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Coordinating Institution Wide Coordinating Institution Wide Implementation of Medication Implementation of Medication
Reconciliation: Reconciliation:
Tips, Strategies & Lessons LearnedTips, Strategies & Lessons Learned
March 25, 2009March 25, 2009Safer Health Care Now! National Webinar / Teleconference Safer Health Care Now! National Webinar / Teleconference
Olavo Fernandes PharmD, FCSHPPharmacy Clinical Site Leader, University Health Network
Assistant Professor, Univ of Toronto and Safety Specialist, ISMP Canada
Interdisciplinary Members of UHN Medication Reconciliation Task Force Image: green.gps.caltech.edu/pictures_images/GreenTree.jpgImage: green.gps.caltech.edu/pictures_images/GreenTree.jpg
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What has your medication What has your medication reconciliation implementation reconciliation implementation journey in your ER been like ?journey in your ER been like ?
OROR
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ObjectivesObjectives
1.1. Highlight Highlight strategies for overcoming strategies for overcoming challenges to successfully implementchallenges to successfully implement medication reconciliation at various medication reconciliation at various interfacesinterfaces
2.2. Share Share coordination tips/ lessons learnedcoordination tips/ lessons learned to to prepare your organization to meet prepare your organization to meet medication reconciliation requirementsmedication reconciliation requirements
3.3. Outline the key elements of an Outline the key elements of an organizational communication plan and organizational communication plan and clinician/ leadership resource packageclinician/ leadership resource package for for
medication reconciliationmedication reconciliation
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How do we Navigate the How do we Navigate the Challenges of Effectively Challenges of Effectively
Meeting Accreditation Meeting Accreditation Requirements for Medication Requirements for Medication
Reconciliation ?Reconciliation ?
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How do we actually “get started and How do we actually “get started and sustain” implementation?sustain” implementation?
Five Tips & StrategiesFive Tips & Strategies
1.1. People – Empowering CliniciansPeople – Empowering Clinicians
2.2. CoordinationCoordination
3.3. CommunicationCommunication
4.4. LeadershipLeadership
5.5. Tools / Systems to Support the Tools / Systems to Support the CliniciansClinicians
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How do we actually “get started and How do we actually “get started and sustain” implementation?sustain” implementation?
LeadershipLeadershipCoordinationCoordination
CommunicCommunicatioationnPeoplePeople
Tools/ SystemsTools/ Systems
Five Tips & StrategiesFive Tips & Strategies
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Challenges & Questions
• Who does the BPMH? Who does the BPMH? • Who does the reconciliation/ resolving the Who does the reconciliation/ resolving the
discrepancies?discrepancies?• Proactive vs. Reactive Multidisciplinary Proactive vs. Reactive Multidisciplinary
practice models ?practice models ?– Proactive: Proactive: BPMH → admission orders (AMO) →reconciliation BPMH → admission orders (AMO) →reconciliation
check check – Reactive/ Concurrent: Reactive/ Concurrent: primary history → AMO →BPMH →reactive primary history → AMO →BPMH →reactive
reconciliationreconciliation– Hybrid Systems Hybrid Systems
• Manual vs. Electronic Processes ?Manual vs. Electronic Processes ?
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Structured Implementation & Rollout Structured Implementation & Rollout
PlanPlan Step-wise Milestones for each Inpatient Clinical Step-wise Milestones for each Inpatient Clinical AreaArea1.1. ID stakeholders/ preliminary educationID stakeholders/ preliminary education2.2. Formal education to unit/clinical area Formal education to unit/clinical area
championschampions3.3. Baseline admission reconciliation data Baseline admission reconciliation data
collectioncollection4.4. Creation of a team practice modelCreation of a team practice model5.5. Finalize practice model – input from staffFinalize practice model – input from staff6.6. Prescriber/ Nursing/ Pharmacist In-Prescriber/ Nursing/ Pharmacist In-
servicesservices7.7. Start Front line implementation- Start Front line implementation-
Admission reconciliationAdmission reconciliation8.8. Sustain as part of daily practice with Sustain as part of daily practice with
ongoing feedback and improvementongoing feedback and improvement
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Questions to Address As a Team
• Who?Who? – Who- in your local practice site, who responsible for BPMH? Who- in your local practice site, who responsible for BPMH?
