Transcript IHI Presentation Medication Reconciliation Project

Medication Reconciliation
at Hospital Admission
Using a Six Sigma Approach
OSF Saint Francis Medical Center
Peoria, Illinois
Howard Cohen MD
Patient Safety Officer
May 15, 2003
OSF Saint Francis Medical Center
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721 beds, 24 patient care units
Tertiary center with 425 physicians and 165 residents
– Level 1 Trauma Center
– Perinatal Center
– Pediatric Critical Care Center
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70 admissions/day
– 30 via ED
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Involved in several Medication Safety Collaboratives
In the midst of IDX rollout
Improve
Discharge
Medication
List
Admission List
Available throughout
hospitalization
Documentation
Collaboration
Involve Patients
Improve
Ambulatory
Medication
List
Improve
Admission
Medication
List
Understanding Medication Reconciliation
Include Rx from
All specialists
Include OTCs
Herbals
Initial Work in Corporate Patient
Safety Collaborative
July, 2001-February, 2002
 Focus across entire hospitalization
 Quantum Leaps Project Replication
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– “IHI” methodology
Issues
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Lack of understanding of what “reconciliation” means
Not sure how to measure
– Whether it happens
– How is it related to Adverse Drug Events?
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Broad scope
Use of the form
Administrative priorities not clear
Accountability
Evolution of 6 Sigma at OSF Saint
Francis Medical Center
Intensive Study of 6 Sigma
 SFMC-Caterpillar Partnership for 6 Sigma
 First projects identified in February, 2002
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– Medication Reconciliation on Admission as first
patient safety project
6 Sigma Infrastructure
Leadership
Project Team
Infrastructure
•Administrative Team
•Determine Critical Success Factors
•Determine Strategic Areas of Improvement
•Steering team determines projects
•Project leadership team
•Assure resources
•Remove obstacles
•Review and reflect
•Assure spread
•All Hold themselves accountable
•DMAIC/ DMEDI methodology
•Communicate
•Pilot (test and learn)
•Recommend Solutions
•Black belts and team members
•Project sponsor
•Process owner
•Financial Representative (FREP)
•Management infrastructure
•Developing 6 Sigma capability
•Department (budget and capital)
•System for spread
Comparison of Different QI Terms
DMEDI
DMAIC
PDSA
DEFINE
MEASURE
EXPLORE
DEVELOP
IMPLEMENT
DEFINE
MEASURE
DEFINE,
MEASURE,
ANALYZE,
IMPROVE,
CONTROL
DEFINE
MEASURE
PLAN, DO, STUDY, ACT
EXPLORE
DEVELOP
IMPLEMENT
CONTROL
ANALYZE
IMPROVE
CONTROL
WHAT IS YOUR AIM?
WHAT ARE YOU GOING TO
MEASURE
WHAT CHANGES ARE YOU
GOING TO MAKE?
RAPID CYCLE PDSA
ACT
MEASURING
DEVELOPING AND
TESTING
SOLUTIONS
Project Goals
Collect a complete list of medications that each
patient was taking before admission – Target 75%
Physician will document reconciliation of each
medication on admission that the patient takes at
home – Target 75%
Reconciliation Process will be complete by 6 hours
after admission – Target 50%
Timeline to complete project in conjunction with 6
sigma training
1.
2.
3.
4.
•
Started February, 2002
Operational Definition
Medication History
