Transcript A Kick Start to Medication Reconciliation

A Kick Start to Medication
Reconciliation
Dr. Hilary Adams
Quality Improvement Physician, Family
Medicine Calgary Health Region
Judy Schoen
Pharmacy Patient Care Manager,
Calgary Health Region
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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)
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Getting Started
• GSK from SHN
• PDSA quality improvement model
• FOCUS
– Find an opportunity
– Organize a team
– Clarify current process
– Understand variability
– Sustain results
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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
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Baseline Measures
Success Index: 56.9%
Mean # of Undocumented
Discrepancies: 0.6/patient
Mean # of Unintentional
Discrepancies: 1.7/patient
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Current process and Variability
• Analyze current process for
gaps and drops
• Understand variability
• ? multiple locations for data
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Past Process: Hospitalist
History and Physical Form
Incomplete
med list
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Past Process: Hospitalist
History and Physical Form
No med list
88
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Past Process: Nursing
Medication History
No med list
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Key Learnings
• Variety of
processes
• Unclear roles
• Concerns about
duplication
• Rework in
locating
information in
chart
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Team Vision:
• Variety of
processes
• Unclear roles
• Concerns about
duplication
• Rework in locating
information in
chart
• Standard approach
• Clear roles
• Single location for
home medication
information in chart
• Collect Best
Possible Medication
History (BPMH) in
24 – 48 hours
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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
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Challenges at the Onset
• No clear owner.
• Variety of processes.
• Obtaining accurate medication information.
• Limited clinical pharmacy resources.
• Physician / nursing buy-in.
• Difficulty in adopting new practices.
• Lack of communication between interfaces.
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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 individuals
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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.
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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
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Step 2: Pre-Admission Medication List
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Step 3 & 4: Additions/Clarifications
of Pre-Admission Medication List
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Step 5: Physician Review
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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
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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?)
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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.
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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
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Step 1:
Assessment
Tool
Step
1: Patient
PatientRisk
Risk
Assessment
Tool
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25
Referrals to Pharmacy
Hospitalist Pharmacist Referrals
40
35
30
25
20
15
10
5
0
Hospitalists
Nurses
Pharmacists
Se
pt
em
be
r
t
Au
gu
s
ly
Ju
ne
Ju
M
ay
Other
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Success Index
Success Index
100
S t re t c h G o a l: 10 0 %
G o a l: 8 5 %
Percent
80
60
40
20
Baseline
(Dr.s
only)
(n=24)
PDSA 1:
Form 1
(Dr.s only)
(n=7)
PDSA 2:
Form 2
(Dr.s
only)
(n=5)
0
Aug.Sep.,
2005
Oct.
12,
2005
Oct.
25,
2005
PDSA 3:
Form 3
(Dr.s only)
(n=11)
PDSA 4:
Form 3
(Dr.s only)
(n=8)
PDSA 5:
Form 3
(Dr.s &
Nurses)
(n=2)
PDSA 6:
Form 4
(Dr.s ,
Nurses &
Pharmacists)
(n=4)
PDSA 7:
Form 4
(Dr.s ,
Nurses &
Pharmacists)
(n=9)
Nov. Dec. 8- Dec. 8- Jan. 17- Feb. 27
16-17,
15,
15,
18,
- Mar.
2005
2005* 2005* 2006 8, 2006
* P DSA 's to o k place during same timeframe
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Undocumented Intentional
Discrepancies
Mean # of Discrepancies
Mean # of Undocumented Intentional Discrepancies
2.5
2
1.5
Baseline
(Dr.s
only)
(n=24)
1
0.5
0
PDSA 1:
Form 1
(Dr.s only)
(n=7)
G o a l: 0 .3
PDSA 3:
Form 3
(Dr.s
only)
PDSA 2:
Form 2
(Dr.s
only)
(n=5)
PDSA 4:
Form 3
(Dr.s only)
(n=8)
PDSA 6: Form 4
(Dr.s , Nurses &
Pharmacists)
(n=4)
PDSA 5:
Form 3
(Dr.s &
Nurses)
(n=2)
PDSA 7:
Form 4
(Dr.s ,
Nurses &
Pharmacists)
(n=9)
S t re t c h G o a l: 0 .2
Aug.- Oct. 12, Oct. 25, Nov.
Sep.,
2005
2005 16/17,
2005
2005
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Dec. 8- Dec. 8- Jan. 17- Feb. 27
15,
15,
18,
- Mar.
2005
2005
2006 8, 2006
Tuesday, November 21, 2006
Unintentional Discrepancies
Mean # of Discrepancies
Mean # of Unintentional Discrepancies
2.8
2.6
2.4
2.2
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
G o a l: 1.3
PDSA 1:
Form 1
(Dr.s only)
(n=7)
PDSA 2:
Form 2
(Dr.s
only)
(n=5)
Baseline
(Dr.s only)
(n=24)
S t re t c h G o a l: 0 .4
Aug.Sep.,
2005
Oct.
12,
2005
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Oct.
25,
2005
PDSA 3:
Form 3
(Dr.s
only)
PDSA 4:
Form 3
(Dr.s only)
(n=8)
PDSA 5:
Form 3
(Dr.s &
Nurses)
(n=2)
PDSA 6:
Form 4
(Dr.s ,
Nurses &
Pharmacists)
(n=4)
PDSA 7:
Form 4
(Dr.s ,
Nurses &
Pharmacists)
(n=9)
Nov. Dec. 8- Dec. 8- Jan. 17- Feb. 27
16/17,
15,
15,
18,
- Mar.
2005
2005
2005
2006 8, 2006
Tuesday, November 21, 2006