Transcript MedRec in a Pre-Admission Clinic

MEDICATION RECONCILIATION
in a Pre-Admission Clinic
CRITICAL SUCCESS FACTORS
Cynthia Turner, B. Pharm, R.Ph.
Medication Reconciliation
Pharmacist
Vancouver Island Health Authority
(VIHA)
1
What It Takes To Produce
Successful Results
At the end of this presentation:
•
IF you are looking for ideas to improve your
results
• THEN complete the checklist to guide
where your team might need to focus their
continuous improvement efforts
2
VIHA
• Serving all of Vancouver Island,
British Columbia, population 730,000
• 15 acute care hospitals
• 1461 acute care beds
• 4760 long term care beds
Royal Jubilee Hospital
3
Med Rec Process Overview
• See Same Day Surgical Admission pts.,
Royal Jubilee Hospital
• In Pre-Admission Clinic (PAC)
• Document BPMH
• Use multiple sources of medication
information
• Involves Multidisciplinary Team
• Reconcile meds on wards
< 24h post-op
4
The Results tell the Story
• Implemented: Aug 06 – 1 ward
• Now – 4 surgical wards involved
Our Results are:
• Sustainable [month to month]
• Reproducible [ward to ward]
• Consistently  goal
• Consistently  national average
5
Royal 2; 1st ward – Sustainability
Unintentional Discrepancies
0.60
0.50
Med Rec
Pharmacist
0.43
Baseline
measurement
= 1 med discrepancy for
every 2.3 pts .
0.30
0.35
Goal within 1 year
(decrease baseline by 75%)
= 0.11
= 1 med discrepancy in 9 pts.
0.20
0.20
0.11
0.10
0.20
0.10
0.09
0
Sample size small
Discrepancies occurred
over weekend
0 discrepancies in 19 pts.
0
0
0
0
0
0
0
5
20
Fe 06
b
20
0
M
ar 6
20
Ap 06
r2
M 006
ay
2
Ju 006
n
20
Ju 06
l2
0
Au 06
g
2
Se 00
p 6
20
O 06
ct
2
N 006
ov
2
D 006
ec
20
Ja 06
n
2
Fe 007
b
20
0
M
ar 7
20
Ap 07
r2
M 007
ay
2
Ju 007
n
20
Ju 07
l2
0
Au 07
g
2
Se 00
p 7
20
O 07
ct
2
N 007
ov
2
D 00
ec 7
20
Ja 07
n
2
Fe 008
b
20
0
M
ar 8
20
Ap 08
r2
M 008
ay
2
Ju 008
n
20
08
Ja
n
20
0
ec
D
ov
20
0
5
0.00
N
Mean
0.40
Month
Actual
Goal
6
West 3; 3rd ward - Reproducibility
Unintentional Discrepancies
1.00
0.90
0.90
0.80
0.70
Baseline Measurement
= 1 med discrepancy for every 1.1 pts.
0.50
Med Rec Pharmacist
Goal within 1 year
= 0.23 (decrease baseline by 75%)
= 1 med discrepancy for every 4.3 pts.
0.40
8 med discrepancies in 35
pts.
(new orthopaedic
surgeons started)
0.30
0.23
0.20
0.11
0.10
0
0.04 0.04
0.02
0
0.07
0.03
0.02
1 med discrepancy in 51 pts.