– Complete and accurate record of medications
taken at home. For each item it includes: name
of drug, dose, frequency, route and last dose
taken.
– For Pediatric patients: concentration for elixir
medications and mg/kg/dose
Project Scope
Includes: All inpatient and observation
admissions, including children and adults
Excludes: Newborns and outpatients
Process Start: Arrival on patient care unit
Process Stop: Completed medication
history list and each medication is reconciled
Medication Reconciliation Process
Medication history is complete
1.
•
Includes name, dose, frequency & route
•
Dose last taken (date and time)
Physician
2.
•
Reviews and acts upon prior medications
•
Documents response
•
Writes medication orders
Pharmacy
3.
•
Reviews medication history
•
Verifies physician orders
•
Enters the order in the computer
Our Team
David Gorenz MD
•Deployment Champion
Tim Miller MD*
•Business Leader
Howard Cohen MD*
•Project Sponsor
Jerry Storm R.Ph.*
Sharon Kauzlarich
•Financial Rep
Becky Hart RN, ED
Cassy Horack, Black Belt
Sara Rusch MD*, Chair Dept. of Medicine Suzette Swanson CCM*, Green Belt
Mary Buis RN, 2700
Nancy Minesinger CCM, Green Belt
Vickie Anderson RN*, Pediatrics
Ryan Taylor Pharm D, Green Belt
LeAnn Hagaman RN, IMSU
Ara Peterson RN, Surgery, Green Belt
Meetings
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Team Meetings
– Bi-weekly
– 2 hours each
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Leadership Meetings
– Weekly
»
»
»
»
»
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Deployment Champion
Business Leader
Project Sponsor
Process Owner
Black Belt
Project Update Meeting
– Weekly
» Project Sponsor
» Black Belt
Initial Project Findings
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Process is diffuse
Patient is asked the same question multiple
times—this has a link to patient satisfaction
Multiple forms are used
Medication history is found in multiple areas on
the chart
Lacks consistency in what is documented related
to medication history
Medication reconciliation process really does not
exist in the hospital
6 Sigma Medication Reconciliation Project
Baseline Data
Medication History Complete
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1.36 Sigma
0.21 Sigma
Nursing
Physician
Complete
Nursing N = 550 medications
Physician N = 592 medications
Not Complete
Not Listed
6 Sigma Medication Reconciliation Project
Nursing & Physician Medication History Information Match
n=592 medications
4% Sources
Match
5% Sources
Don't Match
13% Sources
Match except
Physician
Missing Only
Route
Sigma Level: 0
77% Missing
Data Between
Sources
6/20/02
6 Sigma Medication Reconciliation Project
Medication Cycle Time--Baseline Audit
(Medication History Complete, Orders Written, and Medication Entered into Pharmacy System)
n=317 medications
Median = 8.7
Mean = 33
100%
90
90%
80
80%
70
70%
60
60%
50
50%
40
40%
30
30%
20
20%
10
10%
0
0%
0-2
2-4
4-6
6-8
8-10
10-12 12-14 14-16 16-18 18-20 20-22 22-24 24-48 48-72 Greater
than 72
Cycle Time in Hours
Frequency
Cumulative Percent
Sigma level: 0.64
Cumulative Percent
Number of Times Observed
100
6 Sigma and the Voice of the
Customer
Surveyed MDs, RNs, Pharmacists
 Design a process that is “Easy to Do
Business With”
 Wanted process complete within 2 hours
 Wanted formulary substitutions to be visible
at time of discharge

