Transcript Slide 1

Medication Reconciliation
Tools, Keys and Tips
June 3, 2009
Steven Tremain, MD, FACPE, Convergence Health Consulting
Chief Medical Officer & Chief Medical Information Officer
Contra Costa Regional Medical Center
Session Objectives
Medication Reconciliation…
How  the approach
What  the process
Tools  the forms
Keys  to success
Tips  take home advice
Tools
Keys
Tips
Medication Reconciliation…
…One Patient’s Story
 While an inpatient, an elderly woman was
started on the new anti-hypertensive drug.
 She was discharged with a new RX for blood
pressure medicine.
 After discharge, the woman was seen in one of
the hospital’s ambulatory care clinics
complaining of severe dizziness.
 Her PCP figured out that she was taking the
blood pressure medicine prescribed in the
hospital on top of an earlier prescription she’d
been using at home for the same thing.
Key #1
Find and tell the stories….
….They exist
….They’re powerful
….They’ll engage people
Contra Costa Regional Medical
Center & Health Centers
Martinez
California
San Francisco
Bay Area
About CCRMC
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County hospital with 141 staffed beds
8 owned & operated health centers
Family Practice residents
EMR in ED only
Hospital & clinics still using paper records
Meditech clinical system (incl pharmacy)
CCRMC’s Recognition
• IHI Mentor Hospital since 2006
• IHI Innovation Award Winner (Dec 2007)
• Agency for Healthcare Research & Quality
(AHRQ) Innovation Exchange
(www.ahrq.org)
• Published case study in Joint Commission
Resources’ Medication Reconciliation
Toolkit for Implementing NPSG 8
Improve Medication Safety
Reduce rates of unreconciled
medications
Implement an effective
admission, discharge and
transfer reconciliation
process
Model for Improvement Source:
Institute for Healthcare Improvement
(IHI)
Med Reconciliation Timeline
Year
Month J
A
2005
S O
N
D
J
F
M
A
M
2006
J J
A
S
O
N
D
J
F
M
A
2007
M J J
A
S
O
Pilot unit (4A)
Medicine units
Surgical units
IMCU/ICU
Transfer Rec pilot
Psychiatry units
Transfer Rec live (all areas)
Pediatrics unit
OB unit
Pilot unit (4A)
ICU/IMCU
KEY:
Admission Reconciliation Implemented
Transfer Reconciliation Implemented
Discharge Reconciliation Implemented
Medicine Unit (4B)
Surgical Unit
Psychiatry Unit
Pediatrics unit
OB Unit
N
Tip #1
Segment pieces of the improvement
process in bite size increments.
 Allows for small scale tests of change
 Allows for customization where necessary
 Improves likelihood of success
Our MR Project Team
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•
•
•
•
•
•
•
•
Physician champion (Internist)
Resident
Nursing champion (Medicine unit staff RN)
Pharmacists (2) Pharmacy Tech (1)
Clinical Informaticist (RN)
Forms expert
Nursing rep for every service
MD rep for every service
Leader
Key #2
Multi-disciplinary team
 Physician champion essential
 Typically, pharmacy, nursing and medical
staff
 Best to have a strong leader, not aligned
with primary disciplines
Tip #2
Short (45 minutes) weekly team meetings
 Maintains momentum
 Promotes engagement
Measurement
Outcome Measures
• % unreconciled meds (Goal = 0%)
• % of patients with ALL meds reconciled
(Goal = 100%)
Process Measure
• % Compliance with use of the
forms/process (Goal = 100%)
Results
• We’ve reduced our rates of unreconciled
home medications…
…from 26% to 1% on ADMISSION
…from 23% to 4% on DISCHARGE
• We’ve reduced our rates of unreconciled
medications…
…from 12% to 4% on TRANSFER
• Improvement has been sustained for 3 years.
Measurement Tool
Medication Reconciliation Worksheet: Admission & Discharge Reconciliation (Contra Costa Regional Medical Center)
MRN:
Admit Date:
Unit:
Patient Name:
Discharge Date:
Reviewer:
Patients selected for audit must
have at least 1 pre-admit med.
Do not mark an herbal as
unreconciled upon admission
(not continued, per policy).
ADMISSION RECONCILIATION
Pre-Admit (HX) Meds
If MROF used, no need to list
drugs (just do summary). If no
MROF, list all pre-admit drugs,
including OTCs, vitamins,
herbals & supplements
Meds Pt is Taking Day of D/C
No
No
No
No
No
No
PRNs
Insulin sliding scale
Heparin SQ
antibiotic ointments
IV Chemo
one dose only drugs
Step 2: Does documentation
specify that each drug is C, DC,
M upon discharge? If not, it's
unreconciled.