(new orthopedic surgeons
now educated in Med Rec
process
5
20
Fe 06
b
20
0
M
ar 6
20
Ap 06
r2
M 006
ay
2
Ju 006
n
20
Ju 06
l2
Au 006
g
2
Se 006
p
20
O 06
ct
2
N 006
ov
2
D 006
ec
20
Ja 06
n
2
Fe 007
b
20
0
M
ar 7
2
Ap 007
r2
M 007
ay
2
Ju 007
n
20
Ju 07
l2
0
Au 07
g
2
Se 007
p
20
O 07
ct
2
N 007
ov
2
D 007
ec
20
Ja 07
n
2
Fe 008
b
20
0
M
ar 8
2
Ap 008
r2
M 008
ay
2
Ju 008
n
20
08
Ja
n
20
0
ec
D
ov
20
0
5
0.00
N
Mean
0.60
Month
Actual
Goal
7
No
v0
De 5
c05
Ja
n0
Fe 6
b06
M
ar
-0
6
Ap
r- 0
M 6
ay
-0
6
Ju
n06
Ju
l-0
6
Au
g0
Se 6
p06
O
ct
-0
6
No
v06
De
c06
Ja
n0
Fe 7
b07
M
ar
-0
7
Ap
r- 0
M 7
ay
-0
7
Ju
n07
Ju
l-0
7
Au
g0
Se 7
p07
O
ct
-0
7
No
v07
De
c07
Ja
n08
Fe
b08
M
ar
-0
8
Ap
r- 0
M 8
ay
-0
8
Ju
n08
Mean Number of Unintentional Discrepancies per Patient
Unintentional Discrepancies
Local Teams better than National average
2.00
1.50
Baseline Average
R2/R3/W3
= 0.95
1.00
0.50
Average of all 3 RJH
wards: R2+R3+W3
0.01 - 0.14
0.00
Local Team
Month
National
8
Unintentional Discrepancies
1.6
“Then and Now” – < Target Goal
Number per patient
1.31
1.2
0.9
0.8
0.43
0.4
0.02
0.018
0.02
0
Royal 2
Royal 3
Baseline
West 3
2007 Impact of MedRec Pharmacist
9
Med Rec Steering Group
• Bob Clark - Executive Director, Pharmacy, Diagnostic & Surgical
Services
• Dr. Con Rusnak - Executive Medical Director, Pharmacy, Diag. &
Surgical Services
• Leslie Moss - Executive Director, Quality & Patient Safety
• Michele Babich - Director of Pharmacy
• David McCoy – Director, Post-Surgical Care Programs
• Dr. Richard Bachand – Manager, Clinical Pharmacy Services
• Ev Pearce – Manager, Quality and Safety
• Andrea Bentley – Manager, Booking and Pre-Admission
10
Team Members
•
•
•
•
•
•
•
•
•
•
•
•
Cynthia Turner - Medication Reconciliation Pharmacist
Lori Brodie - Facilitator
Alyse Capron - Quality Improvement Consultant
Dr. Hans Cunningham - Chief of Surgery; Surgical Services
Sarah Crawford - Clinical Nurse Leader, Royal 2
Robyne Maxwell - Clinical Nurse Educator, Royal 2/Royal 3, BU
Andrea Taylor - Clinical Nurse Leader, Royal 3
Kristie Waterman – Clinical Nurse Leader, West 3
Marian Chalifoux - Clinical Nurse Educator, West 3
Rhonda Porter - Clinical Nurse Leader, Surgical Daycare
Claire Fisher - RN, Pre-Admission Clinic
Dr. Richard Bachand - Manager, Clinical Pharmacy Services
11
CRITICAL SUCCESS FACTORS
1.
2.
3.
4.
5.
Documentation
Communication
Education
Program Sustainability
Spread Mentor
12
CRITICAL SUCCESS FACTORS
1. Documentation
a) Build in process to double check
BPMH
b) BPMH same place in chart every time
c) Accuracy of medication information
TRUST is KEY
13
1. Documentation
a) Build in process to double check
BPMH
 if BPMH not used right away
 keeps info. current
 our process: SDC Nurse notifies both
Physician and Med Rec Pharmacist
of med. changes
14
1. Documentation
b) BPMH in same place in chart every
time
 Ensure the physician can find the BPMH
 Process to alert physicians to presence
of BPMH
 Reminder notice where
to find
 Form in Physician Order section of chart
REMINDER
Please Complete Home
Medication Reconciliation
Physician Order Form
PDSA cycles
15
1. Documentation
c) Accuracy of BPMH
Use multiple sources of info.
 Family Physician History
 Patient Clinic Questionnaire
 B.C. PharmaNet profile (14 mos)
 Pt. Interview
~ 100%
16
Case Study
NEW PROCESS: Pharmacist involved
BPMH
Family
Physician
Patient Clinic
Questionnaire
B.C.