Process Design

Partnership with OSFMG & Sister’s Community Clinic
– Wallet cards
– Medication Bags to bring pill bottles to hospital
– “Know Your Medications” Posters
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Developed Medication Reconciliation and Amendment Forms
Developed “Scripting & Tips” sheet
One Form in One Location
Emergency Department
– “Know Your Medications” Poster
– Send patient’s pill bottles to the nursing units
– Wallet Cards
Process Design: other aspects
Survey of other institutions
 FMEA

PILOT FORM
This form is an official part of the Medical Record
Trial form: approved by Howard Cohen, MD & Tim Miller, MD
Admission Orders for Home Medications
Allergies: Drug/Foods
Do you have a latex allergy or sensitivity?  Yes  No  Unsure
If yes, describe type of reaction:______________________________
Are you allergic to iodine?  Yes  No
Are you allergic to dyes?  Yes  No
Reactions/Side Effects
Height: Actual________cm
Weight: Actual________kg
Information Source:
 On No Medications at Home
 Unable to Obtain Medication History—Reason:
 Patient  Spouse  Wallet Card
 Brought meds from home
 Other (Specify)_______________________
Home Medications on Admission
(Prescriptions, OTC, Herbals, Patches, Inhalers, Eye Drops & Supplements)
Physician Medication
Orders on Admission
(Check Only One)
Drug Name
Dose
Route
Initials
Freq
Last Taken
Date/Time
Order
Unchanged
Change
(Use Order
Sheet)
DO NOT
ORDER
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Person(s) Gathering Medication History:_____________________________________Date/Time____________________
 Sent to Pharmacy
_____________________________________ Date/Time____________________
Ordering Physician Signature: _____________________________________________Date/Time_____________________
Dictation #: _____________________________________________
DO NOT REMOVE FROM THE CHART
Please place Reconciliation Forms as the bottom sheet in the Physician Order Section
Page_____of_______
Pilot Form
This form is an official part of the Medical Record
Trial form: approved by Howard Cohen, MD & Tim Miller, MD
Pediatrics
Admission Orders for Home Medications
Allergies: Drug/Foods
Do you have a latex allergy or sensitivity?  Yes  No  Unsure
If yes, describe type of reaction:______________________________
Are you allergic to iodine?  Yes  No
Are you allergic to dyes?  Yes  No
Reactions/Side Effects
Height: Actual________cm
Weight: Actual________kg
 On No Medications at Home
 Unable to Obtain Medication History—Reason:
 Swallows Pills  Crushes Pills  Liquid Medications Only
Home Medications on Admission
(Prescriptions, OTC, Herbals, Patches, Inhalers, Eye Drops & Supplements)
Initials
Dose
Drug Name
Strength/Concentration
Route
Freq
 Parent/Guardian  Wallet Card
 Brought meds from home
 Other (Specify)_______________________
Physician Medication Orders
Calculated
on Admission
Information Source:
Last
Taken
Date/Time
mg/kg/dose
of Home Med
(Check Only One)
Order
Unchanged
Change
(Use Order
Sheet)
DO NOT
ORDER
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Person(s) Gathering Medication History:________________________________________Date/Time________________
 Sent To Pharmacy
____________________________________ Date/Time______________
Ordering Physician Signature: ________________________________________________Date/Time________________ _
Dictation #:_________________________________________
DO NOT REMOVE FROM THE CHART
Please place Reconciliation Forms as the bottom sheet in the Physician Order Section
Page_____of_______
PILOT FORM
This form is an official part of the Medical Record
Trial form: approved by Howard Cohen, MD & Tim Miller, MD
Amendment Form for Home Medication History
For use in modifying/updating Home Medication History
Home Medications on Admission
(Prescriptions, OTC, Herbals, Patches, Inhalers, Eye Drops & Supplements)
Date/
Time
Drug Name
Dose
Route
Freq
Order?
Comments
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
Person Completing Form:________________________________________________________
Date/Time:______________________________
Physician Signature:_____________________________________________________________
Date/Time:______________________________
Dictation Number:____________________________________
DO NOT REMOVE FROM THE CHART
Please place as the bottom sheet in the Physician Order Section below the Reconciliation Form
**This will be in triplicate
MEDICATION HISTORY SCRIPTING & TIPS FOR COLLECTING
GUIDELINES
Medication Allergies
What medications are you allergic to? What did you experience last time it was given to you?
How long ago did this reaction occur? Have you received and tolerated the medication since then?
What other medications would you rather not receive because of a bad drug reaction (other than allergy)?
Current Prescription Medications
What prescription medications do you currently take? Why (or for what reason)?
Are there any that you take only sometimes or when you need it? What and how often?
Current Nonprescription Medications/Supplements
What over-the-counter or nonprescription medications/supplements do you take? Why (or for what reason)?
Are there any that you take only sometimes or when you need it? What and how often?
Compliance/Education Opportunity
How do you take your medicines (with food, morning, night, etc.)?
What barriers prevent you from taking your medications as prescribed? (time, money, etc.)
What medications have you recently stopped on your own? When and why?
Who assists you with your medications? Have you taken anyone else’s medications recently?
Do you bring your medications with you to your doctor’s office or carry a wallet med card?
Physician/Pharmacy
What pharmacy/pharmacies do you currently use?
Do you see more than one physician (cardiologist, endocrinologist, oncologist, family physician, etc.)?
Things to remember when interviewing:
 Utilize open-ended questions (what, how, why, when) and balance with yes/no questions
 Use nonbiased questions that do not lead the patient into answering something that may not be true
 Pursue unclear questions until they are clarified
 Ask simple questions, avoid using medical jargon, and always invite the patient to ask questions
 Let pt know the importance of using one central pharmacy/pharmacist
 Educate the pt on the importance of using a med wallet card and bringing their meds to the hospital, physician’s office, etc.
 When asking about all medications, be sure to get name, dosage form, dosage, dosing schedule, last dose taken – be as specific as
possible about prn medications
 Prompt the patient to try and remember patches, creams, eye drops, inhalers, sample meds, shots, otc, herbals, vitamins, minerals
 When discussing allergies, educate pt on the difference between a side effect and a true allergy - rash, breathing problems, hives
 Have pt describe how and when they take their medications (more vague responses may indicate noncompliance)
Steps to take if patient cannot remember a medication or if clarification is needed:
 Obtain a detailed description of the medication from pt or family member - dosage form, strength, size, shape, color, markings,
 Talk to any family members that are there or contact someone that could possibly bring in the medication or read it over the
phone
 Try calling the patient’s pharmacy to obtain a list of medications that patient has been regularly filling
 Contact the patient’s physician/physicians to try and get an accurate listing of their current medications
 Obtain previous medical records
Pilots
TIHU
 Emergency Department

