Transcript the Slides Only - American Academy of Pediatrics

Achieving Compliance with
Medication Reconciliation
Utilizing Improvement Methods
Tuesday, July 1, 2008
12:00 – 1:00 p.m. EDT
© American Academy of Pediatrics 2008
Moderator:
Uma Kotagal, MD, MBBS, MSc, FAAP
Vice President for Quality and Transformation
Director, Center for Health Policy and Clinical Effectiveness
Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio
DISCLOSURES
Financial Relationships
One individual involved in this webinar:
Melissa A. Singleton, M.Ed., Project Manager-Consultant
has disclosed a financial relationship with an entity producing, marketing,
re-selling, or distributing health care goods or services consumed by, or
used on, patients. Her husband is employed by Walgreen Co. as a
Workforce Administration Manager (technology position) for the
company’s call centers. The AAP determined that this financial
relationship does not relate to the educational assignment.
None of the other involved individuals (Speakers, Moderators, Project
Advisory Committee members, or Staff) has disclosed a relevant
financial relationship.
Refer to full AAP Disclosure Policy & Grid available below for
download.
DISCLOSURES
Off-Label/Investigational Uses
None of the individuals (Speakers, Moderators, Project Advisory Committee
members, or Staff) has disclosed that they intend to discuss or demonstrate
pharmaceuticals and/or medical devices that are not approved.
Refer to full AAP Disclosure Policy & Grid available below for
download.
This activity was funded through an educational
grant from the Physicians’ Foundation for Health
Systems Excellence.
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CME CREDIT
Live Webinar Only
The American Academy of Pediatrics (AAP) is accredited by the
Accreditation Council for Continuing Medical Education to provide
continuing medical education for physicians.
The AAP designates this educational activity for a maximum of 1.0 AMA
PRA Category 1 Credit™. Physicians should only claim credit
commensurate with the extent of their participation in the activity.
This activity is acceptable for up to 1.0 AAP credits. These credits can be
applied toward the AAP CME/CPD Award available to Fellows and
Candidate Members of the American Academy of Pediatrics.
OTHER CREDIT
Live Webinar Only
This program is approved for 1.0 NAPNAP contact hours of which 1.0
contain pharmacology (Rx) content per the National Association of
Pediatric Nurse Practitioners Continuing Education Guidelines.
The American Academy of Physician Assistants accepts AMA PRA Category
1 Credit(s)TM from organizations accredited by the ACCME.
Important Note:
You must have been pre-registered for this webinar in order to claim
CME or other credit for your participation.
Speaker:
Maria Etris, RN, BSN
Project Manager, Division of Patient Safety
Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio
Speaker:
Jason Olivea, MS, MPA
Quality Improvement Consultant
Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio
Speaker:
Christine White, MD, MAT
Pediatric Chief Resident
Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio
LEARNING OBJECTIVES
Upon completion of the webinar, participants will be able to:
• Cite the requirements of medication reconciliation and
one hospital’s compliance prior to implementing
improvement strategies.
• Describe improvement strategies that were tested and
implemented to achieve success with completing
medication reconciliation within 24 hours of admission.
• Apply improvement strategies to sustain success with
medication reconciliation compliance.
Achieving Compliance with Medication
Reconciliation Utilizing Improvement Methods
Safer Health Care for Kids Webinar
July 1, 2008
Maria Etris, RN, BSN Project Manager, Patient Safety
Jason Olivea, MS, MPA Quality Improvement Consultant
Christine White, MD, MAT, Pediatric Chief Resident
Medication Reconciliation
Endorsed as a Safe Practice throughout the nation.
Medication Reconciliation & The Joint Commission…
2005: “New” National Patient Safety Goal with 1 year
phase in period to be implemented by January ’ 06
Included:
 Creating the Medication List
 Reconciling the list at admission, transitions in care, & at
discharge
 Providing list to family
2006: Many FAQ’s and varied interpretations of Goal
2007: Additional Expectation
 Provide list to next care provider
2008: No Change
% Reconciled
Week Ending
Median (% Reconciled)
5/11/2008 n=194
4/27/2008 n=204
4/13/2008 n=182
3/30/2008 n=181
3/16/2008 n=199
2007-08
Implementation
& Spread Phases
3/2/2008 n=218
60%
2/17/2008 n=213
2/3/2008 n=272
1/20/2008 n=214
1/6/2008 n=203
12/23/2007 n=179
12/9/2007 n=171
11/25/2007 n=160
11/11/2007 n=224
2007
Improvement
Phase
10/28/2007 n=186
10/14/2007 n=186
9/30/2007 n=204
9/16/2007 n=178
9/2/2007 n=179
8/19/2007 n=196
8/5/2007 n=186
7/22/2007 n=183
2006
7/8/2007 n=185
20%
6/24/2007 n=164
40%
6/10/2007 n=172
5/27/2007 n=175
5/13/2007 n=210
4/29/2007 n=209
4/15/2007 n=213
4/1/2007 n=168
3/18/2007 n=212
3/4/2007 n=236
2/18/2007 n=160
2/4/2007 n=210
1/21/2007 n=214
1/7/2007 n=270
% of patients
CCHMC’s Historical Performance with Medication Reconciliation
Medical Services
Inpatient Medication Reconciliation Compliance Upon Admission
100%
80%
2008
Sustainability
Phase
Baseline
0%
Chartering our Improvement Team
I.
II.
III.
IV.
Team Name: Inpatient Medical Services Medication Reconciliation Team
(Steering & Improvement Teams)
Date we started & Median Performance: 12/06 & 60%
Date we finished & Median Performance: 1/08 & 94%
Keys for Team Successes:




V.
Have the right people at the table
Well defined project & start small
Pick an area where you have buy-in with support & commitment to testing
Pick an area where you can see & measure the change
Project Constraints:



Technical availability (Currently, Information Services focus is on EPIC,
questions surround the ability to provide timely enhancements to MRT.)
Resources for data collection at Admission & Discharge.
Multiple Medication Reconciliation Tools are being utilized (i.e. paper &
electronic versions)
Medication Reconciliation Steering Team
Purpose of Team:
(a) To provide strategic Direction & Feedback (b) To receive
monthly Updates from the Improvement Team (C) Assist in removing organizational
Barriers.
Team Members:
Uma Kotagal:
William Kent:
Michael Farrell:
Cheryl Hoying:
Peter Clayton:
Andy Spooner:
Lori Mackey:
MaryAnn Morris:
Sr. VP Quality Transformation
Sr. VP Patient Care
Chief of Staff
Sr. VP of Patient Services
VP of Surgical Services
Chief Information Officer
VP CHRF
Sr. Director of Accredation
Frequency of Meetings: Monthly
Medication Reconciliation Improvement Team
Purpose of the Team:
Utilization of Improvement Science Methodologies to achieve
90%> Compliance re: Admission Medication Reconciliation for Inpatient Medical Services
(AIM).
Team Members:
Cherly Braumbaugh:
Donna Tinker:
Amanda Carver:
Rafael Mena
Maria Etris:
Jason Olivea:
Christine White
Frequency of Team Meetings:
APN
Clinical Manager
RN
Resident Physician
Project Manager
Quality Improvement Consultant
Chief Resident
Bi-Weekly
January 2007
Where we started Heading…….
The Utilization of Improvement Science Methodology
• A different way of thinking- What Are We Trying
to Accomplish & How Will We Know?
• Focus on Improving the System and not simply
ensuring compliance
• Pt. Safety Focus not simply a Joint Commission
requirement
What are we trying to accomplish?
What changes can we make that will result in improvement?
How will we know that a change is an improvement?
Plan
Do
Act
Study
The Improvement Approach
It all Starts at the Top
• Organizational Support and Leadership
– Cabinet Support (Steering Committee)
– Cabinet Physician Champion
• Strategic Improvement Priority
• Quarterly Scorecard
Strategic Priorities Quarterly Score Card
CSI Inpatient Unit Level Quarterly Quality
Dashboard
PROJECT MANAGEMENT PHASES
1.0
Define
Project
(D)
2.0
Measure
Current
State
(M)
3.0
Analyze
Current
State
(A)
4.0
Plan, Do,
Study, Act
Cycles
(P)
5.0
Implement
Improvement
(I)
6.0
Spread
Improvements
(S)
7.0
Sustain
Improvement
(S)
DEFINE PHASE: To Identify Problem Area, Scope of Project, Charter Team
What is the problem?
1.0
Define
Project
(D)
What are we trying to accomplish (i.e. AIM)?
What were the initial Key Drivers to achieve success?
What does the Process look like?
Potential Medication Reconciliation Areas
Requiring Improvement
• Inpatient Admission
1.1
Define
The
Problem
Area to
Focus On
– Creating the List
– Reconciling the List
•
•
•
•
•
Inpatient Discharge
Outpatient Admission
Outpatient Discharge
Available to Parents
Available to Next Care provider
Why Selected?
Develop a S.M.A.R.T AIM for the Project
1.2
What are we
trying to
Accomplish?
S = Specific
M= Measurable
A = Actionable
R = Relevant
T = Timebound
To increase from 57% to 90% (which
includes sustained process stability) for
Inpatient Medical Services
Medication Reconciliation Upon
Admission by 12/31/07.
(% Weekly Performance on Run
Chart)
Identify Key Drivers
1.3
Key Drivers:
Identified components
of the system or
process that are
vital to
Achieving the AIM
• Sr. Physician & Nurse Leadership support.
• An effective/efficient means to capture pt.
medications for reconciliation.
• Make each defined Clinical Area
Performance Highly Visible
• High Reliability Med. Rec. Prescriber
Practices
• Prioritize & standardize Updater Work Flow
• Up to Date Prescriber & Updater Knowledge
of requirements
1.4
Key Driver
Diagram
CCHMC Inpatient Medical Services Medication Reconciliation KEY DRIVER Diagram
KEY DRIVERS
Sr. Physician & Nurse
Leadership’s to support &
sustain a Culture of Safety
AIM
