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1
MEDICATION RECONCILIATION
in a Pre-Admission Clinic
CRITICAL SUCCESS FACTORS
Cynthia Turner, B. Pharm, R.Ph.
Medication Reconciliation Pharmacist
Vancouver Island Health Authority (VIHA)
2
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
3
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
4
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
5
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
6
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
7
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
8
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
9
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
10
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
11
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
12
CRITICAL SUCCESS FACTORS
1. Documentation
2. Communication
3. Education
4. Program Sustainability
5. Spread Mentor
13
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
14
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
15
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
16
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%
17
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.)
18
11
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
18
19
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
20
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
21
2. Communication
a) Speak language of audience
Two examples
• IMPACT of program on patient safety
• IMPACT of program on patient admissions
22
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
23
Impact of Process at RJHALL Admissions
Jan to Jun 2007
Med Rec Process
8 %
Non Med Rec 92 %
24
Impact of Process at RJH
Non-Emergency admissions Jan to Jun 2007
Med Rec Process
18%
Non Med Rec 82%
25
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.
26
2. Communication
c) Show-off your results
- Before & after measures on wards
- Poster in Senior Executive area
- Display in cafeteria, newsletter etc.
27
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
28
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
29
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
30
… one person needs time off
31
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?
32
33
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?
34
35
Contact Information
• Cynthia Turner, Med Rec [email protected]
• Lori Brodie, [email protected]
• Richard Bachand Manager, Clinical Pharmacy Services