ahrq medication reconciliation

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Medications at Transitionsand Clinical Handos(MATCH) Toolkit orMedication Reconciliation


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Medications at Transitions and ClinicalHandos (MATCH) Toolkit or MedicationReconciliation

Prepared or:Agency or Healthcare Research and QualityU.S. Department o Health and Human Services540 Gaither Road

Rockville, MD 20850www.ahrq.gov

Contract No. HHSA2902009000 13C

Prepared by:Northwestern Memorial HospitalChicago, IllinoisKristine Gleason, R.Ph.Helga Brake, Pharm.D.

Island Peer Review Organization, Inc.Lake Success, New York

Victoria Agramonte, R.N, M.S.N.Carrie Peretti, Esq.

AHRQ Publication No. 11(12)-0059Revised August 2012


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This document is in the public domain and may be used and reprinted without permission exceptthose copyrighted materials that are clearly noted in the document. Further reproduction o thosecopyrighted materials is prohibited without the specic permission o copyright holders.

Suggested Citation:

Gleason KM, Brake H, Agramonte V, Peretti C. Medications at Transitions and ClinicalHandos (MATCH) Toolkit or Medication Reconciliation. (Prepared by the Island Peer ReviewOrganization, Inc., under Contract No. HHSA2902009000 13C.) AHRQ Publication No. 11(12)-0059. Rockville, MD: Agency or Healthcare Research and Quality. Revised August 2012.

Acknowledgments

This toolkit is based on the Medications at Transitions and Clinical Handos (MATCH)Web site developed by Gary Noskin, M.D., and Kristine Gleason, R.Ph., o NorthwesternMemorial Hospital in Chicago, Illinois, through the support o the Agency or Healthcare

Research and Quality (AHRQ) under Grant No. 5 U18 HS015886 and collaborationbetween Northwestern University Feinberg School o Medicine and The Joint Commission.

The authors, who were supported in part by AHRQ Contract No. HHSA2902009000 13C,are responsible or the content, ndings, and conclusions in this document, and it does notnecessarily represent the view o AHRQ. No statement in this report should be construed asan ocial position o AHRQ or o the U.S. Department o Health and Human Services.


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ContentsAcknowledgments ..........................................................................................................................ii

Introduction ...................................................................................................................................1

How to Use This Toolkit ...........................................................................................................2

Chapter 1: Building the Project Foundation: Gaining Leadership Support Within

the Organization ............................................................................................................................3

Medication Reconciliation as a Patient Saety Issue ....................................................................3

Resource Justication to Produce a Successul Project ................................................................4

Linking Medication Reconciliation with Other Initiatives ...........................................................6

Chapter 2: Building the Project Foundation: Project Teams and Scope .........................................11

Step 1: Identiy and Assemble an Interdisciplinary Team ..........................................................11

Step 2: Create a Flowchart o the Current Medication Reconciliation Process ..........................13Step 3: Develop a Project Charter or Work Plan or Improvements ..........................................17

Step 4: Establish a Measurement Strategy ................................................................................18

Chapter 3: Developing Change: Designing the Medication Reconciliation Process ......................21

Guiding Principles or Designing a Successul Medication Reconciliation Process .....................21

One Source o Truth ............................................................................................................22

Dening Roles and Responsibilities or Medication Reconciliation ...........................................25

Integrating Medication Reconciliation into Existing Workfow .................................................26

Flowcharting the Design or Redesign or Medication Reconciliation ........................................26

Designing the ProcessConsiderations or Various Practice Settings .......................................27

Chapter 4: Developing and Pilot Testing Change: Implementing the Medication Reconciliation

Process .........................................................................................................................................35

Pilot Testing the Solution ........................................................................................................35

Preparing or Implementation ..................................................................................................37

Developing the Implementation Strategy .................................................................................38

Chapter 5: Education and Training ...............................................................................................41

Education and Training Strategy ..............................................................................................41

Education and Training Curriculum on Medication Reconciliation ..........................................41

Chapter 6: Assessment and Process Evaluation ..............................................................................49

Examples o Metrics and Auditing Tools ..................................................................................51Reporting Audit Results...........................................................................................................52

Post-Implementation Strategies to Increase and Sustain Compliance ........................................52Special Considerations: The National Coordinating Council or Medication Error Reporting

and Prevention......................................................................................................................54


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Chapter 7: High-Risk Situations or Medication Reconciliation ..................................................... 57

Health Literacy ......................................................................................................................... 57

The Cognitively Impaired Patient ............................................................................................. 58

External Transer Cases ............................................................................................................. 59

Conclusion .................................................................................................................................... 61

Reerences ..................................................................................................................................... 63

Appendix: The MATCH Work Plan ............................................................................................. A-1


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IntroductionMedication reconciliation is a complex process that aects all patients as they move through all

health care settings. It is a comparison o the patients current medication regimen against thephysicians admission, transer, and/or discharge orders to identiy discrepancies. Any discrepanciesnoted are discussed with the prescriber, and the order is modied, i necessary. (A completedenition o medication reconciliation is available in the Appendix at pg. A-25)

Although this toolkit is based on processes developed in acute-care settings, the core processes, tools,and resources can be adapted or use in non-acute acilities.

Medication reconciliation is a process to decrease medication errors and patient harm in theollowing ways:

Obtaining, veriying, and documenting the patients current prescription and over-the-countermedicationsincluding vitamins, supplements, eye drops, creams, ointments, and herbals

when he or she is admitted to the hospital or is seen in an outpatient setting. Considering the patients pre-admission/home medication list when ordering medicinesduring a hospital encounter and continuing home medications as appropriate, and comparingthe patients pre-admission/home medication list to ordered medicines and treatment plans toidentiy unintended discrepancies (i.e., those not explained by the patients clinical condition orormulary status).

Veriying the patients home medication list and discussing unintended discrepancies with thephysician or resolution.

Providing an updated medication list and communicating the importance o managingmedication inormation to the patient when he or she is discharged rom the hospital or at the

end o an outpatient encounter.The eectiveness o a sound medication reconciliation process within and among care settings isan important component o patient saety goals. While many health care providers already havemedication reconciliation processes in place, this toolkit helps acilitate a review and improvement ocurrent practices to strengthen the process with the result o improved patient saety.

This toolkit is based on the Medications at Transitions and Clinical Handos (MATCH) Website developed through the support o the Agency or Healthcare Research and Quality (AHRQ)and collaboration between Northwestern Memorial Hospital, Northwestern University FeinbergSchool o Medicine in Chicago, Illinois, and The Joint Commission. It is available at http://www.nmh.org/(search or toolkit). In addition to elements rom the MATCH Web site, this toolkitalso incorporates the experiences and lessons learned rom sta o acilities that have implemented

MATCH and acilities that received technical asssistance on MATCH through the AHRQ QualityImprovement Organization (QIO) Learning Network.

While your acility may already have a medication reconciliation process in place, this toolkit will helpyou evaluate the eectiveness o the existing process, as well as identiy and respond to any gaps.It promotes a successul approach to medication management and reconciliation that emphasizesstandardization o the process or doctors, nurses, and pharmacists within the acility to document
http://www.nmh.org/nm/for-physicians-matchhttp://www.nmh.org/nm/for-physicians-matchhttp://www.nmh.org/nm/for-physicians-matchhttp://www.nmh.org/nm/for-physicians-match


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and conrm a patients home medication list upon admission. It also emphasizes the need to clearlydene roles and responsibilities o clinical sta. Standardizing the process or collecting homemedication lists, as well as the location and means o documenting this inormation, ensures that the

most accurate, complete medication history is documented or each patient; all the inpatient andhome medications are reconciled; and the inormation is accessible to the entire health team.

How to Use This ToolkitThis toolkit provides a step-by-step guide to improving the medication reconciliation process. Usersare encouraged to ollow the steps in the order presented. Each step builds upon the next to presenta systematic methodology or critically reviewing and improving the medication reconciliationprocesses.