To increase from 57% to
90%> & sustain process
stability at 90%> for
Inpatient Medical Services
Medication Reconciliation
Upon Admissions
by 12/31/07.
(% of Weekly Compliance
via Run Chart)
An effective/efficient means to
capture patient medications for
reconciliation
Make each MicroSystem’s
performance Highly visible
High Reliability Med. Rec.
Presriber practices
Prioritized & standardize Updater
work flow
Prescriber & Updater knowledge of
1. Med. Rec. expectations
2. Med. Rec. Tool enhancements
3. Process Re-Design
Medical Inpatient Medication Reconciliation Process
Wednesday, December 12, 2007
Pt. Admitted
Prescriber
Completes
Medication
Reconciliation
Nurse Updates
Medication List
(20minute goal)
Presriber Selects
Yes
Prescriber Writes
Orders in ICIS and
sees prompt
Presriber Selects
No
Prompt Remains
in ICIS
Presriber Selects
Done
Prompt
disappears in ICIS
1.5
What does
the
Process
look like?
Pt Ready for
Discharge
Medication List
Reconciled via
Discharge
Summary
MD signs
Discharge
Summary
Prompt
disappears in ICIS
Prompt with
Checkbox to
Confirm
Medication List is
Complete for
Needed Home
Medications
Yes
AM Rounds
Orders Reviewed
New Orders
Written
MD looks for
Prompt
Is Prompt
Present?
No
Medication List
Given to Patient/
Family
Assumed
Medication
Reconciliation
Complete
Discharge
Summary Faxed
to PCP (includes
Medications)
Medication
Reconciliation
NOT complete.
Delegated to be
done by 1pm
Process Ends
Focus of Improvement Team’s Work
Page 1
MEASUREMENT PHASE: To gather data to build a quantified (data driven)
understanding of the current state of the process.
• Operationally define measures
2.0
Measure
Current
State
(M)
• How we used to use and share data
• Determine Baseline Data via Run Chart
• Develop Additional Charts as needed
(i.e. Sustain/Process Stability)
Medication Reconciliation
Operational Definition of Measures
Operational Definition
MEASUREMENT: Percent compliant with medication reconciliation upon inpatient
admission
I. Description and Rationale
This measure answers the question:
What percentage of inpatient admissions have completed medication reconciliation within
24 hours of being admitted?
It is measured as percent of inpatient admissions with a length of stay greater than 23
hours that have medication reconciliation updated in ICIS by a nurse and verified by a
physician within 24 hours of being admitted.
II. Population Definition
All inpatient admissions with a length of stay greater than 23 hours
2.1
Operational
Definition
Re: Med. Rec.
III. Data Source(s)
Numerator: The medication reconciliation reports created by IS from ICIS found on the
medication reconciliation tab of Clinical Links
Denominator: A daily report compiled from KIDS and saved on Report.Web
IV. Sampling and Data Collection Plan
Census of all inpatients with a length of stay greater than 23 hours.
V. Calculation
Numerator: Number of inpatients meeting above population having medication
reconciliation documented in ICIS by a nurse and verified by a physician within 24 hours
of admission.
Denominator: All inpatient with a length of stay greater than 23 hours
VI. Analysis Plan and Frequency of Reporting
Data is collected and reported weekly.
VII. Reporting Venues
 Weekly charts are available on the Pursuing Perfection intranet website under the
accreditation link
 Results are reported quarterly on the Inpatient CSI Dashboard.
% Updated by Nursing - Includes those Reconciled
% Reconciled
Week Ending
Median (% Reconciled)
5/11/2008 n=264
4/27/2008 n=289
4/13/2008 n=253
3/30/2008 n=251
3/16/2008 n=286
3/2/2008 n=290
2/17/2008 n=292
2/3/2008 n=348
1/20/2008 n=282
1/6/2008 n=257
12/23/2007 n=244
12/9/2007 n=246
11/25/2007 n=208
11/11/2007 n=305
10/28/2007 n=253
10/14/2007 n=244
9/30/2007 n=267
9/16/2007 n=252
9/2/2007 n=265
8/19/2007 n=289
8/5/2007 n=305
7/22/2007 n=270
7/8/2007 n=271
6/24/2007 n=256
6/10/2007 n=238
5/27/2007 n=246
5/13/2007 n=287
4/29/2007 n=279
4/15/2007 n=282
4/1/2007 n=245
3/18/2007 n=296
3/4/2007 n=316
2/18/2007 n=228
2/4/2007 n=295
1/21/2007 n=277
1/7/2007 n=324
2.2
Med. Rec.
Run Chart
% of patients