Reconciliation? Shared responsibility? Who does what? (MD/ Reconciliation? Shared responsibility? Who does what? (MD/ RN/ Phmt/ Technician/ Students)RN/ Phmt/ Technician/ Students)
– BPMH training: designated individuals or “organization-wide”BPMH training: designated individuals or “organization-wide”• How? How?
– How are medication histories currently being conducted? How are medication histories currently being conducted? Does med rec implementation involve building upon pre-Does med rec implementation involve building upon pre-existing practice or a major shift in practiceexisting practice or a major shift in practice
• Where? Where? – Decide where the BPMH is documented (visible to all staff, Decide where the BPMH is documented (visible to all staff,
only useful if everyone knows where it is, can find it, can use only useful if everyone knows where it is, can find it, can use it). it).
– Will it be a pre-printed form/ computerized record/ clinical Will it be a pre-printed form/ computerized record/ clinical notes? notes?
S. Ingram BScPhm, ACPR, ED- TGH
UHN Clinician Validation UHN Clinician Validation ProgramProgram
• Interactive Learning/ Education SessionInteractive Learning/ Education Session• Key ReadingsKey Readings• Standardized Patient Validation ProgramStandardized Patient Validation Program
– Obtaining BPMH from a standardized Obtaining BPMH from a standardized patient–actor patient–actor
– Admission reconciliation to identify Admission reconciliation to identify discrepanciesdiscrepancies
– Coding of discrepanciesCoding of discrepancies– Interactive discussion on areas of strength / Interactive discussion on areas of strength /
improvementimprovement
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Getting Started/ Focussed Limited ResourcesWhy is Medication Reconciliation so important in the ED ?
• ““Gateway”Gateway” to acute care admission and to acute care admission and transitions in caretransitions in care
• ““Opportunity”Opportunity” – ideally med rec performed as – ideally med rec performed as close to arrival/ decision to admitclose to arrival/ decision to admit– Family / medication vials & lists optimally availableFamily / medication vials & lists optimally available
• ““Efficiency”Efficiency” – upstream reconciliation/ – upstream reconciliation/ resolution improves safety/ saves times and resolution improves safety/ saves times and resources downstream to subsequent resources downstream to subsequent transitionstransitions
• ““Shared Responsibility”Shared Responsibility” – ED/ Admitting – ED/ Admitting services; all health care professionals – services; all health care professionals – physicians, nurses, pharmacists, allied health physicians, nurses, pharmacists, allied health and patients and patients
S. Ingram BScPhm, ACPR, ED- TGH/
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Synchronization Challenge of Synchronization Challenge of Discharge Tools at Many InstitutionsDischarge Tools at Many Institutions
Patient Care System
Dear Dr
Letter
EMITT Letter
Patient schedule
DischargePrescription
Patient Wallet card
J. Wong BScPhmJ. Wong BScPhm
Manual Manual ElectronicElectronic ElectronicElectronic
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Multidisciplinary Practice ModelMultidisciplinary Practice Model
Challenges of Medication DiscrepanciesChallenges of Medication Discrepancies
MDMD RNRNRXRX
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EMITT2: Schematic of Structured, Multidisciplinary EMITT2: Schematic of Structured, Multidisciplinary
Integrated Medication Reconciliation StrategyIntegrated Medication Reconciliation Strategy
Wong J. [Abstract]Wong J. [Abstract] Pharmacotherapy Pharmacotherapy 2006 ;26: 106 2006 ;26: 106
BPMH medical chart
note
Primary Medication
History: MD or RN
Admission Admission ReconciliationReconciliation
ER
WardBPMH:
Taken by pharmacist
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15
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Medications may be altered: new, adjusted, discontinued
Ward
Decision to discharge patient
BPMDP
Home
Synchronized Synchronized OutputsOutputs
Discharge Discharge ReconciliationReconciliation
Electronically Generated
Prescriptions
Medication Information
Transfer Letter
Patient Medication Grid
Patient Medication Wallet Card
22 33 44 55
Best Possible Medication
Discharge Plan
Physician Discharge
Summary
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Wong J. Annals of Pharmacotherapy 2008 (in press)Wong J. Annals of Pharmacotherapy 2008 (in press)
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18A. Cesta et al.A. Cesta et al. Ann Pharmacother Ann Pharmacother 2006;40:1074-81. 2006;40:1074-81.
