“Presented to”

Georgia Hospitals

July 31, 2013

Kristine Gleason, MPH, RPh - Clinical Quality Leader, Northwestern Memorial Hospital

Vicky Agramonte, RN, MSN - Project Manager, Healthcare Quality Improvement Program , IPRO

Medication ReconciliationMedication ReconciliationUsing the MATCH ToolkitUsing the MATCH Toolkit

Today’sToday’s Objectives Objectives

1. Provide an introduction of the MATCH Toolkit

2. Discuss pre-work requirements to participate in the MATCH-lite Collaborative

3. Discuss strategies to link medication reconciliation with current initiatives

2

MATCH “lite” Collaborative Timeline

• July 17, 2013 HAC Call to introduce collaborative

• July 31, 2013 Introduction to the MATCH toolkit and Collaborative Pre-work

• August 20, 2012 Regional Meeting – Savannah

• August 27, 2013 Regional Meeting – Atlanta

• September/October Coaching Calls – Date/Time TBD

https://members.gha.org/source/Calendar/

A Focus OnMedication Reconciliation

A process to decrease medication errors and patient harm by:

1. Obtaining, verifying, and documenting patient’s current prescription and over-the-counter medications; including vitamins, supplements, eye drops, creams, ointments, and herbals

2. Comparing patient’s pre-admission/home medication list to ordered medicines and treatment plans to identify unintended discrepancies

3. Discussing unintended discrepancies (e.g., those not explained by the patient’s clinical condition or formulary status) with the physician for resolution

4. Providing and communicating an updated medication list to patients and to the next provider of service at discharge

Adapted from The Joint Commission National Patient Safety Goal 03.06.014

Current Evidence to Reduce Readmissions: Current Evidence to Reduce Readmissions: Implementing Bundled InterventionsImplementing Bundled Interventions

Source: Hansen et al. Interventions to Reduce 30-Day Rehospitalization: A Systematic Review. Ann Intern Med. 18 October 2011;155(8):520-528.

Pre-Discharge Intervention

Bridging Interventions

Post-Discharge Intervention

• Patient education• Medication Reconciliation• Discharge planning•Scheduling follow-up appointment

• Transition coaches•Physician continuity across settings•Patient-centered discharge instruction

• Follow-up telephone calls• Patient-activated hotlines•Timely communication with next provider of service•Timely follow-up with ambulatory provider

Note: Individual components of these change packages have not been tested by themselves and might not reduce the risk for 30-day rehospitalization.

5

Does Medication Reconciliation Impactthe Patient Experience?

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Domains:•Communication with Nurses

•Communication with Doctors

•Responsiveness of Hospital Staff•Pain management*

•Communication about medicines*

•Discharge information*

•Cleanliness of hospital environment

•Quietness of hospital environment

•Overall rating of hospital

•Willingness to recommend hospital

*Impacted by Medication

Reconciliation

Source: HCAHPS Fact Sheet. Available at: http://www.hcahpsonline.org/facts.aspx (accessed 2012 June 20)6

7

Opportunities to Educate and Communicate

• Use Medication Reconciliation as an opportunity to educate patients on their medications throughout their hospital stay – Home medications that are continued during the hospitalization

– Home medications that were discontinued and why

– Ordered medications, include indication and possible side effects

– Ordered as-needed (PRN) medications that are available to them by asking

• Empower patients to ask questions and become active partners

• Trace patients through hospital stays to identify opportunities for interaction

“Bundling” Medication Reconciliationwith Current Initiatives

Harm Estimate/Evidence from Literature Harm Estimate/Evidence from Organization

Med History, Reconcile

Order, Transcribe,

Clarify

Procure, DispenseDeliver

Administer Monitor Educate, Discharge

Phases of Medication Management

Measurement / Analysis

Prioritize / Implement Evidence-Based Interventions

Care Transitions

8 Measure Improvements / Monitor for Sustainability

A Step-by-Step Guide to Improving the A Step-by-Step Guide to Improving the Medication Reconciliation ProcessMedication Reconciliation Process