Inpatient Medication Reconciliation Compliance Upon Admission
100%
80%
60%
40%
20%
0%
% Reconciled
Average
UCL
Week Ending
LCL
5/11/2008 n=264
4/27/2008 n=289
4/13/2008 n=253
3/30/2008 n=251
3/16/2008 n=286
3/2/2008 n=290
2/17/2008 n=292
2/3/2008 n=348
1/20/2008 n=282
1/6/2008 n=257
12/23/2007 n=244
12/9/2007 n=246
11/25/2007 n=208
11/11/2007 n=305
10/28/2007 n=253
10/14/2007 n=244
9/30/2007 n=267
9/16/2007 n=252
9/2/2007 n=265
8/19/2007 n=289
8/5/2007 n=305
7/22/2007 n=270
7/8/2007 n=271
6/24/2007 n=256
6/10/2007 n=238
5/27/2007 n=246
5/13/2007 n=287
4/29/2007 n=279
4/15/2007 n=282
4/1/2007 n=245
3/18/2007 n=296
3/4/2007 n=316
2/18/2007 n=228
2/4/2007 n=295
1/21/2007 n=277
1/7/2007 n=324
% of patients
2.3
Med. Rec.
Control
Chart
Inpatient Medication Reconciliation Compliance Upon Admission
P-Chart
100%
80%
current control limits based on data from 8/26/07 1/6/08
60%
Very High Census
40%
20%
0%
ANALYZE PHASE: To assess & identify Contributing & Root Causes
associated with Problem Area Team is Focused on Improving
• Review Data & Assess for Process Stability
3.0
Analyze
Current
State
(A)
• Conduct Simplified Failure Mode Effects
Analysis
• Intense Reviews of Individual Failure
Modes (Ask 5 Why’s)
% Updated by Nursing - Includes those Reconciled
% Reconciled
Week Ending
Median (% Reconciled)
5/11/2008 n=264
4/27/2008 n=289
4/13/2008 n=253
3/30/2008 n=251
3/16/2008 n=286
3/2/2008 n=290
2/17/2008 n=292
2/3/2008 n=348
1/20/2008 n=282
1/6/2008 n=257
12/23/2007 n=244
12/9/2007 n=246
11/25/2007 n=208
11/11/2007 n=305
10/28/2007 n=253
10/14/2007 n=244
9/30/2007 n=267
9/16/2007 n=252
9/2/2007 n=265
8/19/2007 n=289
8/5/2007 n=305
20%
7/22/2007 n=270
% of patients
40%
7/8/2007 n=271
6/24/2007 n=256
6/10/2007 n=238
5/27/2007 n=246
5/13/2007 n=287
4/29/2007 n=279
4/15/2007 n=282
4/1/2007 n=245
3/18/2007 n=296
3/4/2007 n=316
2/18/2007 n=228
2/4/2007 n=295
1/21/2007 n=277
1/7/2007 n=324
3.1
Med. Rec.
Run Chart
Inpatient Medication Reconciliation Compliance Upon Admission
100%
80%
60%
1. What is the current
performance?
2. How much variability in the data
exists week to week?
0%
Simplified FMEA: High Level version of traditional FMEA
PLANNED IMPROVEMENTS
CURRENT
PROCESS
FAILURE MODES
3.2
Simplified
FMEA
Medication Reconciliation Admission Process- ‘Is MRT signed onto & patient accessed?’
a) Sr. Leadership to support and instill value of
MRT
Example of One Step
Within Med. Rec.
Process
b) Identify best place to write orders & do Med.
Rec. w/out distraction
c) MRT completed as part of ED/OR
Admissions process by ED/OR staff
d) Analyze physician workflow to determine if
alternative opportunities exists to complete
MRT
MRT signed
onto & patient
accessed
a) Create down
time paper MRT
Forms
Click Yes
a) Work with IS
to resolve content
sharing
User ID &
Password
a) Value of MRT tool vs. Perceived burden
a) Slowness of MRT
Software
a) Slowness of
MRT sign on
b) Not aware of recent enhancements
b) MRT software is down
b) Need to sign on
using multiple steps
(lack of content
sharing)
c) Lack of flexibility of MD to do MRT due to
workload
a) Work with IS to
resolve
Find patient
based upon
MR#
a) Multiple patient
identifiers to access
information (ie. ICIS
Pat. ID # & MRT
Pat. MR #)
d) Easy distractibility when utilizing MRT
e) RN Med. List not in MRT
Revision 3 - 2/14/05
Individual Failure Mode Identification
Inpatient Medical Services
Medication Reconciliation Bundle Compliance Reporting Tool
Unit/Dept Pt. Admitted: _______________________________________
Date Pt. Admitted: ________________
Time Pt. Admitted: ________________
Service Team: __________________________________
Shift Pt. Admitted:
 Day
 Evening
 Night
Medication Reconciliation Updated by Nursing
1. From the time the patient was admitted, how many minutes did
it take for the admitting nurse to update the Medication
Reconciliation Tool?
# of minutes: __________________
Medication Reconciliation Completed by Prescriber
2. Was the following components of the Med. Rec. BUNDLE
completed?
a. Did the admitting prescriber reconcile pts. medications?
b. Was the Blue Reminder Prompt used as designed?
3.3
Failure Mode
Reviews

