1 medication reconciliation in a pre-admission clinic critical success factors cynthia turner, b....

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MEDICATION RECONCILIATION

in a Pre-Admission Clinic

CRITICAL SUCCESS FACTORS

Cynthia Turner, B. Pharm, R.Ph.

Medication Reconciliation Pharmacist

Vancouver Island Health Authority (VIHA)

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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

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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

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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

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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

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0.43

0.35

0.20

0.110.09

0 0 0 0 0

0.10

0

0.20

000.00

0.10

0.20

0.30

0.40

0.50

0.60

Nov 2

005

Dec 2

005

Jan

2006

Feb

2006

Mar

200

6

Apr 2

006

May

200

6

Jun

2006

Jul 2

006

Aug 2

006

Sep 2

006

Oct 2

006

Nov 2

006

Dec 2

006

Jan

2007

Feb

2007

Mar

200

7

Apr 2

007

May

200

7

Jun

2007

Jul 2

007

Aug 2

007

Sep 2

007

Oct 2

007

Nov 2

007

Dec 2

007

Jan

2008

Feb

2008

Mar

200

8

Apr 2

008

May

200

8

Jun

2008

Month

Me

an

Actual Goal

Baseline measurement

= 1 med discrepancy for every 2.3 pts .

Med Rec Pharmacist

Goal within 1 year (decrease baseline by 75%)

= 0.11 = 1 med discrepancy in 9 pts.

0 discrepancies in 19 pts.

Sample size smallDiscrepancies occurredover weekend

Royal 2; 1st ward – SustainabilityUnintentional Discrepancies

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0.90

0.020

0.02

0.23

0.03

0.070.11

0

0.040.04

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

Nov 2

005

Dec 2

005

Jan

2006

Feb

2006

Mar

200

6

Apr 2

006

May

200

6

Jun

2006

Jul 2

006

Aug 2

006

Sep 2

006

Oct 2

006

Nov 2

006

Dec 2

006

Jan

2007

Feb

2007

Mar

200

7

Apr 2

007

May

200

7

Jun

2007

Jul 2

007

Aug 2

007

Sep 2

007

Oct 2

007

Nov 2

007

Dec 2

007

Jan

2008

Feb

2008

Mar

200

8

Apr 2

008

May

200

8

Jun

2008

Month

Me

an

Actual Goal

Baseline Measurement= 1 med discrepancy for every 1.1 pts.

Goal within 1 year= 0.23 (decrease baseline by 75%)

= 1 med discrepancy for every 4.3 pts.

Med Rec Pharmacist

8 med discrepancies in 35 pts.

(new orthopaedic surgeons started)

1 med discrepancy in 51 pts. (new orthopedic surgeons now educated in Med Rec process

West 3; 3rd ward - ReproducibilityUnintentional Discrepancies

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Unintentional Discrepancies

Local Teams better than National average

0.00

0.50

1.00

1.50

2.00

Month

Mea

n N

um

ber

of

Un

inte

nti

on

al D

iscr

epan

cies

per

Pat

ien

t

Local Team National

Baseline Average R2/R3/W3

= 0.95

Average of all 3 RJH wards: R2+R3+W3

0.01 - 0.14

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0.43

1.31

0.9

0.018 0.02 0.02

0

0.4

0.8

1.2

1.6

Royal 2 Royal 3 West 3

Nu

mb

er p

er p

atie

nt

Baseline 2007 Impact of MedRec Pharmacist

Unintentional Discrepancies

“Then and Now” – < Target Goal

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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

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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

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CRITICAL SUCCESS FACTORS

1. Documentation

2. Communication

3. Education

4. Program Sustainability

5. Spread Mentor

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CRITICAL SUCCESS FACTORS

1. Documentationa) Build in process to double check

BPMH

b) BPMH same place in chart every time

c) Accuracy of medication information

TRUST is KEY

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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

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1. Documentationb) 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

PDSA cycles

REMINDER

Please Complete Home

Medication Reconciliation

Physician Order Form

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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%

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Case Study NEW PROCESS: Pharmacist involved

Home

Medication ListFamily

PhysicianPatient Clinic Questionnaire

B.C. Pharma-Net

Profile

Patient Interview

Metformin 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

Metoclopramide 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

Source Accuracy: 68% 79% 76%

BPMH

100 % (Based on 49 pt.)