Pharma-Net
Profile
Patient
Interview
500 mg tid
500 mg tid
500 mg tid
500 mg tid
Ramipril
2.5 mg daily
2.5 mg daily
5 mg daily
2.5 mg daily
Atorvastatin
10 mg daily
20 mg daily
10 mg daily
10 mg daily
Pantoprazole
40 mg daily
40 mg daily
?
40 mg daily
10 mg tid
?
10 mg tid
10 mg tid
Magic m/wash
?
20 mL tid
20 mL tid
20 mL tid
Oxycontin
?
?
30 mg q12h
30 mg q12h
Home
Medication List
Metformin
Metoclopramide
Source Accuracy:
68%
79%
76%
100 %
(Based on 49 pt.)
17
Intro. Med Rec Form:
BPMH documentation/Rx
at present – Draft 21
Physicians
Order Form
Home Medication Reconciliation
PDSA Cycle #2
To
identify Form as an
Order
PHYSICIAN INSTRUCTIONS


Please approve the following medications taken at home for continuation in the hospital by ticking the appropriate boxes
marked YES, NO or CHANGE. If YES, NO or CHANGE is not ticked, the medication(s) will NOT be processed until an
order has been received. If changed please complete the physician order at the bottom of this form, including reason for change
Signature /date of Physician or Read-back Telephone Order by nurse are required to process
HOME MEDICATION PROFILE:
PRESCRIPTION and Select
Over the Counter Medications
Dose
Route
Frequency
(Pharmacist to complete)
Date &Time Continue on Admission Already
of Last Dose  Yes / No / Change (MRP) Ordered

(SDC Nurse
CHANGE
YES
No
(MRN)
with initials)
Order below
1.
PDSA Cycle #5
To clearly define
area of
responsibility
on Form
2.
3.
PDSA Cycle #3
To
focus Physician to their
area
(yellow
highlighting)
4.
5.
6.
7.
8.
9.
Please complete ALL pages
PDSA Cycle #4
To eliminate SDC
Nurses from
documenting
medications on Form
(new process)
FORM COMPLETED BY:
Page _____ of _____
AUTHORIZING PHYSICIAN
___________________________
Pharmacist Signature
___________________
Time/Date
______________________________________
Physician Signature (or Read-back Telephone Order)
______________
Time/Date
PHYSICIAN ORDER for changed home medication (if CHANGE box ticked above)
Date
Medication
Dose
Route
Frequency
(Do Not Use “Unsafe
Abbreviations”- see reverse)
Reason for change
_________________________________________________
Physician Signature (or Read-back Telephone Order)
Draft 21
Dr. R Bachand
Please FAX Completed Form to Pharmacy
Use FAX Stamp
1
18
18
Documentation Summary
TRUST IS KEY!!!



Physicians, nurses, pharmacists all
need to TRUST the documentation
is accurate
At our site – becomes a Physician
Order
Time saving step for multidisciplinary
team
19
CRITICAL SUCCESS FACTORS
2. Communication
a) Speak language of audience
b) Preparation and Follow-up are
critical
c) Show-off your results
BIGGER THAN 1ST THOUGHT
20
2. Communication
a) Speak language of audience
Two examples
• IMPACT of program on  patient
safety
• IMPACT of program on patient
admissions
21
OVERVIEW of
Unintentional Discrepancies
• 6 month review
615 patients (3570 meds reconciled)
• BASELINE PREDICTION: 615
• WHAT REALLY HAPPENED WITH
MED REC?
24
• DIFFERENCE = potential avoided
discrepancies:
591
22
Impact of Process at RJH
ALL Admissions
Jan to Jun 2007
Med Rec
Process
8%
Non Med Rec
92 %
23
Impact of Process at RJH
Non-Emergency admissions
Jan to Jun 2007
Med Rec
Process
18%
Non Med Rec
82%
24
2. Communication
b) Preparation and follow-up is
critical
Before: Attend physician meetings,
nurse staff meetings etc.
After: Ensure everyone is
performing their role
- problems occur with new
residents, physicians, nurses etc.
25
2. Communication
c) Show-off your results
- Before & after measures on wards
- Poster in Senior Executive area
- Display in cafeteria, newsletter etc.
