Transcript March 25 09 Institution Wide Med Rec Slides Mar 23

Coordinating Institution Wide Implementation of
Medication Reconciliation:
Tips, Strategies & Lessons Learned
March 25, 2009
Safer Health Care Now! National Webinar / Teleconference
Olavo Fernandes PharmD, FCSHP
Pharmacy Clinical Site Leader, University Health Network
Assistant Professor, Univ of Toronto and Safety Specialist, ISMP Canada
Interdisciplinary Members of UHN Medication Reconciliation Task Force
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Image: green.gps.caltech.edu/pictures_images/GreenTree.jpg
What has your medication reconciliation
implementation journey in your ER
been like ?
OR
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Objectives
1.
2.
3.
Highlight strategies for overcoming challenges to
successfully implement medication reconciliation at
various interfaces
Share coordination tips/ lessons learned to prepare
your organization to meet medication reconciliation
requirements
Outline the key elements of an organizational
communication plan and clinician/ leadership
resource package for medication reconciliation
3
How do we Navigate the Challenges of
Effectively Meeting Accreditation
Requirements for Medication
Reconciliation ?
4
How do we actually “get started and sustain”
implementation?
Five Tips & Strategies
1.
2.
3.
4.
5.
People – Empowering Clinicians
Coordination
Communication
Leadership
Tools / Systems to Support the Clinicians
5
How do we actually “get started and sustain”
implementation?
Leadership
Coordination
Communication
People
Tools/ Systems
Five Tips & Strategies
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Challenges & Questions
• Who does the BPMH?
• Who does the reconciliation/ resolving the
discrepancies?
• Proactive vs. Reactive Multidisciplinary practice
models ?
– Proactive:
BPMH → admission orders (AMO) →reconciliation check
– Reactive/ Concurrent:
primary history → AMO →BPMH →reactive reconciliation
– Hybrid Systems
• Manual vs. Electronic Processes ?
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Structured Implementation & Rollout Plan
Step-wise Milestones for each Inpatient Clinical Area
1.
2.
3.
4.
5.
6.
7.
8.
ID stakeholders/ preliminary education
Formal education to unit/clinical area champions
Baseline admission reconciliation data collection
Creation of a team practice model
Finalize practice model – input from staff
Prescriber/ Nursing/ Pharmacist In-services
Start Front line implementation- Admission
reconciliation
Sustain as part of daily practice with ongoing
feedback and improvement
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Questions to Address As a Team
• Who?
– Who- in your local practice site, who responsible for BPMH?
Reconciliation? Shared responsibility? Who does what? (MD/
RN/ Phmt/ Technician/ Students)
– BPMH training: designated individuals or “organization-wide”
• How?
– How are medication histories currently being conducted?
Does med rec implementation involve building upon preexisting practice or a major shift in practice
• Where?
– Decide where the BPMH is documented (visible to all staff,
only useful if everyone knows where it is, can find it, can use
it).
– Will it be a pre-printed form/ computerized record/ clinical
notes?
S. Ingram BScPhm, ACPR, ED- TGH
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UHN Clinician Validation Program
• Interactive Learning/ Education Session
• Key Readings
• Standardized Patient Validation Program
–
–
–
–
Obtaining BPMH from a standardized patient–actor
Admission reconciliation to identify discrepancies
Coding of discrepancies
Interactive discussion on areas of strength /
improvement
Getting Started/ Focussed Limited Resources
Why is Medication Reconciliation so important
in the ED ?