Medication Information Transfer LetterMedication Information Transfer Letter
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Medication Information Transfer Medication Information Transfer LetterLetter
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Horizontal : Patient Medication GridHorizontal : Patient Medication Grid
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Vertical : Patient Medication GridVertical : Patient Medication Grid
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Patient Wallet CardPatient Wallet Card
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0102030405060708090
100
Feb Mar Apr May
BPMDP (E-scriptwith dischargereconciliation)
Manual Script
Safer Health Care Now! National Measure For Safer Health Care Now! National Measure For Discharge Medication ReconciliationDischarge Medication Reconciliation
20072007
%eligible %eligible patientspatients
dischargeddischarged
Team Target Team Target 80%80%
TGH GIM TGH GIM
* Graph does not include * Graph does not include patients discharged without patients discharged without prescriptionsprescriptions
* Sample Feb7 – May 17* Sample Feb7 – May 17
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n= 6976 Patient n= 6976 Patient AdmissionsAdmissions
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CPOE-BASEDCPOE-BASED
MED REC MED REC PRACTICE PRACTICE MODELMODEL
Baseline Data Baseline Data Evaluation Evaluation Literature Review Literature Review Multidisciplinary Multidisciplinary Feedback Feedback
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UHN Implementation & Rollout UHN Implementation & Rollout
PlanPlan
1.1. Admission ReconciliationAdmission Reconciliation• Main priority for ALL inpatient Main priority for ALL inpatient
areasareas2.2. Transfer ReconciliationTransfer Reconciliation3.3. Discharge ReconciliationDischarge Reconciliation4.4. Ambulatory ClinicsAmbulatory Clinics
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Organization Wide : Leadership and Organization Wide : Leadership and
Clinician CommunicationClinician Communication
Formal Training of ChampionsFormal Training of Champions• Education/ learning session, required readings, standardized Education/ learning session, required readings, standardized
patient validation/ certification trainingpatient validation/ certification training
Front-line education in-services:Front-line education in-services: • nurses, medical residents, medical staffnurses, medical residents, medical staff
Other communication tools:Other communication tools:- Paper or electronic chart notification of reconciliation Paper or electronic chart notification of reconciliation
status, promotional video testimonials, hospital intra-status, promotional video testimonials, hospital intra-net website, postersnet website, posters
Leadership presentations:Leadership presentations:- Accreditation team lead meetings, site operations Accreditation team lead meetings, site operations
meetings/ leadership forum, business units, selected meetings/ leadership forum, business units, selected medical rounds, multidisciplinary med rec task forcemedical rounds, multidisciplinary med rec task force
- Board, Senior Management MAC, P&T, UHN Ops…..Board, Senior Management MAC, P&T, UHN Ops…..