This toolkit is divided into seven components to assist with improvement:

1. Building the Project Foundation: Gaining Leadership Support within the Organization2. Building the Project Foundation: Project Teams and Scope

3. Developing Change: Designing the Medication Reconciliation Process

4. Developing and Pilot Testing Change: Implementing the Medication Reconciliation Process

5. Education and Training

6. Assessment and Process Evaluation

7. High-Risk Situations or Medication Reconciliation

The Appendix also unctions as a Work Plan to implement medication reconciliation in your acility

according to the MATCH principles. The Work Plan is available as a standalone le on the AHRQWeb site at http://www.ahrq.gov/qual/match/ so you can print multiple copies or use withleadership, design, and implementation teams.
http://www.ahrq.gov/qual/match/http://www.ahrq.gov/qual/match/


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Chapter 1: Building the Project

Foundation: Gaining Leadership SupportWithin the OrganizationAn essential rst step in implementing a successul medication reconciliation perormanceimprovement project is to gain support within the organization. To be successul, you need thesupport o leadership, physicians, nurses, pharmacists, and other stakeholders that play a role inmedication management practices.

This section presents talking points or making a sound argument or undertaking a medicationreconciliation project. Making the connection to other ongoing patient saety initiatives, regulatory/accreditation requirements, and operational eciencies are important elements that can help youobtain support. Talking points should address all or part o the ollowing components:

Medication reconciliation as a patient saety issue

Resource justication to produce a successul project

Linking medication reconciliation with other initiatives

Medication Reconciliation as a Patient Saety IssueA review o the literature notes several decades worth o articles describing medication discrepanciesor lack o concordance, while ew have addressed solutions to the problem. A publication in2001 by Rozich and Resar1 quantied discrepancies during key transition points such as hospital

admission, intra-hospital transer, and discharge. Additional studies have validated vulnerabilitiesduring these transition points:

Variances between medications patients were taking prior to admission and their admissionorders ranged rom 30 percent to 70 percent in two literature reviews. 2,3

A study o medication reconciliation errors and risk actors at hospital admission noted that 36percent o patients had errors in their admission medication orders with the majority o theseoccurring during the medication history gathering phase.4

A study utilized 12 years o administrative records o all hospitalizations and outpatientprescriptions or almost 400,000 patients age 66 older to determine (1) continuous useo at least 1 o 5 medication classes and (2) ailure to renew prescriptions within 90 days

post-hospital discharge.

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Patients prescribed chronic medications were at higher risk orunintentional discontinuation ollowing hospital discharge, and intensive care unit (ICU) stayduring hospitalization increased the risk o medication discontinuation even urther.

Findings rom these studies as well as many others reinorce the need or a structured process ocomparison and resolutionsuch as medication reconciliationto help ensure patient saety andmedication continuity during care transitions.


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Resource Justication to Produce a Successul ProjectMost health care acilities today are operating with limited resources, including nancial and stang

limitations. A sound project plan helps to identiy roles, responsibilities, and sta resources. A strongbusiness case outlines the nancial incentives or the acility.

Examples o two models to calculate potential gross savings o a newly designed or improvedmedication reconciliation process are provided. Specically, the rst model demonstrates a cost-benet analysis o reducing preventable adverse drug events (ADEs); the second model demonstratesa cost-benet analysis o the use o pharmacists or other sta to perorm medication reconciliation.

The rst is a nancial model developed by Steven B. Meisel, PharmD, Director o MedicationSaety at Fairview Health Services in Minneapolis, Minnesota. This example is also contained on theMATCH Web site and reproduced with permission in this toolkit.

Published data rom the Institute o Medicine6 and others demonstrate discrepancies in medication

regimens among people admitted to health care acilities, and some o those discrepancies willlead to an ADE that could seriously harm a patient. The estimated cost o a preventable ADE was$4,800 per event, based on a 1997 study done by Bates et al. 7 Some organizations have calculatedan ADE cost as high as $10,375.8 Dr. Meisels internal data show that an eective medicationreconciliation process can detect and avert up to 85 percent o medication discrepancies. Conductingeective medication reconciliation on admission is estimated to take 15 to 30 minutes. With theseassumptions in mind, Meisel outlines the calculations shown in Model 1.

Model 1: Financial Model or Medication Reconciliation

Number o discrepancies per patient

X Number o patients per year that one person can reconcile

X Percent o patients with discrepancies that would result in an ADE

X Percent eectiveness o process

X Cost o an average ADE

= Annual gross cost savings

- Salary o Employee

= Annual Net Savings

Source: Presented by Steven B. Meisel, PharmD, at The Joint Commission/Institute or Sae Medication PracticesMedication Reconciliation Conerence, Nov. 14, 2005.

To calculate the net cost savings, subtract the cost o the anticipated resource investment (sta,equipment, IT) rom the gross cost savings. Net savings will vary depending on the type o stadesignated to perorm medication reconciliation (nurse, pharmacist, pharmacy technician, orphysician), as shown in Table 1 (pg. 5).


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Table 1: Net Savings or Medication Reconciliation

1.5 (discrepancies per patient admitted to Fairview)

X 6000 patients (average o 20 minutes/patient to complete medication reconciliation)X 0.01 (1% o Fairview admissions experience discrepancies that would result in an ADE)

X 0.85 (85% o discrepancies avoided through medication reconciliation process)

X $2500 (conservative cost o an ADE)

= $191,250 annual gross savings

- $45,000 (salary and benets o an incremental pharmacy technician)

= $146,250 annual net savings (325% return on investment in a new sta member)

The second model, developed by Steve Rough, M.S., R.Ph., Director o Pharmacy at the Universityo Wisconsin Hospital and Clinics, includes a template or pharmacist justication to collect andreconcile medication history on admission to a acility. Table 2 (pg. 6), indicates average time

requirements or pharmacists perorming various levels o interaction with patients, records, andinterventions.

Model 2 is an adaptation o the template based on sample data collection at Northwestern MemorialHospital.

Model 2: Pharmacist Justication or Medication History Collection and Reconciliationon Admission

Average # o discrepancies/medication errors per patient 2.2

Number o inpatient admissions per year 43,312 (2006)

Potential medication errors per year that can be avoided 95,286 (2.2 x 43,312)Percent o medications that were potentially harmul to patient duringhospitalization*

2.5%

Number o harmul medication errors avoided per year 2,382

Annual gross savings to hospital ($4,800 per harmul error)* $11,434,320

Average pharmacist time requirement per admission* 21 minutes

Additional pharmacist FTE needed to provide service (based on 115admissions daily)

~ 5 FTE

Cost o additional pharmacist FTE (salary + benets) $625,000

Annual Net Savings/Cost Avoidance $11.4M

Source: This template was presented by Steve Rough, MS, RPh at the American Society o Health-System PharmacistsSummer Meeting, June 26, 2006. Used with permission.


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Table 2: Time Requirements or Pharmacist-Obtained Medication Histories andReconciliation*

Average time to obtain medication history 9 minutes/patient

Average time to obtain medication history andprovide necessary interventions/documentation

12 minutes/patient

Average time or chart review prior to medicationhistory, medication history interview and necessaryinterventions/documentation

21 minutes/patient

*Based on an evaluation o 651 general medicine patients interviewed by a research pharmacist at Northwestern MemorialHospital, Chicago, IL, who obtained a complete medication history and reconciled medications with other documentedmedication histories and current orders.

These templates can be applied to other disciplines, as well as other transitions in care, using

published error data or by looking at error data at your own institution.

Linking Medication Reconciliation with Other InitiativesMaking the connection to other ongoing quality and patient saety initiatives, regulatory/accreditation requirements, and operational eciencies is important or garnering support andachieving a successul medication reconciliation process. Other initiatives that can be linked to yourmedication reconciliation eorts may include: The Joint Commission (TJC) National Patient SaetyGoals (NPSGs), Centers or Medicare and Medicaid Services (CMS) process o care (core) measures,the Survey o Patients Hospital Experience, hospital readmissions, and other national qualityimprovement activities.