• “Gateway” to acute care admission and transitions
in care
• “Opportunity” – ideally med rec performed as close
to arrival/ decision to admit
– Family / medication vials & lists optimally available
• “Efficiency” – upstream reconciliation/ resolution
improves safety/ saves times and resources
downstream to subsequent transitions
• “Shared Responsibility” – ED/ Admitting services;
all health care professionals – physicians, nurses,
pharmacists, allied health and patients
S. Ingram BScPhm, ACPR, ED- TGH/
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Synchronization Challenge of Discharge
Tools at Many Institutions
Patient Care
System
Patient
schedule
Discharge
Prescription
Manual
Dear
Dr
Letter
Electronic
EMITT
Letter
Patient
Wallet card
Electronic
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J. Wong BScPhm
Multidisciplinary Practice Model
MD
RX
RN
Challenges of Medication Discrepancies
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EMITT2: Schematic of Structured, Multidisciplinary
Integrated Medication Reconciliation Strategy
Primary
Medication
History: MD or
RN
ER
Ward
Admission
Reconciliation
BPMH:
Taken by pharmacist
BPMH
medical chart
note
Wong J. [Abstract] Pharmacotherapy 2006 ;26: 106
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Wong J. Annals of Pharmacotherapy 2008 (in press)
Medications may be altered:
new, adjusted, discontinued
Ward
Decision to discharge
patient
Best Possible
Medication
BPMDP
Discharge
Plan
Discharge
Reconciliation
Home
Electronically
Generated
Prescriptions
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Synchronized
Outputs
Medication
Information
Transfer Letter
3
Patient
Medication
Grid
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Patient
Medication
Wallet Card
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Physician
Discharge
Summary
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Medication Information Transfer Letter
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A. Cesta et al. Ann Pharmacother 2006;40:1074-81.
Medication Information Transfer Letter
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Horizontal : Patient Medication Grid
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Vertical : Patient Medication Grid
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Patient Wallet Card
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Safer Health Care Now! National Measure For
Discharge Medication Reconciliation
100
90
%eligible 80
patients 70
60
discharged
50
40
30
20
10
0
Team Target
80%
BPMDP (E-script
with discharge
reconciliation)
Manual Script
* Graph does not include
patients discharged without
prescriptions
Feb
Mar
Apr
TGH GIM
May
2007
* Sample Feb7 – May23
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n= 6976 Patient
Admissions
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CPOE-BASED
MED REC
PRACTICE
MODEL
 Baseline Data
Evaluation
 Literature Review
 Multidisciplinary
Feedback
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UHN Implementation & Rollout Plan
1. Admission Reconciliation
• Main priority for ALL inpatient areas
2. Transfer Reconciliation
3. Discharge Reconciliation
4. Ambulatory Clinics
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Organization Wide : Leadership and Clinician
Communication
Formal Training of Champions
•
Education/ learning session, required readings, standardized
patient validation/ certification training
Front-line education in-services:
•
nurses, medical residents, medical staff
Other communication tools:
-
Paper or electronic chart notification of reconciliation
status, promotional video testimonials, hospital intra-net
website, posters
Leadership presentations:
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Accreditation team lead meetings, site operations meetings/
leadership forum, business units, selected medical rounds,
multidisciplinary med rec task force
Board, Senior Management MAC, P&T, UHN Ops…..
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UHN Medication Reconciliation
Resource Package
Includes:
1. UHN Medical Staff Bulletin
2. UHN Organization Wide Roll Out Plan for
Inpatient and Ambulatory Areas
• Admission, Internal Transfer, Discharge,
Ambulatory Clinics
3. Step-wise implementation plan for each inpatient
ward (admission reconciliation)
4.
5.
Medication Reconciliation Fact Sheets
(accreditation ROPs and current overall status at
UHN)
Communication tools : poster, medication
reconciliation website on UHN intranet, link to
educational video
.....Continued Next Slide
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Hospital Internet Communication
Hospital Internet Communication (continued)
UHN Medication Reconciliation
Resource Package
Includes:
6.
7.
Patient Information on Medication Reconciliation
Screen Shots: EMITT (electronic medication information
transfer tool)
8. Sample documentation/ outputs: EMITT (electronic
medication information transfer tool)
• EPR Medication Reconciliation Status/ BPMH note
• Electronic reconciled discharge prescription, patient
medication schedule, wallet card, medication
information transfer letter
9. Clinician Tools:
• BPMH Tip sheet; Clinician BPMH Interview Guide
10. Prescriber/ Nursing In-service Presentation Slides
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How do we actually “get started and sustain”
implementation?