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UHN Medication Reconciliation UHN Medication Reconciliation Resource PackageResource Package
Includes:Includes:1.1. UHN Medical Staff BulletinUHN Medical Staff Bulletin2.2. UHN Organization Wide Roll Out PlanUHN Organization Wide Roll Out Plan for for
Inpatient and Ambulatory AreasInpatient and Ambulatory Areas• Admission, Internal Transfer, Discharge, Admission, Internal Transfer, Discharge,
Ambulatory ClinicsAmbulatory Clinics3.3. Step-wise implementation plan for each Step-wise implementation plan for each
inpatient ward (admission reconciliation)inpatient ward (admission reconciliation)
4.4. Medication Reconciliation Fact Sheets Medication Reconciliation Fact Sheets (accreditation ROPs and current overall (accreditation ROPs and current overall status at UHN)status at UHN)
5.5. Communication tools :Communication tools : poster, medication poster, medication reconciliation website on UHN intranet, reconciliation website on UHN intranet, link to educational videolink to educational video
.....Continued Next Slide .....Continued Next Slide
Hospital Internet CommunicationHospital Internet Communication
Hospital Internet Communication (continued) Hospital Internet Communication (continued)
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Includes:Includes:6.6. Patient Information on Medication ReconciliationPatient Information on Medication Reconciliation7.7. Screen Shots: EMITT (electronic medication Screen Shots: EMITT (electronic medication
information transfer tool)information transfer tool)8.8. Sample documentation/ outputs:Sample documentation/ outputs: EMITT (electronic EMITT (electronic
medication information transfer tool)medication information transfer tool)• EPR Medication Reconciliation Status/ BPMH noteEPR Medication Reconciliation Status/ BPMH note• Electronic reconciled discharge prescription, Electronic reconciled discharge prescription,
patient medication schedule, wallet card, patient medication schedule, wallet card, medication information transfer letter medication information transfer letter
9.9. Clinician Tools:Clinician Tools:• BPMH Tip sheet; Clinician BPMH Interview Guide BPMH Tip sheet; Clinician BPMH Interview Guide
10.10. Prescriber/ Nursing In-service Presentation SlidesPrescriber/ Nursing In-service Presentation Slides
UHN Medication Reconciliation UHN Medication Reconciliation Resource PackageResource Package
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How do we actually “get started and How do we actually “get started and sustain” implementation?sustain” implementation?
LeadershipLeadershipCoordinationCoordination
CommunicCommunicatioationnPeoplePeople
Tools/ SystemsTools/ Systems
Five Tips & StrategiesFive Tips & Strategies
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Sample Tools in Guide Sample Tools in Guide
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Tools & Strategies on CoPTools & Strategies on CoP
•BPMH guides/ trigger sheetsBPMH guides/ trigger sheets•BPMH FormsBPMH Forms•BPMH leading to admission order BPMH leading to admission order
formsforms•Patient Risk Assessment / ScoringPatient Risk Assessment / Scoring• Instructional VideosInstructional Videos• Empowering patients as part of Empowering patients as part of
the BPMH process the BPMH process
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Medication Reconciliation in Medication Reconciliation in the Ambulatory Clinicsthe Ambulatory Clinics
ISMP Canada / O. Fernandes UHN ISMP Canada / O. Fernandes UHN
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Ambulatory Clinic Medication Reconciliation Ambulatory Clinic Medication Reconciliation
Meetings with Ambulatory Clinic Meetings with Ambulatory Clinic Leaders/ CliniciansLeaders/ Clinicians
• Review models/ tools already in place Review models/ tools already in place • Most clinics do not have pharmacists- Most clinics do not have pharmacists-
will need to consider mainly nursing/ will need to consider mainly nursing/ prescriber based modelsprescriber based models
• Nephrology model – recently updatedNephrology model – recently updated• Presented to UHN Med Rec Task Force & Presented to UHN Med Rec Task Force &
Ambulatory Working Group for feedbackAmbulatory Working Group for feedback• Recognition: different types of clinics Recognition: different types of clinics
(chronic care, procedural, different (chronic care, procedural, different health care professional mix)health care professional mix)
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Considerations: UHN Ambulatory Considerations: UHN Ambulatory Medication Reconciliation Practice Medication Reconciliation Practice
ModelModel
Clinic Chart Med List
Client BPMH on visit
Updated Clinic Chart
Med List
• Discrepancies identified
• Review and follow up where indicated
Nurse
As applicable
Other Healthcare Professional
Tools:
• Paper? (e.g. HD clinic model)
• Electronic? (e.g. OTTR)
• Other?