The Joint Commission Accreditation and Other National Quality Improvement Activities.TJC continues to recognize the importance o medication reconciliation, despite the need or severaliterations to its NPSGs. The revised NPSG 03.06.01, which went into eect July 1, 2011, requiresacilities to maintain and communicate accurate patient medication inormation.9 This revised goalpreserves the intent o the original NPSG while creating a more reasonable approach to tailor theprocess to meet specic medication management needs or a patient within a particular care setting.The MATCH toolkit can help acilities work toward meeting this patient saety goal.

Recent revisions to TJC NPSG take into account eedback rom accredited organizations o thecomplexity o meeting the retired goal #8. Scoring or NPSG 03.06.01 resumed July 2011, and theelements o perormance are noted below:

Obtain and document or veriy patients medication list when admitted or seen as an

outpatient. Medications to inquire about should include current prescription and over-the-counter (OTC) medications, such as vitamins, supplements, eye drops, creams, ointments, andherbals.

Dene the types o medication inormation to be collected in non-24-hour settings anddierent patient circumstances.


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Compare medication inormation the patient brought to the hospital with those ordered toidentiy unintended discrepancies (e.g., those not explained by the patients clinical conditionor ormulary status). A qualied individual conducts the comparison, per TJC requirements.

Discuss unintended discrepancies with the physician or resolution.

Provide the patient/amily with written inormation on the medications the patient should betaking when discharged rom the hospital, or at the end o an outpatient encounter.

Explain the importance o managing medication inormation to the patient when discharged orat the end o an outpatient encounter. Instruct the patient to:

Give a list to their primary care provider.

Update the list when medications are discontinued, doses are changed, or newmedications (including OTC medications) are added.

Carry medication inormation at all times in case o an emergency.

Centers or Medicare and Medicaid Services Process o Care (Core) Measures. Process o care(core) measures demonstrate how oten hospitals adhere to recommended treatments or certainmedical conditions, such as acute myocardial inarction, heart ailure, and pneumonia, or or surgicalprocedures. Hospital perormance is publicly reported on the CMS Web site Hospital Compare(http://www.hospitalcompare.hhs.gov/). Soon, several o these measures will move rom a pay-or-reporting structure to reimbursement based on perormance (value-based purchasing), rewardinghospitals or their achievements as well as improvements. Higher perormance scores may be realizedby applying medication reconciliation elements, or example:

Incorporating a reconciled medication list into the discharge instructions or heart ailurepatients.

Obtaining a vaccination history to determine eligibility to receive infuenza vaccination orpneumococcal vaccination.

Determining whether patients were taking a beta-blocker prior to surgery and reconciling post-operative orders to ensure beta-blocker continuation ater surgery.

Survey o Patients Hospital Experience. Hospitals use the Hospital Consumer Assessment oHealthcare Providers and Systems (HCAHPS) survey, which is the rst national, standardized,publicly reported survey o patients perspectives o hospital care. While many hospitals havecollected inormation on patient satisaction or their own internal use, until HCAHPS there was nonational standard or collecting and publicly reporting inormation about patient experience o carethat allowed valid comparisons to be made across hospitals locally, regionally, and nationally. In theuture, other health care settings (e.g., nursing homes, home health) will have similar requirements.

HCAHPS contains 18 patient perspectives on care and patient rating items that encompass eightkey topics: Communication with doctors, communication with nurses, responsiveness o hospitalsta, pain management, communication about medicines, discharge inormation, cleanliness o thehospital environment, and quietness o the hospital environment.


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Sample survey questions pertaining to medications include:

During this hospital stay, did you need medicine or pain?

During this hospital stay, how oten was your pain well controlled?

During this hospital stay, were you given any medicine that you had not taken beore?

Beore giving you any new medicine, how oten did hospital sta tell you what the medicinewas or?

Beore giving you any new medicine, how oten did hospital sta describe possible side eectsin a way you could understand?

A complete list o HCAHPS survey questions is at http://www.hcahpsonline.org/home.aspx.

Meaningul Use o Electronic Health Records. Many health care providers utilize paper-basedmedical record systems. New government incentives and programs are encouraging health care

providers across the country to convert to or adopt electronic health records (EHRs). Specically,the Health Inormation Technology or Economic and Clinical Health (HITECH) Act provides theU.S. Department o Health and Human Services (HHS) with the authority to establish programsto improve health care quality, saety, and eciency through the promotion o health inormationtechnology (IT), including EHRs and private and secure electronic health inormation exchange.Under HITECH, eligible health care proessionals and hospitals can qualiy or Medicare andMedicaid incentive payments when they adopt certied EHR technology and use it to achievespecied objectives. With respect to EHRs, health care providers are required to succeed in each othese three areas:

1. Gathering o complete and accurate inormation.

2. Achieving improved access to patient inormation.

3. Empowering patients.

The MATCH toolkit can be implemented through an EHR (see examples in Chapter 3, pgs. 28-33) or to help health care providers meet these goals. It provides a ramework to capture completeand accurate medication inormation, improves communication o that inormation among healthcare providers, and empowers the patient to know what medications are needed ater leaving a caresetting.

For more specic details on Meaningul Use, visit the HHS Oce o the NationalCoordinator or Health IT (ONC) Web site at http://healthit.hhs.gov/portal/server.pt?open=512&objID=2996&mode=2. The ONC Health IT Web site also includes inormation onhow to qualiy or Medicare/Medicaid incentive payments related to Meaningul Use.
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Reducing Readmissions and Other National Initiatives. A successul business case should helpleadership make the connection between clinical quality, medication reconciliation, and medicationsaety by highlighting outcomes such as a reduction o ADEs or hospital readmissions due to

medication discrepancies carried across the continuum o care. In 2011, HHS launched the largestnational quality improvement initiative in the history o our health system. The Partnership orPatients initiative has challenged hospitals to improve the quality, saety, and aordability o healthcare or all Americans. This public-private partnership has two main goals: To keep patients romgetting injured or sicker rom the care they receive by reducing preventable hospital acquiredconditions and to help patients heal without complication by improving the transition process. Moreinormation on the Partnership or Patients is available at http://www.healthcare.gov/compare/partnership-or-patients/.

Chapter 1 Lessons Learned

Lessons learned rom sta o acilities that have implemented MATCH and acilities that received

technical assistance on MATCH through the AHRQ QIO Learning Network include:

Leaders who attended MATCH trainings were able to achieve a high level o success as well asgenerate excitement around their medication reconciliation initiatives in their acilities.

Leadership support should encompass more than an organizational endorsement; the supportrequires a sustained commitment o resources and time through the continuum o care.

A leadership team with continual involvement, ocus, and commitment is integral to thesuccess o a medication reconciliation project.

A multidisciplinary team, including patient involvement, ensures the project designincorporates diverse perspectives and practice settings.

The leadership team should promote the concepts o this toolkit into culture and practice orsae medication management in the acility.

Follow the steps in the toolkit sequentially to establish a oundation or the project.Overlooking one step can hinder progress toward the established goal(s).
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Chapter 2: Building the Project

Foundation: Project Teams and ScopeOnce the business case has been made or medication reconciliation and leadership support has beenobtained, the next steps toward building the oundation or your project include:

1. Identiy and assemble an interdisciplinary team.

2. Create a fowchart o the current medication reconciliation process.

3. Develop a project charter or work plan or improvements.

4. Establish a measurement strategy.

The above steps build on one another and are essential in establishing a solid oundation to support

improvement eorts.

Step 1: Identiy and Assemble an Interdisciplinary TeamAssembling a medication reconciliation team is an important rst step. The team will be responsibleor reviewing the current medication reconciliation process, identiying gaps and opportunities orimprovement, and taking the lead on process design/re-design within the health care acility.

The medication reconciliation team may be subdivided into three core groups:

Leadership Team

Design Team

Additional Stakeholders

A stakeholders analysis helps identiy key people in the acility who will be aected by theproject; these individuals can range rom hospital leadership to rontline sta to patients. List eachstakeholders role, impact, and interest in the project.