C
DC
M
C
DC
Med NOT
Reconciled
Med order to
C, DC, M on
discharge?
Comments
Data Summary
M
Was Admit MROF
Used?
Total # of PreAdmit Meds
Total # of PreAdmit meds NOT
reconciled on
admission
Total # of PreAdmit meds NOT
reconciled on
discharge
Was DMOF Used?
DISCHARGE RECONCILIATION
Step 1:List Meds on MAR on
day of d/c with exceptions:
Med order to
C, DC, M on
admission?
Med not rec; but
clinically obvious
Drug
Discharge
Med NOT
Reconciled
Audit Instructions
Med not rec; but
clinically obvious
Admission
Audit Inclusions: Any admission to the service; A least one pre-admit med in hx.
Does DMOF
contain all at
home meds?
Total # of predischarge Meds
Total # of predischarge meds
NOT reconciled on
discharge
Did any med order consist of "continue preadmit meds" or "continue home meds"
without detailing the specific medication?
(Y/N)
Tip #3
Test measurement tool thoroughly
 insures that the data collection process will
produce the information you are seeking
Tip #4
“Measurement is for learning, not for judgment”
“Use data to generate light not heat!”
 Use data to learn where your process is failing
 Data collection should be frequent, small
samples
Admission Reconciliation
• Paper process
• Originally: Admitting provider hand-wrote the list
of medications patient was taking at home on
AMROF, which doubles as an admission order
form.
• Now: Admitting provider prints an eAMROF form
which is pre-populated with the current med list
and uses same form to order medications on
admission.
• Process being used 99% of the time.
Our paper
Admission
Medication
Reconciliation
Order Form
(AMROF)
Our electronic
Admission
Medication
Reconciliation
Order Form
(eAMROF)
Page 1
Key #3
Use “What’s-In-It-For-Me” (WIFM)
approach in workflow design
 Admitting MD  new process was less
work (med list doubles as an order form)
 Admitting MD  eAMROF was less work
(pre-populated list meant less writing)
 Admitting RN  new process was less
work (stopped capturing a med list from
scratch)
Key #4
Customize where necessary; Standardize
where possible
 Allows for unique workflows
 Promotes buy-in from staff
Examples  Peds, OB
Our paper
Pediatric
Admission
Medication
Reconciliation
Order Form
Our paper OB
Admission &
Discharge
Medication
Reconciliation
Order Form
Key #5
Make it easy for staff to use the new process &
difficult or impossible to use the old process
 Key for achieving high compliance with use of
the process
Example  Attached Admission Med Rec form as
page 1 of all admit order forms already in use
(manual at first then via forms vendor)
Transfer Reconciliation
• Electronically printed form contains list of
all active meds as of that moment in time.
• Provider uses form to order medications
on transfer within the facility.
• Process being used 99% of the time.
Our Transfer
Medication
Reconciliation
Order Form
(TMROF)
Key #2 & #6
Use “What’s-In-It-For-Me” (WIFM)
approach in workflow design
 Receiving RN  Less work (no more
“continue previous meds)
Harness Informal Champions
 Receiving RN  Constant reminders to
physicians who didn’t use the new process
Discharge Reconciliation
• Electronically printed form contains list of
all pre-admit meds and active inpatient
meds as of discharge.
• Provider uses form to order discharge
meds
• Patient is provided with a “patient friendly”
list of discharge medications.
• Copy of list is sent to next provider of care.
Our
Discharge
Medication
Reconciliation
Order Form
(DMROF)
Page 1
Our
Discharge
Medication
Reconciliation
Order Form
(DMROF)
Final Page
Our [electronically
generated]
“patient friendly”
Discharge
Medicine List
Key #3 & #5
Use “What’s-In-It-For-Me” (WIFM)
approach in workflow design
 Discharging MD  Less work (home &
inpatient meds print on a report)
 Patient  Now has a concise med list
Make it easy for staff to use the new
process & difficult or impossible to use
the old process
Example  Stamp on old forms
Discharge Reconciliation:
Who Does What…….
• MD
– Review and sign the DMROF. Update RXM
as needed
– Generate needed prescriptions in RXM
– Print Patient Home Medicine List from RXM
(aka Patient Friendly Med List)
– Complete the STOP medication section on
the Med List
Discharge Reconciliation:
Who Does What…….
• Nursing Staff
– Review Patient Home Medicine List with
patient (aka Pt Friendly), make a copy for
the chart.
– Indicate on Patient Home Medicine List, the
time the next dose of any medication is due.
– Write Patient Home Medicine list if not
generated from RXM
Discharge Reconciliation:
Who Does What…….