MATCH Toolkit, with customizable, actionable information, is available

at: http://www.ahrq.gov/qua

l/match/match.pdf

9

YOUR Mission (to implement a successful med rec YOUR Mission (to implement a successful med rec process) if YOU Choose to ACCEPT Itprocess) if YOU Choose to ACCEPT It

Webinar 1July 11

2 Office Hours Calls

Date/Time TBD

Webinar 2July 31

Regional Meetings August 20 OR August 27

Establish a Measurement

Strategy

Design/ Redesign the

Process

Identify Team Members

Process Map

Develop a Charter

Data Collection Plan

Collect Data

Identify Key Drivers

Flow Chart

Gap Analysis

Process Design

Implementation Plan

Pilot Test

Education / Training

Monitor Performance

Address low compliance

Sustainability10

Identify the problem and goal

Measure current performance

Validate key drivers of error

Fix the drivers of poor performance

Use mechanisms to sustain

improvement

Analyze

A Systematic Approach to Improvement

Define Measure Improve Control

DMAIC is a step by step process improvement methodology used to solve problems by identifying and addressing root causes

For more DMAIC information, including free access to a toolkit and project templates, visit the Society for Healthcare Improvement Professionals website at www.shipus.org 11

Build the Project Foundation

Define

12

Assemble Your Team

Team Members: Make significant and focused contributions to timely and successful implementation

Executive SponsorProject responsibilities: provide overall guidance and accountability, remove barriers, provide

strategic oversight and appropriate resources, review progress

Improvement LeaderProject responsibilities: Accountable for using DMAIC to manage project and

complete deliverables in a timely manner, partner with Process Owner

EVERYONE Is Involved and Accountable!

Process OwnerProject responsibilities: Accountable for implementing, controlling and

measuring the project outputs and improvements

SponsorsProject responsibilities: accountable for success, responsible for implementation of

recommendations, provide tactical oversight, reach clinical consensus

13

Map the Current Process

A High Level Process Map is a simple picture of a complex process represented by 4-8 key

steps. It is essential to better understand the process being improved and to gain

agreement on project scope.

14

How to construct a high level process map:

1. Get Team together - include all stakeholders

2. Define and agree to a process

3. List all participants of the process – depts., mgrs, and job performers

4. Define beginning and end points

5. Brainstorm key process steps

6. Determine order of process steps

7. Validate by physically walking through process

15

Develop a Charter

16

Advancing Advancing Excellence in Excellence in Health CareHealth Care

Medication Reconciliation Phase IIIMedication Reconciliation Phase III

Linkage to NMH Goal: Best Patient Experience – Deliver care that is safe and without error.

Problem Statement: NMH has made significant strides in developing and implementing a Medication Reconciliation process organization-wide. Through close measurement and monitoring, we have identified the need for additional efforts including: process reassessment and refinement (SDS, Prentice, Discharge). With the proposed 2009 revision to The Joint Commission standard we are presented with new process design opportunities (ED, Outpatient Areas); and, a renewed focus on transfers

(internal and external).

Goal/Benefit: 1) To measurably decrease the number of discrepant medication orders (both inpatient and outpatient) and the associated potential and actual patient harm. 2) Fully meet the Joint Commission’s National Patient Safety Goal #8,

documentation and reconciliation of all medications at admission, transfer and discharge for all inpatients, ED visits and outpatient encounters and external transfers.

Scope: Focus on outpatient Same Day Surgery, Prentice, ED, and procedural areas, transfer and discharge processes

Deliverables: • Improved compliance of medication reconciliation through refined processes in areas stated above.

• A sustainable measurement and monitoring approach to be embedded in current reporting infrastructure.

Resources Required:• We will need leadership to prioritize med rec work and facilitate manager involvement in design and implementation efforts

Key Metric(s):• % inpatient Med Rec compliance at admission, transfer and discharge by discipline (MD, RN, RPh)• % inpatient Med Rec compliance by service

• % outpatient Med Rec compliance at admission and discharge

Exec Sponsor: C Watts Sponsors: DDerman-MD, CPayson-RN, DLiebovitz–IS, NSoper-Surgery Subject Matter Expert: K Gleason Process Owner: H BrakeJFoody, KOLeary–Medicine, KNordstrom–Pharmacy Improvement Leader: ML Green

Milestones: Description Date (month, 2008-9)

#1 Define Phase July#2 Measure/Analyze August

#3 Improve December#4 Control January

17 17

A Word About Scope

18

Begin by identifying all areas within your facility

where patients receive

medication.