Roles and Responsibilities o Team Members

To gain support, team members must be clear about their role on the committee; being specicabout the expectations o the project will allow each member to decide i they can handle theassignment beore it is given. This will also allow each member to make a commitment to the teamand carry out this responsibility to the end. Examples o establishing dened roles may include:

conducting baseline audits, collecting and analyzing subsequent data, and leading the task ofowcharting.

Leadership Team. The Leadership Team provides oversight or the medication reconciliationproject. The Leadership Team should include Executive Sponsors, Project Sponsors, andImprovement Leaders. The characteristics, roles, and responsibilities include the ollowing:

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Executive Sponsor(s):

Member(s) o the senior management team (e.g., physician, nursing, and executive leaders inthe organization).

Provide executive oversight.

Provide guidance and accountability and endorse recommendations.

Identiy and remove organizational barriers.

May represent inpatient and outpatient practice settings depending on the projects scope;representation rom both settings may help bridge the gap during transitions rom hospital tohome.

Project Sponsor(s):

Leader(s) rom various disciplines such as the pharmacy director, nursing director, hospitalists,department chies, director o inormation systems, chair o the pharmacy and therapeuticscommittee, etc.

Provide support or a timely and successul implementation.

Provide insights rom the perspective o the practices they represent.

Remove discipline-specic barriers.

Approve nal recommendations.

Improvement Leader(s):

Possess operational and quality improvement expertise as well as patient saety and medication

management knowledge to lead medication reconciliation eorts.

Ensure project goals and training are met within established timerames.

Help integrate operational changes into clinical workfow.

Design Team. The Design Team will play an integral role in the development or redesign o themedication reconciliation process. When assembling this team, it is important to include individuals

with actual knowledge o the current medication reconciliation process. The Design Team should becomprised o multidisciplinary members with a strong knowledge o current workfow, recognitiono the problem, and buy-in or improvement. Members may include:

Physicians, nurses, pharmacists, discharge planners, and others representing areas o ocus (e.g.,

inpatient units, outpatient clinics, procedural areas).

Representatives rom inormation systems, the emergency department, and patient saety andquality departments.

Patients, to ensure the design is approached rom their perspective.


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The Design Teams makeup may evolve over time as you work through the process and determineadditional resource requirements

The tool Questions to Ask When Developing the Design Team and Rationale is located in theAppendix (pg. A-2).

Additional Stakeholders. Additional stakeholders who will be directly or indirectly involved withenorcement o the new or redesigned process once implemented should be engaged early on.Engagement o these key stakeholders is important to gain acility wide support or the medicationreconciliation project. Additional stakeholders in the acility may include:

Managers or directors that oversee rontline sta to ensure nal design is carried out.

Department chies, chairs, and clinical program leaders overseeing physician participation in thedesign and implementation.

Leaders rom medical records to ensure orms and documentation are consistent with hospital

policies.

Individuals overseeing quality, licensure, and accreditation to ensure the process meetsregulatory requirements.

Frontline sta, quality committees, patients, etc., that may require periodic communicationand progress reports in preparation or implementation.

Establish a reporting mechanism to keep stakeholders inormed on the teams progress. It will beeasier to understand barriers rom their perspectives and work to develop solutions early on than it

will be much later during rollout and implementation.

Step 2: Create a Flowchart o the Current MedicationReconciliation ProcessThe second step in creating an inrastructure to support improvement o the medicationreconciliation process is to create a fowchart o the current process. A fowchart serves as a guideor developing the charter (see Step 3, pg. 17). In addition, it may help you determine whether todesign a new process or redesign the existing medication reconciliation process.

A fowchart outlines current workfow and helps identiy:

Successul medication reconciliation practices.

Current roles and responsibilities or each discipline at admission, transer, and discharge.

Potential ailures.

Unnecessary redundancies and gaps in the process.


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A fowchart o current practices can be modied during the design or redesign to highlight:

Elimination o unnecessary steps (i.e., simplication o process).

Dening roles and responsibilities in policy and procedure.

Standardization across disciplines and/or practice settings.

How new design steps integrate into existing workfow.

The tool Develop a Flowchart o Your Current Medication Reconciliation Process in theAppendix (pg. A-12) provides questions to guide you in developing the fow diagram or medicationreconciliation at each critical hando point: admission, intra-acility transer, and discharge.

Benets o Creating a Flowchart

Ater creating a fowchart o current practices, acilities reported the ollowing ndings:

Multiple disciplines obtained independent medication histories rom the patient.

Each independent medication history was documented in various discipline-dependent sectionsthroughout the medical record.

No prompts were in place to cross-reerence inormation or documentation.

Multiple medication histories were oten conficting.

The sample process maps at Figure 1 (pg. 15) and Figure 2 (pg. 16) demonstrate how fowchartingthe process can highlight and identiy redundancies as well as gaps in the medication reconciliationprocess.


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Figure 1: Medication Reconciliation Upon Admission: High-Level Process MapBeore Redesign

Multiple, independent medication histories obtained rom patient and documented throughout the

medical record.

No prompts to cross-reerence documentation, which may be conficting.

Nurse obtainsmedication historyand documentsin the nursingadmission patientassessment orm.

Consult services and

ancillary sta obtainmedication historiesas part o their initialassessment and documentin discipline-specicorms/notes.

Nurse administers medications topatient.

Physician ordersmedications basedon med list prior to

admission and patientscurrent clinical status.

No standardized, consistentprocess or physicians todocument and communicateordering decisions oreach home medication.

Intended versus unintendeddiscrepancies oten unclear.

No standardized,consistent processor medicationreconciliation.Increased timespent clariyingdiscrepancies due toinconsistent physician

documentation, otenvreating doublework or nurses andpharmacists.

Nurse reviewsmedicationorders prior toadministration. Anydiscrepancies orissues identiedare resolved with

prescriber.

Pharmacist reviewsmedication ordersprior to vericationand dispensing. Anydiscrepancies or issuesidentied are resolved

with prescriber.

Patient Admitted to Hospital

Physician obtains

medication history anddocuments in admissionnote (history andphysical). Changesor updates to historyburied in progressnotes.


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Figure 2: Medication Reconciliation Upon Discharge High-Level Process MapBeore Redesign

Inconsistent practices or documenting and

highlighting changes or updates or patient tohome medication list.

No standardized, consistent practice orphysicians to perorm discharge medicaitonreconciliation. Patient saety risks o documentingresume home meds not understated. Changesto initial medicaiton history documented toprogress notes/addendum may not be captured

when preparing dischage notes.

No standardized, consistent process or nurseto ensure patient receiving an updated homemedication list. No consistent approach toaddress and rectiy physician documentingresume home meds.

Patient being discharged rom hospital

Physician places discharge order

Physician writes new prescriptions,i needed

Physician prepares dischargeinstructions reerencing initial

medication history within admissionnote (history and physical)

Nurse counsels patient on dischargeinstructions and contacts physician iquestions or clarications are needed

Patient discharged


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Step 3: Develop a Project Charter or Work Plan orImprovements

A project charter provides a summary and high-level roadmap or your work. The importance outilizing a charter throughout the project is oten underappreciated, but its use is paramount inkeeping the project ocused, and it provides a work plan or the design team. The charter will be adynamic document that encompasses the ollowing elements:

Problem statement.

Goals and objectives.

Regulatory and accreditation requirements.

Project scope.

System capabilities/deliverables.

Resources needed or a successul project.

Project milestones (achievements throughout the project) and timeline.

See Developing Your Charter in the Appendix (pg. A-7) or a template charter that can be used asa starting point or the project.

Problem Statement. A problem statement is a concise description o the issues that need to beaddressed by the team and should be presented to them or created by them. A good problemstatement should consider the nature o the problem and how it impacts patient care.

Goals and Objectives. The team should establish goals and objectives that directly relate to theproblem statement. This component o the charter will keep the team ocused on the strategies that

were determined by the design team to improve medication reconciliation. Goals should be specic,measurable, attainable, realistic, and timely. A template or recording goals and objectives is availablein the Appendix (pg. A-9)

Regulatory and Accreditation Requirements. While developing the medication reconciliationcharter, medication policies and procedures and regulatory and accreditation requirements must beconsidered. Ensure that:

Individuals responsible or accreditation and licensure in your organization are integrated intothe team.