Yes

No

Yes

No
c. Did the Sr. Resident ask if Medication Reconciliation was
completed on the pt. during ROUNDS?

Yes

No
d. Did the prescriber utilize the Resident Sign Out as a reminder
to reconcile pt. medications?

Yes

No

Yes

No

Yes

No
3. Cause Analysis (if NO to section 2 above, do WHY WHY till underlying issue(s) identified):
General Comments
IMPROVE PHASE: To identify, test, and select the right improvement
solutions.
4.0
Plan, Do,
Study, Act
Cycles
(P)
• What changes can we make that will
result in an improvement?
• Document Tests via PDSA Cycles
• Run Charts with Annotations of Changes
What changes will lead to improvement?
1.) Identify Senior MD & RN leader to champion
importance, expectations, resources of Medication
Reconciliation
4.1
Interventions
1.) Continue to work with IS to implement Enhancements
based upon physician feedback of Electronic
Medication Reconciliation Tool
2.) Work with IS to streamline access to Electronic
Medication Reconciliation Tool
3.) Work with IS to streamline Electronic Medication
Reconciliation Tool & DSS intergration
4.) Analyze MD work flow to determine if alternative
opportunities exist to complete Electronic Medication
Reconciliation Tool
1.) Post physician & nurse performance on
respective Units/Div. in Noon Conference Room
2.) Develop an E-Mail GROUP LIST to communicate
performance of respective staff & units to Div. Leaders
1.) ID & Mitigate during Rounds
2.) Built in reminders- Labels on Laptops (COW’s)
3.) Resident SignOut Application
1.) Rearrange Updater admission process for all admits.
1.)
2.)
3.)
4.)
5.)
CIS Updates
ELM Revision
New Resident Training
Unit Level Education Rolled out w/ CSI
Inpatient, Practice Council, Education Council Support
Document your learnings thru Plan Do Study
Act (PDSA) Cycles
4.2
PDSA
Cycles
-
Key Components for Documenting your PDSA:
State Objective of Test
Make Prediction
Outline the Execution of Test = PLAN
Document the Facts/Observations of Test = DO
Assess your Results vs. Prediction & Document what
was learned = STUDY
Determine if you Adopt, Adapt, or Abandon = ACT
Example of a PDSA CYCLE
Med. Rec. & Phamracy
To determine if High Alert Medications have been reconciled & the length of time for the
pharmacy to validate that as well as contact MD’s with discrepancy.
Prediction That the pharmacy will not be able to conduct Med. Rec. due to lack of staff and the amount of
time it will take vs. have the actual prescriber do it on the floor.
Population Inpatient Units w/ High Alert Medications
TEST CYCLE 1
Start Date:
3-6-07
End Date:
3-20-07
Plan Brief Description of Test:
Objective
Every time for 3 high alert medications are ordered Pharmacy will check medication
reconciliation tool to see if reconciliation has occurred. If medication dose that is ordered is
different from that of admission the pharmacy will contact the prescriber to review the
discrepancy.
Do
The pharmacist will collect the data regarding how long it takes
Record data & observations:
To check if reconciliation occurred took on avg. of an additional 15 minutes per episode.
If there was an issue that the pharmacist need to contact the presriber to review the discrepancy
took an avg. of an additional 35 minutes per episode.
Study
Any observations which was not part of the plan?
Was test carried out as planned?
Yes
Results vs. prediction:
No
Yes
No
The results matched the prediction.
Act
What did we learn?
Due to multiple layers and systems that are used (MSTAT, Med. Rec. Electronic Tool, Paper)
reviewing took a large amount of time. The averages above demonstrate that pharmacy could