26
Communication examples
Patients:
• Brochure
• Fine tuned questions
Pharmacy:
• UBC presentation
• RJH/VGH/Aberdeen
• 3-5 days training
• Students rotate in
Senior Team:
• Poster
• VIHA Board “Big Dot”
Nurses:
• Cafeteria Day/Newsletter
• Monthly staff meetings
• Muffin “thank you” day
Physicians:
• Surgical Executive
• Presentations
• Chief of Surgery
• Dept. meetings
Training Video
27
CRITICAL SUCCESS FACTORS
3. Education
a) On-going – new staff, new
processes
b) Standardize material
e.g. ward package,
educational video etc.
c) Make use of educational moments
28
CRITICAL SUCCESS FACTORS
4. Program Sustainability
a) Program still functions when key
personnel away
b) People seek you out to be included
c) Use FACTS to sell program
29
… one person needs time off
30
CRITICAL SUCCESS FACTORS
5. Spread Mentor
•
•
•
•
•
Med Rec = part of VIHA Strategic Plan
VGH Pre-Admission Clinic
Residential Long Term Care
Dialysis/renal pts.
Pediatric ward
Total Joint Clinic
TRUST is KEY
31
Med Rec – Critical Success Factors Checklist
Would you like to improve your team’s Med Rec measures?
Are your measures:
q Sustainable (month to month)
q Reproducible as you spread to other areas
q Meeting or beating your goal targets
q Showing better results than the National Average?
If you do not answer “Yes” in the above four boxes, then this checklist might offer guidance as to where to focus
your continuous improvement efforts.
Any tick in a “NO” box below indicates where improvements in this area
may improve your Med Rec measures.
Area
D
O
C
U
M
E
N
T
A
T
I
O
N
Success Factor
Yes
No
IF there is a delay between recording the BPMH and when the physician orders home
medications, is there a process of review of medications on Best Possible Medication History
(BPMH)?
If there is a delay, has our team built in processes to double-check information entered on the
BPMH?
Is there a consistent location where the BPMH is placed on the patient’s chart?
Is there a method of alerting physicians that a BPMH is used on a patient’s chart?
Does our team use the maximum number of available medication information sources to create
the BPMH (family physician, patient questionnaire, PharmaNet profile, patient interview)?
Do stakeholders TRUST that the medications on the BPMH represent an accurate and
complete list at the time of documentation?
32
Med Rec – Critical Success Factors Checklist
Page 2
Area
C
O
M
M
U
N
I
C
A
T
I
O
N
Success Factor
Yes
No
Can we present our data in a more user-friendly format for the average layperson?
Does our team “speak the language of the audience” when sharing information? (e.g. senior
team, physicians, patients)
Have we demonstrated the impact our process is making to the rest of our organization?
Do we have a process for informing nurses and physicians about the medication reconciliation
process BEFORE implementation in their area?
Do we have a process of follow-up AFTER the physician has ordered the home medications?
Do we have a process for informing new residents, physicians and/or nurses of the Med Rec
process?
Have we displayed our results in a public way? e.g. poster to senior exec, newsletters, on wards
33
Med Rec – Critical Success Factors Checklist
Page 3
Area
E
D
U
C
A
T
I
O
N
S
U
S
T
A
I
N
A
B
I
L
I
T
Y
SPREAD
MENTOR
Success Factor
Yes
No
Have we standardized the material we use to educate people about this process?
Do we have a formal process of providing the education? (Attend physician meetings,
staff meetings etc.)
Do we have an informal process of providing education – to either “catch them in the
act of good performance” or redirect their efforts to the intended process?
Have we created any training material that can be used by multiple users e.g. web
info, video etc.
Do our basic processes still function when key personnel are away?
Do we use small tests of change (PDSA cycles) to trial our change processes?
Do physicians ask to be included in your Med Rec processes?
Does Senior Management enthusiastically support our program?
Does your team act as a SPREAD MENTOR – sharing processes, tips for successes,
documentation with other med rec teams?
34
Contact Information
• Cynthia Turner, Med Rec Pharmacist
[email protected]
• Lori Brodie, Facilitator
[email protected]
• Richard Bachand
Manager, Clinical Pharmacy Services
[email protected]
35