The process is designed to meet these requirements.

The design plan incorporates practice settings aected by these criteria.Project Scope. Beore determining the scope o the project, you may nd it helpul to create a listo all areas within your acility where patients receive medications. Create a list o practice settingsthat administer medications, and organize it by the type o patients they serve (inpatient, outpatient,both) and whether they admit and/or discharge patients to assist in prioritization.

Determining the Scope o the Project, located in the Appendix (pg. A-8), will assist in dening thescope o the project.


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Additional questions to consider when determining the scope o the medication reconciliationproject include:

Should the project encompass the entire acility, one practice setting, or several departments?

Should the project ocus on one specic area o identied risk (i.e., inpatient only) or more?

Should the project ocus on one service or unit at a time or more?

Should the ocus start with an admission process then move to discharge or should yourproject concentrate on both at the same time?

Should the initial scope include patients admitted through the emergency department or romprocedural areas, such as ambulatory surgery?

These questions can guide the development o the scope and charter o the project based on theindividuality o the acility and areas with the greatest need.

System Capabilities/Deliverables. The team should understand system level capabilities and/or barriers that may impact the project and use the charter to communicate this inormation to allteam members. An example o this may be leveraging the charter or communicating upcomingconversions rom a paper medical record to an EHR or EHR updates and how the medicationreconciliation process integrates into these conversations and necessary steps to be taken to make thishappen. The charter also outlines upcoming deliverable dates to keep the medication reconciliationproject on track.

Resources Needed or a Successul Project. As you begin the journey to improve your acilitysmedication reconciliation process, you should address resource support with the leadership teamrom the beginning o the project. Depending on the area o ocus, process design or redesignplans, budget constraints, and resource availability, it is crucial to think through each disciplines

role (currently and ideally), current workfow practices, and how medication reconciliation can bebetter integrated in a more ecient, eective manner. For example, or pre-scheduled surgeries that

will result in a planned admission post-operatively, is there a better way to obtain a patients currentmedication inormation during presurgical workups and medical clearance appointments, rather thantrying to gather this type o inormation on the day the patient presents or surgery, when they maybe anxious about their procedure?

Project Milestones and Timeline. Milestones are requently used to monitor progress. Broadproject milestones can be developed initially and modied as the team begins to better understandthe issues at hand. Reviewing project timelines and milestones achieved also keeps the teamenergized and ocused as progress is made.

Step 4: Establish a Measurement StrategyAt the start o the project, create a list o data that will be needed and the departments and peoplewho should be in charge o developing the measurement strategy. For organizations with anestablished EHR, inviting a representative rom your acilitys IT department rom the beginning oproject planning is strongly advised. Share with the IT representative the list o data needed to drivedecisions regarding the needs o the acility and sta, or to understand where to direct the project


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attention rst to explore ways to leverage your EHR to collect this type o inormation electronically.Data that can serve as a starting point could be the acilitys readmission rates (the Financedepartment usually creates these data), ADEs or the acility (the Pharmacy department usually

collects these data), or data specic to the acilitys current process or medication reconciliation.Consider using the audit tool and measures that are used in this toolkit. Chapter 6 (pg. 49) reviewsproject metrics in greater detail.

Collecting baseline data will allow you to determine where to ocus the project initially. Your initialproposal should include baseline data you collected in order to strengthen and support the businesscase you present to senior leadership.

Integrating team members who can assist with perormance measurement will allow each teammember to carry out their role in the project with ease.


Lessons learned rom sta o acilities that have implemented MATCH and acilities that receivedtechnical assistance on MATCH through the AHRQ QIO Learning Network include:

A multidisciplinary team ostered a acility-wide team environment or process improvements.Frontline sta elt more ownership and involvement in the change.

Facilities that developed a project charter, articulated a problem statement, and set goals andobjectives were better prepared to stay on task with the project.

Using the project charter to provide periodic reports to the leadership team supported thedynamic use o the document

Including a review o the project charter at each project meeting kept the team on task.

Process mapping is a critical element or success. Project participants ound that walkingthrough the medication reconciliation process and conrming each step with rontline sta wasan eye-opening experience. Many times the process that is on paper is not what is being doneon the ward, and identication o workarounds is pivotal.

Participants who used this toolkit ound sta workarounds o a process were not necessarilynegative ndings.

Determining the size or scope o the project should be done early in the planning stage.Keeping the initial project ocus reasonable in size and scope is pivotal to the success o theproject. Broad scale eorts consume many resources and can make it dicult to secure andmaintain leadership support. Implementing a successul project on a limited scale oten leads

to a larger eort. Measurement o baseline data was a necessary and crucial element o the project. This helped

identiy areas o ocus, explored depth o issues, and provided the team with a realistic idea othe improvements they were proposing.


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Chapter 3: Developing Change:

Designing the Medication ReconciliationProcessMany organizations are uncertain about how to proceed with designing a workable solution ormedication reconciliation. This chapter provides helpul inormation and tools or designing orredesigning a medication reconciliation process including:

Guiding principles or designing a successul medication reconciliation process.

One Source o Truth.

Dening roles and responsibilities or medication reconciliation.

Integrating medication reconciliation into existing workfow.

Flowcharting the design or redesign or medication reconciliation.

Designing the processconsiderations or various practice settings.

Examples o electronic, paper-based, or hybrid (electronic plus paper-based) systems.

Guiding Principles or Designing a SuccessulMedication Reconciliation ProcessThese essential principles should be considered as you design the medication reconciliation process:

Develop a single medication list (One Source o Truth), shared by all disciplines ordocumenting the patients current medications.

Clearly dene roles and responsibilities or each discipline involved in medicationreconciliation.

Standardize and simpliy the medication reconciliation process throughout the organization,and eliminate unnecessary redundancies (the fowchart o the current process can help youidentiy these redundancies).

Make the right thing to do the easiest thing to do within the patterns o normal practice.

Develop eective prompts or reminders or consistent behavior i true orcing unctions (i.e.,

required reconciliation step presented to the physician during admission order entry within anEHR are not possible.

Educate patients and their amilies or caregivers on medication reconciliation and theimportant role they play in the process.

Ensure process design meets all pertinent local laws or regulatory requirements. Linkingmedication reconciliation to other strategic goals (e.g., heart ailure publicly reported processo care measures related to discharge instructions on medications) and/or other initiatives(e.g., a hospital project working on improving patient satisaction related to pain


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management or patient communication regarding medications) when appropriate can alsostrengthen the importance o this process.

One Source o TruthMedication reconciliation process design should center on the concept o a single list to documentpatients current medications. This will be reerred to as One Source o Truth. This list should beshared and utilized by all physicians, nurses, pharmacists, and others caring or the patient.

All disciplines caring or the patient should be working rom the same medication list,regardless o the ormat (electronic or paper-based).

The list should be centrally located and easily visible within the patients medical record.

This list becomes the reerence point or ordering decisions and reconciliation, screeningmedications to be administered during a procedure/episode o care, and determining the

patients medication regimen upon discharge.

Each discipline should have the ability to update the home medications as new or more reliableinormation becomes available.

In a paper-based ormat, old or modied inormation could be crossed out, new inormationcan be added, and each change can be dated, timed, and signed.

In an electronic system, changes would be date and time stamped, and the prescribers nameautomatically captured. I the patients medication list requires changes at discharge, updatedinormation will remain stored or review and modication or uture admissions.

Samples o One Source o Truth to document and veriy a patients current medications upon

admission to the organization are in Figure 3 (pg. 23) and Figure 4 (pg. 24).


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Figure 3: Medication Reconciliation Upon Admission: High-Level Process Map AterRedesign

Physician obtains anddocuments medicationhistory in Med Prole.

Physician completes thephysician medicationreconciliation ormdocumenting orderingdecisions or homemedications.

