a kick start to medication reconciliation
DESCRIPTION
A Kick Start to Medication Reconciliation. Dr. Hilary Adams Quality Improvement Physician, Family Medicine Calgary Health Region Judy Schoen Pharmacy Patient Care Manager, Calgary Health Region. The team. Multidisciplinary Champions/opinion leaders QI support if possible - PowerPoint PPT PresentationTRANSCRIPT
Safer Healthcare Now! Teleconference Tuesday, November 21, 2006
A Kick Start to Medication
ReconciliationDr. Hilary AdamsQuality Improvement Physician, Family Medicine Calgary Health
Region Judy Schoen
Pharmacy Patient Care Manager, Calgary Health Region
Safer Healthcare Now! Teleconference Tuesday, November 21, 2006
The team• Multidisciplinary• Champions/opinion leaders• QI support if possible• Don’t forget frontline staff!• Distinct group with common
focus (e.g. nursing unit, specific service etc)
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Getting Started
• GSK from SHN• PDSA quality improvement
model• FOCUS
– Find an opportunity– Organize a team– Clarify current process– Understand variability– Sustain results
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Why baseline data
• We don’t know what we don’t know
• Recognize size of problem• Get buy in early• Helps show improvement• Makes it a priority
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Success Index: 56.9%
Mean # of Undocumented Discrepancies: 0.6/patient
Mean # of Unintentional Discrepancies: 1.7/patient
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Baseline Measures
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Current process and Variability
• Analyze current process for gaps and drops
• Understand variability• ? multiple locations for data
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Past Process: Hospitalist History and
Physical Form
Incompletemed list
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Past Process: Hospitalist History and
Physical Form
No med list
88
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Past Process: Nursing Medication
History
No med list
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• Variety of processes
• Unclear roles• Concerns
about duplication
• Rework in locating information in chart
Key Learnings
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• Variety of processes
• Unclear roles• Concerns about
duplication• Rework in
locating information in chart
Team Vision:
• Standard approach• Clear roles• Single location for
home medication information in chart
• Collect Best Possible Medication History (BPMH) in 24 – 48 hours
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Team Charter• Identify all team members• Purpose of project• Guiding principles• Scope and boundary• Goals and objectives• Ideas for change• Principles for working together• Roles and responsibilities
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Challenges at the Onset
• No clear owner.No clear owner.
• Variety of processes. Variety of processes.
• Obtaining accurate medication Obtaining accurate medication
information.information.
• Limited clinical pharmacy resources.Limited clinical pharmacy resources.
• Physician / nursing buy-in.Physician / nursing buy-in.
• Difficulty in adopting new practices.Difficulty in adopting new practices.
• Lack of communication between Lack of communication between
interfaces.interfaces.
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Critical Aspects• No duplication/melds with current
workflow
• Prompts/cues on forms (e.g. dose)
• Involvement of all disciplines
• Education
• Strong leadership
• Monitoring our progress
• Auditing the process, not individuals14
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An Improved Process: What things may look like
• Standardized approach• Multidisciplinary• Clear roles.• Defined location for home
medication information in patient chart.
• Increased awareness of key questions to ask to illicit the BPMH.
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An Improved Process: What things may look
like• Ease of use• Flexible• Does not result in
duplication• Clear communication• Close the loop• Prompts health care
providers to provide BPMH
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Step 2: Pre-Admission Medication List
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Step 3 & 4: Additions/Clarifications of Pre-Admission Medication List
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Step 5: Physician Review
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Challenges• Wellnet – not a complete record• “As directed” on Rx• Patient altering own
medications• Limited sources of information
outside of office hours• Transposing to PCIS (EMR)• Adapting learnings to the
community 21
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Lessons learned• Understand variation in current
practice is critical• Multidisciplinary approach is
essential• Vision of final outcome critical• BPMH auditor must be separate to
the process• Clear definitions• Deal with one issue at a time• Small successes build momentum• Just do it! (when is it right enough?)