• Clerk
– Fax prescriptions to outside pharmacy
Key #7
Identify & Mitigate Failures
 Admission reconciliation failure causes
discharge reconciliation failure
 Develop workflows to identify key failure
points so they can be fixed immediately
Example  Daily report in Pharmacy for
identifying admitted patients w/o AMROF
Where We’ve Been….
Medication Reconciliation: 2005 - 2007
ED Visits
Inpatient
Admission
Admit  Transfer  Discharge
Outpatient
Visits
Where We’re Going…
Medication Reconciliation: 2008 & Beyond
ED Visits
Inpatient Admission
Admit  Transfer  Discharge
Electronic
Med List
Outpt
Visits
Preventing Readmissions
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Focus on CHF
Using LEAN/Kaizen
IS NOT: hospital ‘project’
IS: system way of functioning
Goal: using best practices for rapid
adaption/adoption in our system
• Template for other conditions
• Bonus: close collaboration across “silos”
Our Approach
• Bundle of 5 triggered at Dx
– CHF order set
– Patient education process
– Interdiscpilinary teaching plan
– Discharge appts made at time of admission!
– CHF Discharge Nurse
CHF Discharge Nurse
• Twice weekly phone calls to patients
– First call within 72 hours of discharge
• Real time ongoing medication
reconciliation of all meds
• Education
• Transportation assistance
• Triage
CHF Nurse
Ask the patient: Since leaving the hospital.
•How is your breathing?
Do you have worsening chest pain?
Can you lay flat without shortness of breath?
Are you coughing more?
Have you gained weight? If yes, how many pounds
Are you more dizzy or light headed?
Green Zone
All Clear – This zone is your goal. Your systems are under control
You have
•No shortness of breath.
•No weight gain more than 2 pounds (It may change 1 or 2 pounds).
•No swelling of your feet, ankles, legs or stomach.
•No chest pain.
Yellow Zone
Caution: - This zone is a warning.
CALL YOUR DOCTOR’S OFFICE IF:
•You have a weight gain of 3 pounds or more in 1 day or a weight gain of 5 pounds or more in 1 week.
•More shortness of breath.
•More swelling or your feet, ankles, legs, or stomach.
•Feeling more tired. No energy.
•Worsening cough.
•Dizziness.
•Feeling uneasy, you know something is not right.
•It is harder for you to breathe when lying down. You need to sleep sitting up in a chair.
Red
EMERGENCY
Go to the emergency room or call 911 if you have any of the following:
•Struggling to breath. Unrelieved shortness of breath while sitting still.
•Have chest pain that is different or stronger than normal or usual.
•Have confusion or can’t think clearly.
CONTRA COSTA HEALTH SERVICES
CONTRA COSTA REGIONAL MEDICAL CENTER
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Congestive Heart Failure (CHF) Nurse Tool
CHF Nurse
Call all new CHF referrals received by fax twice a week on Tuesday and Friday:
Assess Clinical Condition (see attached):

Red Zone
 Advised patient to go to ED and Notified ED (370-5973)

Yellow Zone
 Made appointment within 24 hours ---- OR-- Do green zone assessment below and call medicine dept. on call MD to consult.
Green Zone – Initiate discussion with patient or caretaker
Ask patient “teach back” questions:
What gain is concerning enough that you should report to your doctor?
What foods should you avoid?
Do you know what symptoms to report to your doctor?
Review medications:
“Were you able to get prescribed medications after you left the hospital?”
“Do you have the list of medicines they gave you when you left the hospital?”
“What is the name of your water pill(s)?”
Does patient have medications?
 Yes
 No
 Medications Refaxed /called to __________________________ pharmacy
Does patient administer own medications?
 Yes
 No
Medications reviewed with patient/family member_____________
Reinforced “Daily Activities” (daily wt., law-salt diet, activity as tolerated)
Review Appointment(s):
 Patient/family member aware of follow-up appointment(s) __________________________________
__________________________________________________________________________________
 Referral made to Social Worker (925)370-5480 for transportation issues.
 Appointment with Patient Educator made (next available):___________________________________
Other Intervention:
_________________________________________________________________________________________________________________
Follow up:
 Low Risk Patient: Chart check to make sure patient made follow-up appt.
 High risk Patient (any patient requiring consultation with MD or not clear on any items on patient assessment): Chart check for repeat phone
call 3 to 5 days.
Reliabiity
Nolan T, Resar R,
Haraden C, Griffin FA.
Improving the
Reliability of Health
Care. IHI Innovation
Series white paper.
Boston: Institute for
Healthcare
Improvement; 2004.
(Available on
www.IHI.org)
Joint Commission
Resources
(www.jcrinc.com)
Agency for Healthcare Research and Quality (AHRQ)
(www.innovations.ahrq.gov/index.aspx)
Contact Information
[email protected]