Med Prole(One Source o Truth)

Medication(s) Being Given(inpatient)

Current________________________________________________________________________________________________________________________________________________________________________

Past__________________________________________

____________________________________________________________________________________

Prescription(s)/Home Medications(outpatient)

Current________________________________________________________________________________________________________________________________________________________________________

Past______________________________________________________________________________________________________________________________

Physician ordersmedications based on medlist prior to admission andpatients current clinicalstatus.

Depending on the care unit,nurse and/or pharmacist veriymedication history in Med Prole.

Modications made to homemed list i new inormation isavailable.

Physician consulted regardingany changes

Depending on the care unit,nurse and/or pharmacistreconciles medication history withcurrent orders.

Physician consulted regardingunintended discrepancies inrelation to patients care plan.

Nursing (pharmacy) medicationreconciliation orm completed.

Med Prole:

Single location or documentingand conrming home medications,shared by all disciplines.

One Source o Truth or reviewand reconciliation o inpatient andoutpatient medications.

Changes and updates to homemedications clearly accessible (e.g.,not buried in progress notes).

Forms:

Creates standardized approach orphysicians, nurses, and pharmacistsor medication reconciliation.

Standardizes physiciandocumentation regarding orderingdecisions to identiy intended versusunintended discrepancies.

Creates standardized process ornurses and pharmacists to indentiy,resolve, and document ollowupon unintended discrepancies andreduce re-work.

Sequence o Tasks:

Physician prompted to completemedication reconciliation (documenthome meds and ordering decisions)during admission or post-op orderset.

Nurse (or pharmacist in ICUs)prompted to conrm history andreconcile with current orders.

Pharmacist perorms nalreconciliation and ollowupon unresolved or outstandingunintended discrepancies.

Patient Admitted to Hospital


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Figure 4: Medication Reconciliation Upon Discharge: High-Level Process MapAter Redesign

Med Prole:

Single location to review andupdate home medications at timeo discharge.

One Source o Truth or reviewand reconciliation o inpatientand outpatient medications.

Changes and updates to homemedications clearly accessible.

Prescription/home medicationinormation remains stored in thecurrent older and is availableor review and modications oruture admissions.

Forms:

Standardizes physician reviewand documentation o homemedications in preparation ordischarge.

Template provides reminders andsection or physician to highlightchanges to prior medicationsand document new prescriptioninormation.

Creates standardized processor nurses to indentiy, resolve,and document ollowup onunintended discrepancies atdischarge.

Sequence o Tasks:

Physician places medicationreconciliation order, perormsreconciliation, and updates homemedication list in preparation ordischarge.

Nurse prompted to conrmhistory patient receives anupdated medication list uponcompletion o nursing dischargeorm

Physician placesmedicationreconciliation orderand reviews hospitalorders and pre-admission medicationlist.

Physician updates

prescription/homemedications to refectnew dischargemedication list.

Med Prole(One Source o Truth)

Medication(s) Being Given(inpatient)

Current________________________________________________________________________________________________________________________________________________________________________

Past______________________________________________________________________________________________________________________________

Prescription(s)/Home Medications(outpatient)

Current________________________________________________________________________________________________________________________________________________________________________

Past

______________________________________________________________________________________________________________________________

Nurse completesnursing dischargenote and is promptedto conrm patient isbeing discharged withan updated homemedication list romthe physician.

Patient is counseled.

Physician is consultedor resolution odiscrepancies andquestions.

Patient Being Discharged From Hospital

Physician pullsupdated homemedication list intodischarge instructions(or patient) anddischarge summary(or next provider ocare), highlightingchanges.


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Dening Roles and Responsibilities or MedicationReconciliationNow, its time to determine which discipline(s) should be involved in each step o the medicationreconciliation process, including their respective roles and responsibilities. Consider some o theollowing questions:

Which discipline could start building the One Source o Truth upon admission (entry) tothe organization? How will inormation be validated as necessary toward establishing a goodaith eort in building an accurate, complete medication list?

What process steps are needed to perorm medication reconciliation on outpatients andinpatients upon admission (entry), intra-hospital transers (i applicable during a patients stay),and discharge (exit)?

What are the required elements or The Joint Commissions National Patient Saety Goal on

medication reconciliation? What resources are available within the organization to perorm required steps in the process?

During admission and at any point during the episode o care, various disciplines may learn newinormation regarding a patients home medications. In addition, physicians, nurses, and pharmacistshave an active role in reviewing, managing, and monitoring a patients medications. Thereore,consider adopting a team approach or medication reconciliation. Remember, or a team approach tobe eective, it is imperative that roles are clearly dened. I there is ambiguity around an individualsrole, the process cannot be successul. To help drive this point home, here is an oten-shared storyabout our people: Everybody, Somebody, Anybody, and Nobody.

There was an important job to be done and Everybody was asked to do it.

Anybody could have done it, but Nobody did it. Somebody got angry aboutthat because it was Everybodys job. Everybody thought Anybody could do it,but Nobody realized that Everybody wouldnt do it. It ended up that Everybodyblamed Somebody when actually Nobody did what Anybody could have done.(Anonymous)

Thereore, individual roles and responsibilities need to be clearly dened and understood by alldisciplines participating on the medication reconciliation team.

To help determine roles and responsibilities, map out the various admission points in yourorganization. For procedural areas, consider clinics involved with pre-procedural appointmentsor areas that register patients and may be able to contribute to your process. Your list may looksomething like:

Direct Admission (usually rom a doctors oce) Inpatient Unit

Procedural Area or Ambulatory Surgery Unit (pre-registered, early morningadmissions) Inpatient Unit

Emergency Department Inpatient Unit

Triage/Labor and Delivery Unit Inpatient Obstetrical Unit

External Transers (patients transerred rom an outside hospital) Inpatient Unit


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See the Appendix (pgs. A-10 and A-11) or a sample worksheet and or an example o admission,intra-acility transer and discharge process steps to determine disciplines roles and responsibilities ormedication reconciliation.

Second, determine which discipline(s) within each admission point could initiate building the OneSource o Truth, and then conrm the list with the patient or accuracy and completeness. A good-aith eort should be made toward this goal with sta understanding o expectations.

Third, make sure you communicate roles and responsibilities or medication reconciliation clearlyand eectively. Ater determining which discipline will be responsible or implementing medicationreconciliation at certain admission points, make sure to update the policies and procedures to refectthis designation.

Integrating Medication Reconciliation into Existing

WorkfowPrompts to complete required steps or medication reconciliation are essential. To be eective,prompts or reminders need to occur during the appropriate time within the clinicians workfow.

Also, prompts or reminders decrease reliance on memory to perorm required steps.

Incorporating prompts or reminders into a clinicians workfow is one example where automationis benecial. For instance, during the admission order entry phase or a newly hospitalized patient,a physician could be prompted to complete medication reconciliation by documenting the patientspre-admission medications and indicating ordering decisions or each medicine (i.e., continue,discontinue, modiy, etc.). When the physician signs o on the admission order set, this could triggera task or the nurse and/or pharmacist to communicate and educate the patient regarding newmedications that were added or changes that were made in relation to desired treatment plans to

identiy unintended discrepancies.I an organization has a paper-based system, medication reconciliation orms should be kept in themedical record in a highly visible, specied location to serve as a reminder to perorm medicationreconciliation during the episode o care. Regardless o practice settings, clinicians need eectivereminders at the appropriate times within their workfow or consistent behavior i true orcingunctions are not possible.

Flowcharting the Design or Redesign or MedicationReconciliationOnce roles and responsibilities are established and youve determined how the new design or

redesign o an existing process can be integrated into workfow, a fowchart can be created. Thisnew fowchart should be compared to the initial fowchart developed beore redesign to highlighteciencies through streamlined process steps and integration into existing workfow withconsideration to transition points as applicable.


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Designing the ProcessConsiderations or VariousPractice SettingsFinding a starting point or improving the medication reconciliation project should be driven byunderstanding the needs o various departments and clinical roles and responsibilities o sta at eachtransition point is a great way to begin. Below are various transition points that should be consideredas you build a plan to improve the medication reconciliation process.

