Leveraging the Tools You Have Instead Of Waiting for the Perfect Process: Introduction of an EMedication

Reconciliation Process in a Rural Hospital EMR

“Managing the Unexpected”

By Karl E. Weick &Kathleen M. Sutcliffe

High Reliability Organizations

• Tracks Small Failures• Resists Oversimplifications• Remains Sensitive to Operations• Maintains Resiliency• Takes Advantage of Shifting Areas of Expertise

Business as Usual

• Small Failures Go Unnoticed• Simple Diagnosis were Accepted• Frontline Operations were Taken for Granted• Recovery was Treated as Routine• Experts Deferred to Authority

Medical Staff Impression of eMR

Herding Cats

• MMC Hospitalist Practice

Prior eMR Implementations

• CPOE• Nursing Documentation• Medication Management• Diabetic Management• Documentation• PACS

eMedRec Implementation

• Not My Responsibility• ER and ICU too Busy• Not Using Pharmacy MedEx to Properly Identify

Home Medications• Free Texting Medications• Incomplete Home Med Entries• Physicians Workflow Impeded, Especially at Time

of D/C• Physicians Stopped Using eMedRec, 0 Utilization!

What We Did Wrong:

Did Not Track Small Failures!

What We Did Right!(We had to Get IT Right)

• Resist Oversimplification• Remain Sensitive to Operations• Maintain Capabilities for

Resilience• Take Advantage of Shifting Areas

of Expertise

Maintain Capabilities for Resilience

• The Ability to Absorb Strain and Preserve Functioning Despite Adversity

• An Ability to Recover from Adversity• The Ability to Learn and Grow• Team Approach

Deference to Expertise

• Re-educate Nurses, Especially at Point of Initial Contact with the Patient

• Asked Nursing for Their Input• Health IT in Almost Constant Contact with

Vendor, Nursing and Physicians• Getting the Health Care Providers We Could

Leverage to Continue eMedRec• C-Suite Support, Especially CNO

Results

• In 2 Months 52% eMedRec Use• Ortho and OB/Gyn Began to Use• Ability to Use Clinical Decision Support at D/C• Improved Communication of Medications to

the Patient and Family• Improved Communication with Primary Care

Providers

The new age of medicine practiced in the same way that High Reliability Organizations are run--tracking small failures, resisting oversimplifications, remaining sensitive to each patient, finding a way to be resilient and taking advantage of shifting locations of expertise. Suddenly, I felt the wheels hit the runway, maybe a little too hard, but reliably with every one of those 234 passengers safely transitioned back to the ground.

"Physicians are essential to progress in improving healthcare systems. Unprepared or unwilling they can be barriers to badly needed change. If they do not understand-indeed if they do not thrive in-the world of interaction and interdependency in which they work now, and if they unscientifically regard their own deeds as sufficient in excellence, they can confound systemic excellence and impede needed system changes. At their best, well prepared and willing, they can lead and accelerate changes in care processes that are grounded in good clinical data and sound theory". (Berwick & Finkelstein, Acad. Med 2010)

'A physician equipped to help improve healthcare will not be demoralized, but optimistic, not helpless in the face of complexity, but empowered; not frightened by measurement, but made curious and more interested; not forced by culture to wear the mask of the lonely hero, but armed with confidence to make a better contribution to the whole.” (Berwick & Finkelstein, Acad. Med. 2010)