not sustain this practice for the hospital let along only specific medications. As a result, the
pharmacy could not complete Med Rec due to time and resources.
Adapt:
Adopt:
Abandon:
Follow Up on Failure ModesMaking changes
• Access from Order
Writing
• Pt context sharing
• Clarity of
Expectations
• Prompt Visible Until
Reconciliation
Complete
Optimize Application Functionality
• Clarity on Required
Fields
• Improved Error
Identification
• Hold, Resume, and
Confidential
Medication Changes
• Alphabetical Listings
• Improved Discharge
Summary Integration
• Developed Reporting
Functionality
Impact of Improvements in One Area (A7)
Inpatient Reconciliation Compliane on Admission 2007
A7
House
100%
90%
80%
70%
60%
First Weekly email
to PI Leaders
50%
40%
30%
Enhancement:Wording in ICIS
Changed
A7 PDSA w ith Medical
View History/No Home
Meds included in Audits
A7 PDSA all nurses
Enhancement: Confidential Meds
A7 First Round PDSAs
Enhancement: Hold,
Error Ease, DSS Prompt
A7 PDSA w ith Neuro
Team in Rounds
20%
10%
First Improvement Team and
Steering Team Meetings
6/
5/
20
07
5/
8/
20
07
5/
15
/2
00
7
5/
22
/2
00
7
5/
29
/2
00
7
5/
1/
20
07
4/
10
/2
00
7
4/
17
/2
00
7
4/
24
/2
00
7
4/
3/
20
07
3/
6/
20
07
3/
13
/2
00
7
3/
20
/2
00
7
3/
27
/2
00
7
0%
2/
20
/2
00
7
2/
27
/2
00
7
Compliant
4.3
Annotated
Run Charts
Via
PDSA
Cycles
20-Feb
28-Feb
3-Apr
14-May
6-Jun
11-Jun
A7
53%
65%
70%
80%
88%
95%
House
54%
57%
69%
75%
82%
80%
Week
100%
Compliance percentage
90%
80%
70%
60%
IS Enhancement:
Wording in ICIS Admit
Prompt Changed
50%
Wkly Compliance
Reports to LDRS
Meds A7 PDSA
IS Enhancement:
Confidential
40%
30%
20%
1st PI Team
& Steering
Team
Meetings
Med. Director
Alpha Page
PDSA
Salmon Color
Prompt PDSA
IS Enhancement:
Hold, Error Ease,
DSS Prompt
RN Alpha Page
phyisicans PDSA
Green Team
training bundle
Chief Engagement
Rounds PDSA
New
Resident
Training
View Hx/No Home Meds
now included as
Compliant in Audits
Pharmacy PDSA
on High Alert
Meds.
Official Roll out of Green
Team Bundle
Official roll out of
Yellow Team Bundle
10%
0%
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Week
Medical Services
Neuro Team
Green Team
Yellow Team
RCNIC
IMPLEMENTATION PHASE: To implement selected solution & design all
necessary Support Processes for success.
5.0
Implement
Improvement
(I)
• Use of Implementation Check List to ID
the following……
a. Process Owners
b. Hardwire Support Processes
c. Formal Education Roll Out
d. Communication Plans Developed
Process Owners
5.1
Process
Owners
• All Chief Resident are Meso-System
Process Owner (They cover all Service
Areas)
• Medical & Clinical Directors are MicroSystem Process Owners
Support Process
5.2
Support
Process
• Developed an Algorithm
• Tested & showed the ability of Unit
Medical Directors to mitigate failures
• Labeled all COW’s
• Provided Weekly Performance Reports
Formal Education Roll Out for Units
5.3
Education
Communication Plans
• Unit Level Leadership involvement & support
5.4
Communication
Plan
• Unit Level Education Coordinator involvement &
support
• Med. Rec. Posters put up throughout the Unit
• Worked through the Hospital’s Improvement
Structure & various Councils
SPREAD PHASE: To Spread the Changes that have led to an
improvement to all other areas that apply to the Scope of Project.
6.0
Spread
Improvements
(S)
• Use of IHI’s Spread Model
a. Work through each of the 3 Chiefs
b. Systematic with Spread Package
c. Intensive monitoring of data
d. Spread Education Plan
IHI’s Model for Spread
Spread Key Component Checklist



