Transcript Slide 1
Medication Reconciliation
Tools, Keys and Tips June 3, 2009 Steven Tremain, MD, FACPE, Convergence Health Consulting Chief Medical Officer & Chief Medical Information Officer Contra Costa Regional Medical Center
Session Objectives
Medication Reconciliation…
How
the approach
What
the process
Tools
the forms
Keys
to success
Tips
take home advice Tools Keys Tips
Medication Reconciliation… …One Patient’s Story
While an inpatient, an elderly woman was started on the new anti-hypertensive drug.
She was discharged with a new RX for blood pressure medicine.
After discharge, the woman was seen in one of the hospital’s ambulatory care clinics complaining of severe dizziness.
Her PCP figured out that she was taking the blood pressure medicine prescribed in the hospital on top of an earlier prescription she’d been using at home for the same thing.
Key #1
Find and tell the stories….
….They exist ….They’re powerful ….They’ll engage people
Contra Costa Regional Medical Center & Health Centers
Martinez California San Francisco Bay Area
About CCRMC
County hospital with 141 staffed beds 8 owned & operated health centers Family Practice residents EMR in ED only Hospital & clinics still using paper records Meditech clinical system (incl pharmacy)
CCRMC’s Recognition
• IHI Mentor Hospital since 2006 • IHI Innovation Award Winner (Dec 2007) • Agency for Healthcare Research & Quality (AHRQ) Innovation Exchange (www.ahrq.org) • Published case study in Joint Commission Resources’ Medication Reconciliation Toolkit for Implementing NPSG 8
Improve Medication Safety Reduce rates of unreconciled medications Implement an effective admission, discharge and transfer reconciliation process
Model for Improvement Source: Institute for Healthcare Improvement (IHI)
Med Reconciliation Timeline
Year Month J A 2005 S O N D J F M A M 2006 J J A S O N D J F M A M 2007 J J A S O N
Pilot unit (4A) Medicine units Surgical units IMCU/ICU Transfer Rec pilot Psychiatry units Transfer Rec live (all areas) Pediatrics unit OB unit Pilot unit (4A) ICU/IMCU KEY: Medicine Unit (4B)
Admission Reconciliation Implemented Transfer Reconciliation Implemented Discharge Reconciliation Implemented
Surgical Unit Psychiatry Unit Pediatrics unit OB Unit
Tip #1
Segment pieces of the improvement process in bite size increments.
Allows for small scale tests of change Allows for customization where necessary Improves likelihood of success
Our MR Project Team
• Physician champion (Internist) • Resident • Nursing champion (Medicine unit staff RN) • Pharmacists (2) Pharmacy Tech (1) • Clinical Informaticist (RN) • Forms expert • Nursing rep for every service • MD rep for every service • Leader
Key #2
Multi-disciplinary team
Physician champion essential Typically, pharmacy, nursing and medical staff Best to have a strong leader, not aligned with primary disciplines
Tip #2
Short (45 minutes) weekly team meetings
Maintains momentum Promotes engagement
Measurement
Outcome Measures
• % unreconciled meds (Goal = 0%) • % of patients with ALL meds reconciled (Goal = 100%)
Process Measure
• % Compliance with use of the forms/process (Goal = 100%)
Results
• • •
We’ve reduced our rates of unreconciled home medications…
…from 26% to 1% on ADMISSION …from 23% to 4% on DISCHARGE
We’ve reduced our rates of unreconciled medications…
…from 12% to 4% on TRANSFER
Improvement has been sustained for 3 years.
Measurement Tool
Medication Reconciliation Worksheet: Admission & Discharge Reconciliation (Contra Costa Regional Medical Center) MRN: Admit Date: Unit: Patient Name: Discharge Date: Admission Discharge Reviewer: Audit Instructions Med order to C, DC, M on admission?
Med order to C, DC, M on discharge?
Comments C DC M C DC M Pre-Admit (HX) Meds If MROF used, no need to list drugs (just do summary). If no MROF, list all pre-admit drugs, including OTCs, vitamins, herbals & supplements Data Summary Was Admit MROF Used?
Total # of Pre Admit Meds Patients selected for audit must have at least 1 pre-admit med.
Do not mark an herbal as unreconciled upon admission (not continued, per policy).