6 Sigma Medication Reconciliation Project
Pilot Data
Medication History Complete
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0.33 Sigma
2.11 Sigma
3.52 Sigma
TIHU Pre-Pilot
TIHU Pilot
ED Pilot
Complete
Pre-Pilot N = 50 medications
Pilot N = 507 medications
ED Pilot N = 232 medications
Not Complete
Not Listed
For TIHU data,
P = 0 (Chi Square)
6 Sigma Medication Reconciliation Project
Pilot Data
Dose Last Taken Documented
0.43 Sigma
2.33 Sigma
2.49 Sigma
TIHU Pre-Pilot
TIHU Pilot
ED Pilot
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Yes
Baseline N = 550 medications
Pre-Pilot N = 20 medications
Pilot N = 444 medications
ED Pilot N = 231 medications
For TIHU data,
P = 0 (Chi Square)
No
6 Sigma Medication Reconciliation Project
Baseline and Pilot Data
Physician Documented Reconciliation
0.14 Sigma
1.77 Sigma
Baseline
Pilot
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Yes
Baseline N = 592 medications
Pilot N = 51medications
No
6 Sigma Medication Reconciliation Project
Medication Cycle Time--TIHU pilot
(Medication History Complete, Orders Written, Reconciliation Documented and Medication Entered into Pharmacy System)
n=192 medications
Median = 2. 5
Mean = 5.6
90
90%
80
80%
70
70%
60
60%
50
50%
40
40%
30
30%
20
20%
10
10%
72
G
re
at
er
th
a
n
-7
2
48
-4
8
24
-2
4
22
-2
2
20
-2
0
18
-1
8
16
-1
6
14
-1
4
12
-1
2
10
810
68
46
0%
24
0
Cycle Time in Hours
Frequency
Cumulative Percent
P = 0 (by ANOVA and T test)
Difference = 27.46 (95% CI = 18.31 and 36.62)
Sigma level: 2.51
Cumulative Percent
100%
02
Number of Times Observed
100
Implementation (and Control)
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Identified Process Owner and Sub-Process
Owners
House-wide implementation
Control Plan
– Project Turnover
– Measurement
– Contingency Plan
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IDX Implementation
– Incorporation of Medication Reconciliation
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Next reconciliation Projects
Implementation
On Hospital Units
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Nursing & Unit Staff
– Unit posters
– Education provided to managers and educators
of each patient care unit
– Detailed education packet
– Educational poster display
– Educational flyers in staff restrooms
Implementation
Medical Staff and Pharmacy
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Physician
– Presentations at Medical Staff Committee Meetings
– Educational flyers
» Dictation cubicles & Restrooms
» Mailbox
» Offices
Pharmacy
– Staff meetings
– Educational poster display
– Educational information
» mailbox and email
6 Sigma Medication Reconciliation Project-TIHU
Medication History Complete
Control Phase Measurement
0.33 Sigma
2.11 Sigma
2.95 Sigma
2.93 Sigma
TIHU PrePilot
TIHU Pilot
Post-Pilot 1
Post Pilot 2
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Complete
Pre-Pilot N = 50 medications
Pilot N = 507 medications
Post-Pilot 1 N = 96 medications
Post Pilot 2N = 288 medications
April N = 33 medications
Not Complete
Not Listed
TIHU April
2003
6 Sigma Medication Reconciliation Project
Pilot Data
Dose Last Taken Documented
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0.43 Sigma
TIHU Pre-Pilot
2.33 Sigma
3.11 Sigma
TIHU Pilot
TIHU Post 1
Yes
Pre-Pilot N = 20 medications
Pilot N = 444 medications
Post-Pilot 1 N = 94 medications
Post Pilot 2 N = 276 medications
No
2.59 Sigma
TIHU Post 2
6 Sigma Medication Reconciliation Project
Physician Documented Reconciliation in TIHU
Control Measurement
0.14 Sigma
1.77 Sigma
2.88 Sigma
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Baseline
Pilot
Post Pilot 1
Yes
Baseline N = 592 medications
Pilot N = 51medications
Post Pilot N = 82 medications
No
Apr-03
Cycle Time Measurement
35
30
Hours
25
mean
median
20
15
10
5
0
baseline
pilot
Apr-03
Conclusions
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Six Sigma Process allowed us to
successfully implement new process of
medication reconciliation on admission
– More complete medication history
– Viewed favorably by all
– Allows pharmacy new view of patient’s home
meds
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Labor and resource intensive
Barriers
Resources
 Pharmacy Resources in the ED
 Culture
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–
–
–
–
Bureaucracy
Complexity of Communication
Issues of accountability
Lack of teamwork
Lessons Learned
1. Would have used small workgroups to work on pieces
of the project—then have the workgroup report back to
the team during team meetings. We lost a lot of time in
team meetings debating and discussing issues that we
could have handled this way.
2. Keep VOC survey small (don’t ask too many questions,
overwhelming to the customer)
3. Set longer team meeting times
4. Could have been ready with discharge piece sooner so team could
continue with work
5. Should have included Nursing Leadership more intimately
Unanswered Questions
How accurate is the information?
 Will reconciliation improve the accuracy of
the information?

– Are there better models?

Will reconciliation help prevent medication
errors and ADEs?