1.
Is this a strategic improvement priority? Yes, NPSG.
2.

3.
Is there a cabinet champion (or senior leader) who is responsible for the spread? All THREE
Chief Residents
Is there a credible leader identified who will create and manage the day-to-day spread activities?
Christine White along with 2 other Chiefs with Support from Maria Etris & Jason Olivea

4.








Is the improvement ready for spread? e.g. successful test ramp(s) Yes, see performance via
testing and chart
5. Are the target sites for spread identified? Yes via Service (see our Improvement Team Chart
Schedule)
6. Are the key stakeholders who make the adoption decision in the target site(s) defined and
aligned? Are there local, credible spread champions? Chief Residents and Attending/Fellows in
ICU’s. Clinical & Medical Directors are ID as spread champions.
7. Have the interventions been assessed for ease of adoption and methods identified to enhance
acceptance by the target site(s)? Yes
8. Are the specific change interventions clearly defined for spread? Have you identified what must
be standardized across all sites vs. what can be customized? Yes. (Example is in e-mail we
send to new Units who we are spreading to. Also we standardized the RN’s Updating in ICU’s.
9. Do you have a strategy and timeline to reach all sites? (change matrix) Yes. See our
Improvement Team’ Chart and Schedule).
10. Has a communication plan/strategy been developed to support your spread plan including key
messages, messengers, audiences, and methods? Yes. We have worked thru CSI and Councils
Structures..
11. Is there a sustainability plan that includes a measurement system to monitor performance and
feedback data to key process owners? Yes. Formalizing the final document/version.
12. Have critical infrastructure/system changes (support systems or support processes?) been
identified to ensure sustainability? Yes. Formalizing the final document/version.
Med. Rec. Spread Owners:
Chief Resident
6.1
Spread
Owners
Services/Teams
Med. Rec. Ownership
Dr. Christine White
Red, Blue, Purple, Green,
Orange, Neuro
Primary Owner for all of
Medication Reconciliation
Performance
Dr. Donna Claes
A5S, RCNIC, PICU, Heme/Onc
Secondary Owner
Dr. Brad Sobolewski
Cardiology, GI, Yellow
Secondary Owner
6.2
Systematic
&
Monitoring
Of
Spread
Formal Education Roll Out for Units
Medication Reconciliation Improvement Team
Medical Inpatient Admission Bundle
Thursday, September 06, 2007
AIM: To SPREAD Med. Rec. Bundle for all Medical Services to all
Inpatient Units by Jan. 2008
(% of Inpatient Unit spread to performing at 90%&<)
14 Units Total
Workflow/ Process
Preparation/Awareness
6.3
Education







Nursing Awareness
CSI
NPC
Nursing Education Council
Unit Directors
Prescriber Awareness
Chiefs
Resident Team Meetings
Rounding Service Leaders
Monitor/ Follow Up
RN complete Medication List within
20 minutes of patient arrival/ admission




Weekly Compliance Reports
Daily Failure Identification
Microsystem Process Owners
Mesosystem Process Owners
Prescriber completes Medication
Reconciliation as part of admission
process