Meds Pt is Taking Day of D/C
Step 1:
List Meds on MAR on day of d/c with exceptions: No PRNs No Insulin sliding scale No Heparin SQ No antibiotic ointments No IV Chemo No one dose only drugs
Step 2:
Does documentation specify that each drug is C, DC, M upon discharge? If not, it's unreconciled.
Audit Inclusions: Any admission to the service; A least one pre-admit med in hx. Total # of Pre Admit meds NOT reconciled on admission Total # of Pre Admit meds NOT reconciled on discharge Was DMOF Used?
Does DMOF contain all at home meds?
Total # of pre discharge Meds Total # of pre discharge meds NOT reconciled on discharge Did any med order consist of "continue pre admit meds" or "continue home meds" without detailing the specific medication? (Y/N)
Tip #3
Test measurement tool thoroughly
insures that the data collection process will produce the information you are seeking
Tip #4
“
Measurement is for learning, not for judgment” “Use data to generate light not heat!” Use data to learn where your process is failing Data collection should be frequent, small samples
Admission Reconciliation
• Paper process • Originally: Admitting provider hand-wrote the list of medications patient was taking at home on AMROF, which doubles as an admission order form.
• Now: Admitting provider prints an eAMROF form which is pre-populated with the current med list and uses same form to order medications on admission.
• Process being used 99% of the time.
Our paper Admission Medication Reconciliation Order Form (AMROF)
Our
electronic
Admission Medication Reconciliation Order Form (eAMROF) Page 1
Key #3
Use “What’s-In-It-For-Me” (WIFM) approach in workflow design
Admitting MD new process was less work (med list doubles as an order form) Admitting MD eAMROF was less work (pre-populated list meant less writing) Admitting RN new process was less work (stopped capturing a med list from scratch)
Key #4
Customize where necessary; Standardize where possible
Allows for unique workflows Promotes buy-in from staff
Examples
Peds, OB
Our paper Pediatric Admission Medication Reconciliation Order Form
Our paper OB Admission & Discharge Medication Reconciliation Order Form
Key #5
Make it easy for staff to use the new process & difficult or impossible to use the old process
Key for achieving high compliance with use of the process
Example
Attached Admission Med Rec form as page 1 of all admit order forms already in use (manual at first then via forms vendor)
Transfer Reconciliation
• Electronically printed form contains list of all active meds as of that moment in time.
• Provider uses form to order medications on transfer within the facility.
• Process being used 99% of the time.
Our Transfer Medication Reconciliation Order Form (TMROF)
Key #2 & #6
Use “What’s-In-It-For-Me” (WIFM) approach in workflow design
Receiving RN Less work (no more “continue previous meds)
Harness Informal Champions
Receiving RN Constant reminders to physicians who didn’t use the new process
Discharge Reconciliation
• Electronically printed form contains list of all pre-admit meds and active inpatient meds as of discharge.
• Provider uses form to order discharge meds • Patient is provided with a “patient friendly” list of discharge medications.
• Copy of list is sent to next provider of care.
Our Discharge Medication Reconciliation Order Form (DMROF) Page 1
Our Discharge Medication Reconciliation Order Form (DMROF) Final Page
Our [electronically generated] “patient friendly” Discharge Medicine List
Key #3 & #5
Use “What’s-In-It-For-Me” (WIFM) approach in workflow design
Discharging MD Less work (home & inpatient meds print on a report) Patient Now has a concise med list
Make it easy for staff to use the new process & difficult or impossible to use the old process
Example
Stamp on old forms
•
Discharge Reconciliation: Who Does What…….
MD
– Review and sign the DMROF. Update RXM as needed – Generate needed prescriptions in RXM – Print Patient Home Medicine List from RXM (aka Patient Friendly Med List) – Complete the STOP medication section on the Med List
•
Discharge Reconciliation: Who Does What…….
Nursing Staff
– Review Patient Home Medicine List with patient (aka Pt Friendly),
make a copy for the chart
.
– Indicate on Patient Home Medicine List, the time the next dose of any medication is due.
– Write Patient Home Medicine list if not generated from RXM
•
Discharge Reconciliation: Who Does What…….
Clerk
– Fax prescriptions to outside pharmacy
Key #7
Identify & Mitigate Failures
Admission reconciliation failure causes discharge reconciliation failure Develop workflows to identify key failure points so they can be fixed immediately
Example
Daily report in Pharmacy for identifying admitted patients w/o AMROF
Where We’ve Been….