Leadership
Coordination
Communication
People
Tools/ Systems
Five Tips & Strategies
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Sample Tools in Guide
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Tools & Strategies on CoP
• BPMH guides/ trigger sheets
• BPMH Forms
• BPMH leading to admission order
forms
• Patient Risk Assessment / Scoring
• Instructional Videos
• Empowering patients as part of the
BPMH process
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Medication Reconciliation in the
Ambulatory Clinics
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ISMP Canada / O. Fernandes UHN
Ambulatory Clinic Medication Reconciliation
Meetings with Ambulatory Clinic Leaders/
Clinicians
• Review models/ tools already in place
• Most clinics do not have pharmacists- will
need to consider mainly nursing/ prescriber
based models
• Nephrology model – recently updated
•
•
Presented to UHN Med Rec Task Force &
Ambulatory Working Group for feedback
Recognition: different types of clinics (chronic
care, procedural, different health care
professional mix)
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Considerations: UHN Ambulatory Medication
Reconciliation Practice Model
Nurse
Clinic Chart
Med List
Client BPMH
on visit
Other
Healthcare
Professional
As
applicable
Phmt
• Discrepancies
identified
Tools:
• Review and follow
up where indicated
• Paper? (e.g. HD clinic
model)
Updated
Clinic Chart
Med List
• Electronic? (e.g. OTTR)
• Other?
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Practical Tips to Sustain Med Rec
Kim Streitenberger RN, The Hospital for Sick Children, Oct 2008
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2.
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6.
7.
Consider sustainability & spread from the moment you
start developing the med rec process in your pilot area
Consider change fatigue & competing local & corporate
initiatives
Embed intervention in existing processes e.g. med rec
form doubles as order form
Identify frontline med rec champions to provide direct
implementation support
Make it difficult for people to revert to “old ways” of
doing things
Provide visible leadership support
Share results with patients, families & staff
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Take Home Messages
• Consider Five Strategies for implementation
–
–
–
–
–
People- empowering clinicians
Coordination
Communication
Leadership
Tools & systems
• Involve all team members in developing processes
designed for everyday practice
• Incorporate tools, systems, clinician education
programs and strategies
• Use data and ongoing performance to drive and
inspire change
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More: Tips from Front Line
Clinicians:
• Develop a system/ practice where clinicians “could not imagine
going back to old practice”
• Physician engagement:
– Involve physicians right from the beginning in the planning process
– “buy in” vs. “ownership”
– Value added / Time saving – medication reconciliation engrained into
everyday practice
– Efficicincies : BPMH form that leads to MD orders
– Show the local patient safety impact in your ED (SHN data collection)
– Share your data regularly and visibly
• Site Visits- Successful Teams and Colleagues
– How are medication histories currently being conducted? Does med rec
implementation involve building upon pre-existing practice or a major
shift in practice
52 UHN
S. Ingram/ J. Volling/ O. Fernandes
More: Tips from Front Line
Clinicians:
• Involve Patients!
– patient satisfaction/ engagement
– enjoy/ empowered when they are participating in care ,
– instills confidence in their care); patient-friendly brochures,
posters and forms to document medications
• Know the limitations of your medication information sources/
systems?
– DPV viewer – insurance database- not actual patients doses and
frequencies
• Upstream ED reconciliation
– empowers admitting services to optimally perform discharge
reconciliation
– Synchronize/ coordinate with ward clinicians
• Make the best of what is already out there/ tested tools &
strategies:
– BPMH form to MD orders samples, pre-printed orders, BPMH
interview guides, education and training programs, in-services,
Posters & videos
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S. Ingram/ J. Volling/ O. Fernandes UHN
Questions
[email protected]
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