2007: Full Implementation
March 2007: Survey Repeated
May 2007: Results Presented
July–August 2007: Focus Groups Met
Initial FTE Requirements
 7.6 FTE’s; 10 hour shifts 7on / 7off
 Open pharmacist position (1 FTE)
converted to 2.8 FTE’s
 Redeployed 2.0 FTE’s
 Requested a net of 2.8 new FTE’s
Initial UBT Assignments
UBT Responsibilities
 Delivery of medications directly to
nurse or nurse server
 Resolution of missing medications
 Facilitating transfer of medications
on/off unit with patient
 Removal/return of discontinued meds
 Automated Dispensing Cabinet
troubleshooting/restock
UBT Responsibilities
 Delivery of cart fill to nurse server
 Med error/ADR reporting to
pharmacist
 Notification of allergy/height/ weight
 Monthly nursing unit inspections
 Assistance with faxing of orders
 Obtain new orders from units and
expedite medication needs
Customer Service Survey
Pharmacy Customer Service Survey
All Nursing Units - Medical Center
2006
2007
Pharmacy Customer Service Survey
Areas Serviced by Unit-Based Technicians - Medical Center
2006
2007
Survey Comments and
Suggestions
 “These techs are the smartest thing I’ve
seen around here in a long time. They are
beyond measure – an asset to having
quality – acceptable nursing care.”
 “Excellent teamwork – assists nurses to
complete essential nursing tasks & focus
on this vs. non-nursing duties.”
 “Go unit based techs! You rock.”
Survey Comments and
Suggestions
 “Still have a problem with medication
missing, but turn around time to get it is
much better.”
 “The morning meds that are due before
breakfast…are scheduled at 0730 and this
isn’t working well. By the time we get out of
report, the breakfast trays have already
been passed. Can these meds please be
scheduled for 0630?”
Reconciliation Process
Home
Admission
Discharge
Home Med
List Created
Addressed by
MD
Reconciled by
RPh
Communicated to
Patient by Nurse
Addressed
& Reconciled
by MD
Transfer
List Provided to Next
Provider of Care
Reconciled by MD
New Home
Med List
Created
Identifying Deficiencies
• Discharge Medication List
• Heart Failure Core Measure HF-1 Scores
• Average Fiscal Year 2008: 53.4%
• TJC Average: 75.8%
• Majority of failures due to transcription errors
• Admission Medication List
• Staff observed errors and omissions
• Garbage In / Garbage Out
NGHS Performance Improvement Dashboard
Medication Reconciliation
Responsibilities
 Admission
• Interview patient at admission
• Document home medication list
• Print list for physician to address
 Discharge
• Document discharge medication list as
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specified by physician orders
Notify nurse of discrepancies
Technician Training
 Software
• Demonstrate Proficiency in Entry
 Procedure
• Identify Discrepancies
 Communication
• Demonstrate Appropriate Body Language
• Review Principle
• Identify Barriers
Pilot: Heart Failure
 Pharmacist Pre-Pilot
• October to Mid-December 2008
 Locations
• Emergency Department
• 3 Medical/Cardiac Inpatient Units
 Redistribution of Workload
• Reduced # Beds/UBT
• Added 3 Positions per Week
Pilot UBT Assignments
Pharmacy-Based Medication Reconciliation Pilot
Starts December 16th
Here to Help
Here to Help
Rx
Rx
Coverage from 0700-2300
Floors Participating:
S3E
S4D
S4E
ED
Goals:
1) To improve patient safety and care by striving to optimize the medication reconciliation process
2) To demonstrate improvement through increased Heart Failure Core Measure scores
Pharmacy Tech Duties
Admission
Nurse Duties
•Interview admitted patients and document
current home medication list
•Print “Admission Medication List” and attach it
to the chart
•Late admissions will be completed the
following morning
•If medication history is needed immediately
and a pharmacy technician is not available,
collect and document current home medication
list
•Record “MD Discharge Medication Orders” in
Clinical Profile
•Notify nursing of any discrepancies
•Resolve discrepancies with physician
•Review and sign off “MD Discharge Medication
Orders”
•Counsel the patient on discharge
medications and instructions
•Sign “Patient Discharge Medication List”
Discharge
•Sign “MD Discharge Medication Orders” to
indicate completion
Technician-Assisted
Medication Reconciliation
HF-1 Score Adjusted Score
2008 Average
53.4%
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1st Quarter 2009
75.4%
92.1%
2nd Quarter 2009
70.1%
85%
January
63.6%
77.3%
February
March
72.7%
73.9%
86.4%
91.3%
NGHS Performance Improvement Dashboard
Current UBT Assignments
Cumulative HF Scores
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
1st Qrt
08
2nd Qrt
08
3rd Qrt
08
4th Qrt
08
1st Qrt
09
2nd Qrt
09
HF-1 Score
3rd Qrt
09
4th Qrt
09
1st Qrt
10
2nd Qrt
10
Pharmacy Adjusted Score
3rd Qrt
10
4th Qrt
10
1st Qrt
11
Cumulative Failure Origin
30
25
20
15
10
5
0
1st Qrt 09
2nd Qrt 09
3rd Qrt 09
Technician
4th Qrt 09
1st Qrt 10
Nurse
2nd Qrt 10
3rd Qrt 10
4rd Qrt 10
Physician
1st Qrt 11
Opportunities for
Improvement
 Nurse/Technician Clarifications
 Developed a formal discrepancy form
 Discharge Summary
 Development of electronic bridge
 Improperly Completed Forms
 Form revision
Discrepancy Reasons
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Therapeutic Interchange
New Prescription
Duplicate Therapy
Medication Not Addressed
No Prescription
Inappropriate Form Completion
Inappropriate Alteration of Form
Best Practice Power Hour
Medication Reconciliation:
Pharmacy Integrated
Model
Steve A. Carlson, RPh
Sara E. Grove, Pharm.D.
Northeast Georgia Health System (NGHS)
Gainesville, Georgia