Inpatient Practice Setting. One goal or medication reconciliation is to standardize and simpliythe process throughout the organization. Oten, nuances within various practice settings createchallenges or medication reconciliation when patients transition through the hospital. It isimportant to recognize and understand these nuances, modiy them as appropriate to minimize

variations, and then integrate them into the overall process design. Begin by designing a core orprimary process.

How can each o the admission points be integrated into a primary or core process?

Could one or more disciplines within each admission point initiate a One Source o Truth orconrm the list with the patient or accuracy and completeness?

Oten, the fowchart is the primary process that encompasses the most high-volume entry points intothe acility. Sample fowcharts by practice setting are provided or reerence in the Appendix (pgs.

A-16A-18).

One Source of Truth Ambulatory Surgery or Procedural Area, the Emergency Department, andTriage/Labor and Delivery Unit. Ambulatory surgery can be a successul starting point o the OneSource o Truth medication list. It is a relatively controlled environment that pre-schedules patient-nurse interactions and that commonly encompasses a medication review with each patient. In mostcases, the patient is not acutely ill and can provide accurate inormation when given adequate time.Piloting the improved process in this department is a good way to establish the culture o using aOne Source o Truth.

Post-Acute Care Settings. While the majority o discussion and examples within this toolkitocus on inpatient settings, post-acute care acilities can adapt the same concepts to strengthenor implement a medication reconciliation process. A skilled nursing acility would look at all theprocesses that are common conduits or nursing home placement. Using admission directlyrom a hospital as the core process, the acility could then look at all variations on admissions thatare encountered and make changes to the core process similar to the examples provided. Some

variables may include admissions directly rom home, admissions and reerrals rom home with theinvolvement o a home health provider, and even respite stays.

Similarly, a home health care provider could dene its core process as an admission directly rom aninpatient hospital stay to the services to be provided. In mapping out their process, the home healthcare provider could determine variations to this core process (e.g., admission rom a skilled nursingacility, admission directly rom home) and then integrate these scenarios into the core reconciliationprocess.


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While many health care acilities are not ully electronic, it is important to have a goodunderstanding o the needs o the clinician workfow and the process, as well as have a soundunderstanding o each departments individual needs, as this will assist in the choice o an electronic

system or to build a process once there is a choice o EHR.

Medication Reconciliation upon Admission, Intra-Hospital Transer, and Discharge ina Hospital with an Electronic Health Record. The ollowing examples provide guidance onincorporating an electronic medication reconciliation process that includes One Source o Truthinto the admission, transer, and discharge workfow in order to make the right thing to do the easything to do.

Admission. A medication prole within a patients EHR can serve as a One Source o Truthor viewing inpatient medication orders and a patients prescription/home medication list all inone location. A medication prole could be pulled into orms or presented when patients currentmedication lists are obtained and documented (i.e., making the right thing to do easier). (See Figure5, pg. 31.)

Within an EHR, incorporating medication reconciliation steps into a physicians workfow mayinclude:

Building One Source o Truth that includes documentation and conrmation o a patientscurrent medication list with buttons to indicate the accuracy, completeness, and inormationsources utilized (evidence o a good aith eort or obtaining the patients current medicationinormation).

Ability to indicate the plan or each home medication (such as discontinuing, continuing, ormodiying current medications) in relation to the intended treatment goals or the episode ocare when placing medication orders.

Prompts to complete medication reconciliation when placing an admission or post-op orderset.

Depending on the care unit, incorporating medication reconciliation steps into the nurse and/orpharmacist workfow may include:

Receiving a task ater the physician completes medication reconciliation to veriy homemedications documented by the physician with the patient, amily, or other sources.

Verication is an important step, as patients oten orget to mention medications orOTC medications/herbal supplements during the initial medication collection. Any newinormation regarding the patients home medication list should be discussed with thephysician and resulting changes documented.

This verication step also provides an educational opportunity to teach patients about themedications ordered or them in the hospital in relation to their home medications, andcomment on any dierences.

Reconciling home medications with current inpatient orders.

Clariying unintended discrepancies (i.e., discrepancies that are not explained by the currentcare plan, by the patients clinical status, or ormulary substitution) with the physician orresolution.


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Completing a discipline-specic orm with buttons and comment sections to documentinteractions and clarications with patients, other sources, and the prescriber to trace ollow-through on discrepancies and resulting clarications and modications, i needed. (See Figure

6, pg. 32, and Figure 7, pg. 33.)

Intra-hospital Transfer. When a transer order is placed indicating the patient is ready or transerto another unit within the hospital, the physician may receive a prompt or reminder to perormmedication reconciliation. Instructions may be included or the physician to:

Assess current medication orders and make any changes or modications in preparation or thenew level o care.

Review the patients pre-admission medication list. Home medications initially held may nowbe appropriate to restart upon transer.

Nurses and/or pharmacists may be involved during intra-hospital transers to ensure medicationorders or the new level o care are consistent with desired treatment plans and to provide anindependent double check that pre-admission medications initially held are appropriately restarted.

Physician Prompting at Discharge. Physicians may be prompted or reminded to perorm medicationreconciliation when placing a discharge order, indicating the patient is ready or discharge. Adischarge checklist could also be created listing elements that need to be completed prior todischarge (e.g., remove heplock, perorm medication reconciliation, prepare discharge medicationlist, educate patient, etc.). The goal or discharge medication reconciliation includes:

Comparing the patients pre-admission medication list with the patients current inpatientmedications.

Updating the patients pre-admission medication list to refect the patients medicationregimen upon discharge. This list may be integrated into Discharge Instructions (or thepatient) and Discharge Summary (or the next provider o service).

Providing the patient/amily with written inormation on the medications the patient shouldbe taking when discharged rom the hospital, or at the end o an outpatient encounter.

Explaining the importance o managing medication inormation to the patient whendischarged or at the end o an outpatient encounter. Instruct patient to:

Give a list to their primary care provider.

Update the list when medications are discontinued, doses are changed, or newmedications (including OTC medications) are added.

Carry medication inormation at all times in case o an emergency.


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Nurse and/or Pharmacist Prompting. Discharge medication reconciliation may be integrated withinthe nurses and/or pharmacists discharge workfow with a prompt or instructions to:

Contact the physician i the patients discharge medication list is not updated and/or complete(note: when establishing roles and responsibilities or preparing patients discharge medicationlists, a blanket statement such as resume home medications is not acceptable).

Contact the physician to clariy patient questions encountered during the patient counselingsession prior to discharge.

External Transfers. An external transer patient is a patient who is transerred rom a hospital outsideo your own system. Such transers may occur based on patient or provider request, specialty servicesrequired, or additional acute care needs.

External transer patients have additional complexity in regards to medication reconciliation becausethree sources o inormation require review and reconciliation:

Patients list o medications prior to his or her hospitalization.

Medications that are being administered to the patient at the outside hospital prior to transer.

Medications ordered at your hospital.

I the organization receives transers rom other hospitals, you should ensure a process is in place toaddress these reconciliation needs. Adequate communication and handos rom the sending acilityare critical to ensure all medication therapies are addressed and reconciled during the assessment anddevelopment o the patients care plan at the organization.


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Figure 5: Screenshot 1: Medication Management Essentials


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Figure 6: Screenshot 2: Nursing - Medication Reconciiation


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Figure 7: Screenshot 3: Pharmacy - Medication Reconciliation


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Lessons learned rom sta o acilities that have implemented MATCH and acilities that receivedtechnical assistance on MATCH through the AHRQ QIO Learning Network include:

It is important to realize several key elements regarding medication reconciliation beoregetting started, especially as they apply to any practice setting (i.e., inpatient, outpatient) andany type o medical record system (i.e., electronic, paper based, or both).

There is no electronic substitution or a thorough medication interview with patients and/ortheir caregivers to obtain and veriy current medication regimens. I patients and/or caregiversare able to participate in an interview, clinicians should ask what medications patients aretaking and how they are taking them to identiy discrepancies or uncover potential medicationproblems.