Phmt
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Practical Tips to Sustain Med Practical Tips to Sustain Med RecRec
Kim Streitenberger RN, The Hospital for Sick Children, Oct 2008Kim Streitenberger RN, The Hospital for Sick Children, Oct 20081.1. Consider sustainability & spread from the Consider sustainability & spread from the
moment you start developing the med rec moment you start developing the med rec process in your pilot areaprocess in your pilot area
2.2. Consider Consider change fatigue & competingchange fatigue & competing local & local & corporate initiativescorporate initiatives
3.3. Embed intervention in existing processesEmbed intervention in existing processes e.g. e.g. med rec form doubles as order form med rec form doubles as order form
4.4. Identify Identify frontline med rec champions tofrontline med rec champions to provide provide direct implementation supportdirect implementation support
5.5. Make it difficult for people to Make it difficult for people to revert to “old revert to “old ways”ways” of doing things of doing things
6.6. Provide Provide visible leadershipvisible leadership support support
7.7. Share resultsShare results with patients, families & staff with patients, families & staff
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Take Home MessagesTake Home Messages• Consider Consider Five StrategiesFive Strategies for implementation for implementation
– People- empowering cliniciansPeople- empowering clinicians– CoordinationCoordination– CommunicationCommunication– LeadershipLeadership– Tools & systemsTools & systems
• Involve all team membersInvolve all team members in developing in developing processes designed for everyday practice processes designed for everyday practice
• Incorporate Incorporate tools, systems, clinician tools, systems, clinician educationeducation programs and strategies programs and strategies
• Use Use data and ongoing performance to drive data and ongoing performance to drive and inspire changeand inspire change
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More: Tips from Front Line Clinicians:
• Develop a system/ practice where clinicians Develop a system/ practice where clinicians “could not “could not imagine going back to old practice”imagine going back to old practice”
• Physician engagement:Physician engagement:– Involve physicians right from the beginning in the planning Involve physicians right from the beginning in the planning
processprocess– ““buy in” vs. “ownership”buy in” vs. “ownership”– Value added / Time saving – medication reconciliation Value added / Time saving – medication reconciliation
engrained into everyday practice engrained into everyday practice – Efficicincies : BPMH form that leads to MD orders Efficicincies : BPMH form that leads to MD orders – Show the local patient safety impact in your ED (SHN data Show the local patient safety impact in your ED (SHN data
collection)collection)– Share your data regularly and visibly Share your data regularly and visibly
• Site Visits- Successful Teams and ColleaguesSite Visits- Successful Teams and Colleagues– How are medication histories currently being conducted? How are medication histories currently being conducted?
Does med rec implementation involve building upon pre-Does med rec implementation involve building upon pre-existing practice or a major shift in practiceexisting practice or a major shift in practice
S. Ingram/ J. Volling/ O. Fernandes UHN
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More: Tips from Front Line Clinicians:
• Involve Patients!Involve Patients!– patient satisfaction/ engagementpatient satisfaction/ engagement– enjoy/ empowered when they are participating in care ,enjoy/ empowered when they are participating in care ,– instills confidence in their care); patient-friendly instills confidence in their care); patient-friendly
brochures, posters and forms to document medicationsbrochures, posters and forms to document medications• Know the limitations of your medication information sources/ Know the limitations of your medication information sources/
systems?systems?– DPV viewer – insurance database- not actual patients doses and DPV viewer – insurance database- not actual patients doses and
frequenciesfrequencies
• Upstream ED reconciliationUpstream ED reconciliation– empowers admitting services to optimally perform empowers admitting services to optimally perform
discharge reconciliationdischarge reconciliation– Synchronize/ coordinate with ward cliniciansSynchronize/ coordinate with ward clinicians
• Make the best of what is already out there/ tested Make the best of what is already out there/ tested tools & strategies:tools & strategies:– BPMH form to MD orders samples, pre-printed orders, BPMH form to MD orders samples, pre-printed orders,
BPMH interview guides, education and training programs, BPMH interview guides, education and training programs, in-services, Posters & videosin-services, Posters & videos
S. Ingram/ J. Volling/ O. Fernandes UHN
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QuestionsQuestions
olavo.fernandes@uhn.on.caolavo.fernandes@uhn.on.ca
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