Reminders
ICIS Prompt
Rounds
Resident Sign Out Tool
Page 1
SUSTAIN PHASE: To sustain improvement & ensure stability.
7.0
Sustain
Improvement
(S)
• Weekly Posting of Performance Reviews
• Algorithm to guide Process Owners
• Making System Visible- Performance Poster in
Resident Noon Conference Room
• On-Going Education Plan
Weekly Updates
7.1
Weekly
Updates
% Reconciled
Week Ending
Median (% Reconciled)
5/11/2008 n=194
4/27/2008 n=204
4/13/2008 n=182
3/30/2008 n=181
3/16/2008 n=199
3/2/2008 n=218
2/17/2008 n=213
2/3/2008 n=272
1/20/2008 n=214
1/6/2008 n=203
12/23/2007 n=179
12/9/2007 n=171
11/25/2007 n=160
11/11/2007 n=224
10/28/2007 n=186
10/14/2007 n=186
9/30/2007 n=204
9/16/2007 n=178
9/2/2007 n=179
8/19/2007 n=196
8/5/2007 n=186
7/22/2007 n=183
7/8/2007 n=185
6/24/2007 n=164
6/10/2007 n=172
5/27/2007 n=175
5/13/2007 n=210
4/29/2007 n=209
4/15/2007 n=213
4/1/2007 n=168
3/18/2007 n=212
3/4/2007 n=236
2/18/2007 n=160
2/4/2007 n=210
1/21/2007 n=214
1/7/2007 n=270
% of patients
Medical Services
Inpatient Medication Reconciliation Compliance Upon Admission
100%
80%
60%
40%
20%
0%
Inpatient Medical Services Admit Medication Reconciliation
Compliance Process Map
Version 4, 12/22/2007
Chief Resident
(Mesosystem
Process Owner)
Weekly
Performance
Reviews of
Services by Chief
Document & Track
Team Compliance
Weekly on Poster
in Conference
Room
Is Service compliance at
90%?
Yes
Celebrate
sustained success
& ID Lessons
Learned
No
7.2
Algorithm
For
Process
Owners
1. Discuss in Noon Conference
2. Email Nofitication to:
a. All resident members of team
b. CC associated service process owners for
awareness & support.
Yes
Has Service compliance
been <85% for 2
consecutive weeks?
No
1. Re-peat Steps for 2 Week Non-Compliance.
2. Assign Sr. Resident on Team to do daily ID &
Mitigate on Failures, implement corrections, &
report back to Chief.
3. Dr. Javier Gonzalez aware
Yes
Has Service compliance
been <85% for 3
consecutive weeks?
No
1. Repeat Steps for 2 and 3 Week Non
Compliance.
2. Involve CSI Inpatient Microsystem Leaders in
ID& Mitigate Process.
Yes
Has Service compliance
been <85% for 4
consecutive weeks?
Process Ends
Ex: of Ownership & use of Algorithm for Sustain
7.3
Poster for
Resident
Noon
Conf. Rm
Resident Noon Conference Room
On-Going Education Plan
Annual Training of New Resident Physicians7.4
On-Going
Education
Plan
New Resident Training will be done by a Project Manager for
Patient Safety or CIS Ed team in the Spring of each year. It
will include: (1) review of the application (2) the expectations
Annual Training of New FellowsFellow Training will be done by a Project Manager for Patient
Safety or CIS Ed team in the Spring of each year. It will
include: (1) review of the application (2) the expectations
Training for new RN’s- Incorporated into Patient Services
Orientation
% Reconciled
Week Ending
Median (% Reconciled)
5/11/2008 n=194
4/27/2008 n=204
4/13/2008 n=182
3/30/2008 n=181
3/16/2008 n=199
3/2/2008 n=218
2/17/2008 n=213
2/3/2008 n=272
1/20/2008 n=214
1/6/2008 n=203
12/23/2007 n=179
12/9/2007 n=171
11/25/2007 n=160
11/11/2007 n=224
10/28/2007 n=186
10/14/2007 n=186
9/30/2007 n=204
9/16/2007 n=178
9/2/2007 n=179
8/19/2007 n=196
8/5/2007 n=186
7/22/2007 n=183
7/8/2007 n=185
6/24/2007 n=164
6/10/2007 n=172
5/27/2007 n=175
5/13/2007 n=210
4/29/2007 n=209
4/15/2007 n=213
4/1/2007 n=168
3/18/2007 n=212
3/4/2007 n=236
2/18/2007 n=160
2/4/2007 n=210
1/21/2007 n=214
1/7/2007 n=270
% of patients
Have We Sustained Success Our?
Medical Services
Inpatient Medication Reconciliation Compliance Upon Admission
100%
80%
60%
YES!
40%
20%
0%
New Med. Rec. Team launched:
“Inpatient Surgical Services”
• We have carried over many lessons learned from the
previous Project which include:
 Strong phyisican leadership up front
 Understanding of process variability & performance prior to launch
of new team
 Daily PDSA cycle testing
 More aggressive with ensuring the right people are at the table
As a result of the above, this new team has been chartered
to complete its work in 90 Days.
“Summary”
• Front line nurses & physicians aligned/involved
• Make the system visible
• Effective utilization of Improvement Science
Methodology
• Committed Process Owners w/ support
processes
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