• Keep it simple … anyone should be able to review your charter and know what you are looking to do and why it is important

• Include data … If you do not have initial data, use placeholders

• Identify where the project “Starts – Stops”

• Ensure your scope reflects your time horizon

• Try to avoid projects over 12 months long

• Estimate where necessary, refine over time … ‘something’ provides a guide, ‘nothing’ causes delays

• Focus on outcomes

Tips for Successful Chartering

19

Establish a Measurement

Strategy

Measure

20

Caution: Jumping into data collection without a clear plan wastes time, energy, resources, etc.

What to Measure

Operational Definition

Collection Method

Sampling Plan

What Where When How ManyQuestion the

data will answerSpecific

DefinitionSystem, existing

forms, new handwritten forms, etc.

Elements to be collected

Physical location

Timing and frequency of

collection

Number of data points

to be collected

Was an updated medication list provided to the

patient and reviewed at discharge?

“Medication instructions

were reviewed with the patient”

checked on At-Home Meds

List form

Manual collection from existing forms

Copy of At-Home Meds

List form, reasons for

non-compliance.

Use Med Rec audit form GI Lab

2-weeks all shifts.

August 15 - 31 All visits

Data Collection Plan

21

Collect Data

• Work with the team and staff to identify potential drivers and build a data

collection form

• Seek assistance from the team and staff in collecting the data to increase buy-in

• Observe the data collection process periodically to identify issues, errors

• Graph the data you intend to collect to (1) confirm how

you plan to use the data and (2) identify any missing

data elements

Identify Key Drivers

23 Involvement of Frontline Staff is KEY

The backside of the baseline data collection form:

Identifying (& addressing) the problematic

issues that drive outcomes

will lead to lasting

improvement

Design/Redesign the Process

Analyze

24

Flow Chart

25

A flowchart outlines current workflow and helps identify:

•Successful medication reconciliation practices

•Current roles and responsibilities for each discipline at admission, transfer, and discharge

•Potential failures •Unnecessary redundancies

and gaps in the process

Gap Analysis

• Assess the current state of your facility’s medication reconciliation process

• Identify gaps between your current process and one that comprises best practices

• Collect policies, procedures, programs, metrics, and personnel that support the current process

• Describe barriers and rate implementation feasibility

26

Design a Successful Med Rec Process

Best Practice: Develop a single medication list, "One Source of Truth”

27

Guiding Principles• Clearly define roles and responsibilities

• Standardize, simplify, and eliminate unnecessary redundancies

• Make the right thing to do the easiest thing to do

• Develop effective forcing functions, prompts, and reminders

• Educate workforce, and patients, families, and caregivers

• Ensure process design meets all pertinent local laws or regulatory requirements

28

Strategies to OvercomeLack of Resources and Time

1. Get Leadership Buy-In• Let them know why they should care: Patient Safety,

Public Reporting, Financial Incentives

2. Bundle the Work• Identify similarities among projects – get 2 things

accomplished for the price of 1

3. Identify Opportunities for “Quick Wins”• Prioritize changes that may be easily developed and

implemented

29

Homework Complete prior to the regional meeting:

1. Put together a High Level Process Map for med rec. Remember: Keep it high level – No more than 8 steps

2. With your team, create a project charter. Use the template on the next slide

3. Adopt a plan to collect baseline data and audit 5 medical records for compliance with the current process

30

31

Vicky Agramonte, RN, MSNProject Manager

Healthcare Quality Improvement Program Island Peer Review Organization, Inc. (IPRO)

 Albany, NY 12211-2370(518) 426-3300 X115vagramonte@ipro.org

Kristine Gleason, MPH, RPhClinical Quality Leader

Northwestern Memorial Hospital Chicago IL 60611

312.926.9172kmgleaso@nmh.org

Questions and Discussion

THANK YOU!THANK YOU!

If you want to learn more about IPRO, please visit our website at: http://www.ipro.org If you want to learn more about Northwestern Memorial Hospital, please visit our website at http://www.nmh.org