Medication Reconciliation: 2005 - 2007
Inpatient Admission Admit Transfer Discharge Outpatient Visits
Where We’re Going…
ED Visits Medication Reconciliation: 2008 & Beyond Inpatient Admission Admit Transfer Discharge Outpt Visits
Electronic Med List
Preventing Readmissions
• Focus on CHF • Using LEAN/Kaizen • IS NOT: hospital ‘project’ • IS: system way of functioning • Goal: using best practices for rapid adaption/adoption in our system • Template for other conditions • Bonus: close collaboration across “silos”
Our Approach
• Bundle of 5 triggered at Dx – CHF order set – Patient education process – Interdiscpilinary teaching plan – Discharge appts made at time of
admission
!
– CHF Discharge Nurse
CHF Discharge Nurse
• • Twice weekly phone calls to patients – First call within 72 hours of discharge
Real time ongoing medication reconciliation of all meds
• Education • Transportation assistance • Triage
CHF Nurse Ask the patient: Since leaving the hospital.
•How is your breathing?
Do you have worsening chest pain?
Can you lay flat without shortness of breath?
Are you coughing more?
Have you gained weight? If yes, how many pounds Are you more dizzy or light headed? Green Zone All Clear
–
This zone is your goal. Your systems are under control You have •No shortness of breath.
•No weight gain more than 2 pounds (It may change 1 or 2 pounds).
•No swelling of your feet, ankles, legs or stomach.
•No chest pain.
Yellow Zone Caution: - This zone is a warning. CALL YOUR DOCTOR •Worsening cough. •Dizziness.
’ S OFFICE IF: •You have a weight gain of 3 pounds or more in 1 day or a weight gain of 5 pounds or more in 1 week.
•More shortness of breath.
•More swelling or your feet, ankles, legs, or stomach.
•Feeling more tired. No energy.
•Feeling uneasy, you know something is not right.
•It is harder for you to breathe when lying down. You need to sleep sitting up in a chair.
Red EMERGENCY Go to the emergency room or call 911 if you have any of the following:
•
Struggling to breath. Unrelieved shortness of breath while sitting still.
•
Have chest pain that is different or stronger than normal or usual.
•
Have confusion or can’t think clearly.
• • • • • • • • • CONTRA COSTA HEALTH SERVICES CONTRA COSTA REGIONAL MEDICAL CENTER
Congestive Heart Failure (CHF) Nurse Tool CHF Nurse
Call all new CHF referrals received by fax twice a week on Tuesday and Friday: Assess Clinical Condition (see attached):
Red Zone
Advised patient to go to ED and Notified ED (370-5973)
Yellow Zone
Made appointment within 24 hours ---- OR-- Do green zone assessment below and call medicine dept. on call MD to consult.
Green Zone
– Initiate discussion with patient or caretaker
Ask patient “teach back” questions:
What gain is concerning enough that you should report to your doctor?
What foods should you avoid?
Do you know what symptoms to report to your doctor?
Review medications:
“Were you able to get prescribed medications after you left the hospital?” “Do you have the list of medicines they gave you when you left the hospital?” “What is the name of your water pill(s)?” Does patient have medications?
Yes No Medications Refaxed /called to __________________________ pharmacy
Does patient administer own medications?
Yes No Medications reviewed with patient/family member_____________
Reinforced “Daily Activities” (daily wt., law-salt diet, activity as tolerated)
Review Appointment(s): Patient/family member aware of follow-up appointment(s) __________________________________ __________________________________________________________________________________ Referral made to Social Worker (925)370-5480 for transportation issues.
Appointment with Patient Educator made (next available):___________________________________ Other Intervention: _________________________________________________________________________________________________________________ Follow up: Low Risk Patient: Chart check to make sure patient made follow-up appt. High risk Patient (any patient requiring consultation with MD or not clear on any items on patient assessment): Chart check for repeat phone call 3 to 5 days.
Reliabiity
Nolan T, Resar R, Haraden C, Griffin FA.
Improving the Reliability of Health Care.
IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org
)
Joint Commission Resources
( www.jcrinc.com
)
Agency for Healthcare Research and Quality (AHRQ)
( www.innovations.ahrq.gov/index.aspx
)