Medication reconciliation should be an integral part o handos and communication duringtransitions in care.

The patient plays a key role in medication reconciliation and should be educated on theimportance o managing medication inormation at the time o discharge or at the end o anoutpatient encounter. This education should include the importance o:

Giving a list to their primary care provider.

Updating their own list when medications are discontinued, doses are changed, or newmedications (including OTC medications) are added.

Carrying their medication inormation at all times in case o an emergency. This can helpensure patients are prepared to share an accurate medication list with their health careproviders at each health care encounter.

Enlist the support o primary care physicians and community pharmacists to encourage patientsto carry and update their medication list at every encounter.

Look or ways to make medication reconciliation a value-added process. Consider integratingmedication review and reconciliation in daily rounds so medications can be reviewed at thepoint when clinical decisions are made and modied accordingly.


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Chapter 4: Developing and Pilot Testing

Change: Implementing the MedicationReconciliation Process

Pilot Testing the SolutionI you have applied all o the steps and guiding principles outlined in Chapters 1-3 to your own

work, you should have designed or redesigned medication reconciliation process that addresses gapsidentied in the fowchart and assessment o your existing process, while helping to maintain current

work fow. At this point, resist the urge to implement the redesigned process acility-wide andinstead, pilot test the solution.

A pilot test provides an opportunity to implement a new process on a small scale and receive input.Any weaknesses in the process can be addressed beore implementation acility-wide. While thisprocess may seem like it will delay improvement overall, it can actually ensure success when you doimplement it acility-wide. Beore instituting the pilot, you should consider the ollowing questions:

Where would you like to pilot test the process?

Are the areas chosen or the pilot already engaged and bought into the process?

What mechanism will be in place to give and receive eedback rom rontline sta during thepilot?

What structure will be put in place to support sta during the pilot period?

What roles can the leadership team play in the pilot?

Are the stakeholders engaged, and have roadblocks been identied and removed prior topiloting in those practice settings?

What are the process measures (i.e., quantity, adherence to process) to determine complianceduring the pilot?

What are the quality measures to determine impact on patient saety?

There are many potential settings or pilot testing. Some ideas include:

A unit that directly admits patients.

One medicine unit and one surgical unit.

One team o physicians or one service, such as hospitalists.

Engaging a ew clinicians to use the orm or a ew days on their patients.


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Regardless o the approach, the goal is to test the process or a short period o timein most cases,less than a week or within a certain timerame contingent on resources and scope o the projecttoidentiy and correct major gaps within the process, and conrm its utility within current workfow.

The process should continue to be enhanced and the pilot testing expanded as appropriate.

Although design team members are oten eager to pilot their work, you should also include rontlinesta who were not involved in the design. They will be able to:

Provide additional insight into how intuitive the new design is.

Identiy training requirements.

Identiy additional areas or improvement.

To allow or eedback during a pilot, small ocus groups can be held on nursing units orapproximately 15-30 minutes. This may be an eective means to acilitate a dialogue about therevised process. This could also be used as an opportunity to thank those who agreed to participate

in the pilot.

Sample questions that may be used during ocus groups with physicians are provided in Figure 8 (pg.37). These can be adapted or use with various disciplines and practice settings to elicit eedback onthe process during the pilot phase.

Incorporating a structured, robust auditing and eedback method to identiy design faws and tounderstand underlying root causes or medication reconciliation ailures (i.e., knowledge decits,lack o buy-in, system design issues, etc.) is important during the pilot. It is equally importantto highlight successes and compliment individual contributions. For more inormation onmeasurement, see Chapter 6: Assessment and Process Evaluation (pg. 49).


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Figure 8: Medication Reconciliation Process Physician Focus GroupInterview Questions

Medication Reconciliation Process

Physician Focus GroupInterview QuestionsThe medication reconciliation process requires several steps upon admission, transer, and dischargeto ensure patient saety. Physicians, nurses, and pharmacists each have individual responsibilities orcertain steps within the process.

1. In your own words, please describe what the medication reconciliation process means.

2. As a physician, please describe your specic role and responsibility in the medicationreconciliation process:

a. When the patient is admitted.

b. I a patient is transerred within the hospital.

c. When the patient is discharged.

3. How did you learn about your role in the medication reconciliation process? Did you eel this wasan eective method o communication/education?

4. Were you ever trained on how to document and update home medications in [insert the name oyour orm/One Source o Truth]? I so, please describe the type o training you received. Do youeel this method o communication and education was eective? Why or why not?

5. (I the answer to the rst part o question 4 was no, skip question 5.) Since your training, have youbeen consistently documenting and updating home medications in the [insert the name o yourorm/One Source o Truth]? Why or why not?

Preparing or ImplementationYou have designed the process, piloted-tested the solution, and made any necessary enhancements.Now you are ready or a ull-scale rollout. Some may choose to develop a committee to handleacility-wide implementation; others may use the original team to carry out implementation. Thereare advantages and disadvantages to both approaches:

Design team members may nd it dicult to accept when their design isnt working asplanned, despite pilot testing.

New members may be more open to change and may contribute new suggestions orimprovement.

Depending on the scope o the project, additional members, identied through a stakeholderanalysis, may be needed to help acilitate implementation.


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As you move into the implementation phase, you may want to consider developing animplementation charter to supplement the design charter. This will provide a ramework or:

Dening implementation goals and objectives.

Identiying key metrics or implementation.

Determining implementation resources and support system requirements.

Developing a training curriculum.

Establishing continuous eedback mechanisms or receiving suggestions rom and providingollowup to sta throughout implementation.

Developing the Implementation StrategyPlanning and Communication o Implementation Strategy. To successully coordinate an

implementation strategy, mandatory meetings, led by the leadership team, should be held withstakeholders representing physicians (i.e., clinical program leaders, departmental chies, and chairs)and patient care (i.e., nursing directors and managers, pharmacy director and managers).

During this meeting, implementation plans and training curricula can be presented. Amultidisciplinary training approach (i.e., physicians, nurses, and pharmacists attending training classestogether) is encouraged. A number o dates and time periods should be determined based on theneeds and availability o various disciplines. Classes should be oered early in the morning, duringthe day, in the evening, and on weekends to accommodate a variety o schedules.

Email reminders and memos sent rom discipline-specic leadership to sta may be an eectivemethod to increase attendance and participation while highlighting leadership support or the

process. The Appendix oers customizable memos to announce and promote training sessionsand educational eorts to the sta: Sample Letter to Discipline-Specic Leaders on MeetingRegarding Training and Implementation Strategy or Medication Reconciliation (pg. A-26) andSample Communication rom Discipline-Specic Leadership to Sta on Medication ReconciliationEducational Training Sessions (pg. A-27).

Rollout Strategies. Just like pilot testing, there are several dierent strategies to roll out the process.Depending on the scope o the project, some implementation strategies may include:

By unit (e.g., all ICUs).

By service (e.g., surgical services).

By discipline (e.g., rollout process to all physicians, then to all nurses, and then to all

pharmacists).

Hospital-wide, all disciplines.


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You should establish an implementation timeline. This helps ensure a timely rollout whilemaintaining fexibility i unanticipated issues arise. See the Appendix or Example TimelineHospital-Wide Rollout by Discipline (pg. A-24).

Sta should be well inormed and given adequate notice regarding training dates andimplementation strategies prior to rollout. Sta communication may need to occur through a varietyo channels such as emails, brie announcements at sta meetings, and memos posted in nursingunits, report rooms, conerence areas, etc. A fier can be one way o communicating the rolloutplans. See the Appendix or Sample Sta Flier to Announce Rollout/Implementation o MedicationReconciliation Process (pg. A-28). For email announcements, consider having departmental ordiscipline leaders send prepared messages directly to their colleagues to convey the importance oimplementation and adoption o the process.


Lessons learned rom sta o acilities that have implemented MATCH and acilitie

ahrq medication reconciliation

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