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HOME MEDICATION PROFILE:

Continue on Admission Yes / No / Change (MRP)

PRESCRIPTION and Select Over the Counter Medications

(Pharmacist to complete)

Dose Route

Frequency

Date &Time of Last Dose

(SDC Nurse with initials) YES No CHANGE

Order below

Already Ordered

(MRN)

1.

2.

3.

4.

5.

6.

7.

8.

9.

Please complete ALL pages Page _____ of _____

Home Medication Reconciliation

Draft 21 Dr. R Bachand

Please FAX Completed Form to Pharmacy Use FAX Stamp

______________________________________ ______________ Physician Signature (or Read-back Telephone Order) Time/Date

___________________________ ___________________ Pharmacist Signature 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)

FORM COMPLETED BY: AUTHORIZING PHYSICIAN

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

Physicians Order Form

Intro. Med Rec Form: BPMH documentation/Rx

at present – Draft 21

PDSA Cycle #2 To identify Form as

an Order

PDSA Cycle #3 To focus Physician to

their area (yellow highlighting)

PDSA Cycle #4 To eliminate SDC

Nurses from documenting

medications on Form (new process)

PDSA Cycle #5 To clearly define

area of responsibility

on Form

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Documentation Summary TRUST IS KEY!!!

Physicians, nurses, pharmacists all need to TRUST the documentationis accurate

At our site – becomes a Physician Order

Time saving step for multidisciplinary team

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CRITICAL SUCCESS FACTORS

2. Communicationa) Speak language of audience

b) Preparation and Follow-up are critical

c) Show-off your results

BIGGER THAN 1ST THOUGHT

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2. Communication

a) Speak language of audience

Two examples

• IMPACT of program on patient safety

• IMPACT of program on patient admissions

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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

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Impact of Process at RJHALL Admissions

Jan to Jun 2007

Med Rec Process

8 %

Non Med Rec 92 %

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Impact of Process at RJH

Non-Emergency admissions Jan to Jun 2007

Med Rec Process

18%

Non Med Rec 82%

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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.

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2. Communication

c) Show-off your results

- Before & after measures on wards

- Poster in Senior Executive area

- Display in cafeteria, newsletter etc.

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Communication examplesPatients:• Brochure• Fine tuned questionsPharmacy: • UBC presentation• RJH/VGH/Aberdeen• 3-5 days training• Students rotate inSenior Team:• Poster• VIHA Board “Big Dot”

Nurses:• Cafeteria Day/Newsletter• Monthly staff meetings• Muffin “thank you” dayPhysicians:• Surgical Executive• Presentations• Chief of Surgery• Dept. meetingsTraining Video

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CRITICAL SUCCESS FACTORS

3. Educationa) On-going – new staff, new

processes

b) Standardize material e.g. ward package,educational video etc.

c) Make use of educational moments

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CRITICAL SUCCESS FACTORS

4. Program Sustainabilitya) Program still functions when key

personnel away

b) People seek you out to be included

c) Use FACTS to sell program

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… one person needs time off

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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

Med Rec – Critical Success Factors Checklist

Would you like to improve your team’s Med Rec measures?Are your measures:   Sustainable (month to month)   Reproducible as you spread to other areas   Meeting or beating your goal targets   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 Success Factor Yes No

D

O

C

U

M

E

N

T

A

T

I

O

N

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?

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Med Rec – Critical Success Factors ChecklistPage 2

Area Success Factor Yes No

C

O

M

M

U

N

I

C

A

T

I

O

N

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

Med Rec – Critical Success Factors ChecklistPage 3

Area Success Factor Yes No

E

D

U

C

A

T

I

O

N

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.

S

U

S

T

A

I

N

A

B

I

L

I

T

Y

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?

SPREAD MENTOR

Does your team act as a SPREAD MENTOR – sharing processes, tips for successes, documentation with other med rec teams?

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Contact Information

• Cynthia Turner, Med Rec Pharmacistcynthia.turner@viha.ca

• Lori Brodie, Facilitatorlori.brodie@viha.ca

• Richard Bachand Manager, Clinical Pharmacy Services

richard.bachand@viha.ca