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Gains
A nurse on Unit 62 received a phone call from a patient’s wife. She asked why her husband was on lasix. The nurse pulled the patients chart and referred to the BPMH form in which the MD had documented that lasix was to be ‘held’ due to dehydration. The nurse was able to efficiently respond to the patient’s wife.
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Baseline Measures
Success Index: 56.9% at baseline to as high as 92.8%
Mean # of Undocumented Discrepancies: 0.6/patient to as few as 0.0
Mean # of Unintentional Discrepancies: 1.7/patient to as few as 0.4
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Step 1: Patient Risk Assessment Tool
Step 1: Patient Risk Assessment Tool
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Referrals to Pharmacy
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Hospitalist Pharmacist Referrals
05
10152025303540
Hospitalists
Nurses
Pharmacists
Other
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Success Index
Success Index
0
20
40
60
80
100
Aug.-Sep.,2005
Oct.12,
2005
Oct.25,
2005
Nov.16-17,2005
Dec. 8-15,
2005*
Dec. 8-15,
2005*
Jan. 17-18,
2006
Feb. 27- Mar.
8, 2006
Per
cen
t
Baseline (Dr.s only)
(n=24)
PDSA 1: Form 1
(Dr.s only)(n=7)
PDSA 2: Form 2(Dr.s only)(n=5)
PDSA 3: Form 3
(Dr.s only)(n=11)
PDSA 4: Form 3
(Dr.s only)(n=8)
Stretch Goal: 100%
Goal: 85%
PDSA 5: Form 3 (Dr.s & Nurses)(n=2)
* P DSA's took place during same timeframe
PDSA 6: Form 4 (Dr.s ,
Nurses & Pharmacists)
(n=4)
PDSA 7: Form 4 (Dr.s ,
Nurses & Pharmacists)
(n=9)
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Undocumented Intentional Discrepancies
Mean # of Undocumented Intentional Discrepancies
0
0.5
1
1.5
2
2.5
Aug.-Sep.,2005
Oct. 12,2005
Oct. 25,2005
Nov.16/17,2005
Dec. 8-15,
2005
Dec. 8-15,
2005
Jan. 17-18,
2006
Feb. 27- Mar.
8, 2006
Mea
n #
of
Dis
crep
anci
es
Stretch Goal: 0.2
Goal: 0.3
Baseline (Dr.s only)
(n=24)
PDSA 1: Form 1
(Dr.s only)(n=7)
PDSA 2: Form 2(Dr.s only)(n=5)
PDSA 3: Form 3(Dr.s only)
PDSA 4: Form 3
(Dr.s only)(n=8)
PDSA 5: Form 3 (Dr.s & Nurses)(n=2)
PDSA 6: Form 4 (Dr.s , Nurses & Pharmacists)
(n=4)PDSA 7: Form 4 (Dr.s ,
Nurses & Pharmacists)
(n=9)
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Unintentional Discrepancies
Mean # of Unintentional Discrepancies
00.20.40.60.8
11.21.41.61.8
22.22.42.62.8
Aug.-Sep.,2005
Oct.12,
2005
Oct.25,
2005
Nov.16/17,2005
Dec. 8-15,
2005
Dec. 8-15,
2005
Jan. 17-18,
2006
Feb. 27- Mar.
8, 2006
Mea
n #
of
Dis
crep
anci
es
Stretch Goal: 0.4
Goal: 1.3
Baseline (Dr.s only)
(n=24)
PDSA 1: Form 1
(Dr.s only)(n=7)
PDSA 2: Form 2(Dr.s only)(n=5)
PDSA 3: Form 3(Dr.s only)
PDSA 4: Form 3
(Dr.s only)(n=8)
PDSA 5: Form 3 (Dr.s & Nurses)(n=2)
PDSA 6: Form 4 (Dr.s ,
Nurses & Pharmacists)
(n=4)
PDSA 7: Form 4 (Dr.s ,
Nurses & Pharmacists)
(n=9)