Medication Reconciliation:Medication Reconciliation:Pharmacy Integrated Pharmacy Integrated Model Model

Steve A. Carlson, RPhSara E. Grove, Pharm.D.

Northeast Georgia Health System (NGHS)Gainesville, Georgia

Best Practice Power HourBest Practice Power Hour

NGHSNGHS

Private, not-for-profit, community Accredited by DNV 557 inpatient beds 261 skilled nursing beds Serves almost 700,000 people in more

than 13 northeast Georgia counties

Inpatients 30,364 Outpatients 238,542 Surgeries

Outpatient 10,801 Inpatients 7,466 Emergency Visits 99,456

Deliveries 4,087

Patients ServedPatients Served

32.04 Pharmacists (including management) 6 Clinical Pharmacy Specialists

Department of PharmacyDepartment of Pharmacy

41 Technicians (3:1 ratio in GA) Unit-Based Pharmacy Technicians

Cardiology Critical Care Internal Medicine

Oncology Women & Children’s Health Emergency Medicine

Cardiology Critical Care Internal Medicine

Oncology Women & Children’s Health Emergency Medicine (2)

* Reflects staffing only at the medical center

Customer Service is a major focus of the facility Patient Staff

Developed a Unit-Base Pharmacy Technician Model

Providing Exceptional Providing Exceptional ServiceService

Unit-BasedUnit-Based Pharmacy Pharmacy Technician (UBT) ProgramTechnician (UBT) Program

Established in February 2007 Initially 4 Pairs of Technicians Goals

Optimize Distribution Establish Direct Communication Provide Focused Service

Qualified Staff Certified Technicians Experienced Senior Staff

Review of EventsReview of Events

January 2006: Nurse Managers Interviewed March 2006: Base-Line Survey Conducted May 2006: Results Presented May 2006: Pilot on 2 Floors Conducted July 2006: Proposal Presented & Approved November 2006: Initial Deployment February 2007: Full Implementation March 2007: Survey Repeated May 2007: Results Presented July–August 2007: Focus Groups Met

Initial FTE RequirementsInitial FTE Requirements

7.6 FTE’s; 10 hour shifts 7on / 7off Open pharmacist position (1 FTE)

converted to 2.8 FTE’s Redeployed 2.0 FTE’s Requested a net of 2.8 new FTE’s

Initial UBT AssignmentsInitial UBT Assignments

UBT ResponsibilitiesUBT Responsibilities

Delivery of medications directly to nurse or nurse server

Resolution of missing medications Facilitating transfer of medications

on/off unit with patient Removal/return of discontinued meds Automated Dispensing Cabinet

troubleshooting/restock

UBT ResponsibilitiesUBT Responsibilities

Delivery of cart fill to nurse server Med error/ADR reporting to

pharmacist Notification of allergy/height/ weight Monthly nursing unit inspections Assistance with faxing of orders Obtain new orders from units and

expedite medication needs

Customer Service SurveyCustomer Service Survey

2006 2007

Pharmacy Customer Service SurveyPharmacy Customer Service SurveyAll Nursing Units - Medical Center

Pharmacy Customer Service SurveyPharmacy Customer Service Survey

2006 2007

Areas Serviced by Unit-Based Technicians - Medical Center

Survey Comments and Survey Comments and SuggestionsSuggestions

“These techs are the smartest thing I’ve seen around here in a long time. They are beyond measure – an asset to having quality – acceptable nursing care.”

“Excellent teamwork – assists nurses to complete essential nursing tasks & focus on this vs. non-nursing duties.”

“Go unit based techs! You rock.”

Survey Comments and Survey Comments and SuggestionsSuggestions

“Still have a problem with medication missing, but turn around time to get it is much better.”

“The morning meds that are due before breakfast…are scheduled at 0730 and this isn’t working well. By the time we get out of report, the breakfast trays have already been passed. Can these meds please be scheduled for 0630?”

Reconciliation ProcessReconciliation Process

Home

Transfer

DischargeAdmission

Home Med List Created

Addressed by MD

Reconciled by RPh List Provided to Next

Provider of Care

Reconciled by MD

Addressed & Reconciled

by MD

New Home Med List

Created

Communicated to Patient by Nurse

Identifying Deficiencies Identifying Deficiencies

• Discharge Medication List • Heart Failure Core Measure HF-1 Scores

• Average Fiscal Year 2008: 53.4%

• TJC Average: 75.8%

• Majority of failures due to transcription errors

• Admission Medication List• Staff observed errors and omissions

• Garbage In / Garbage Out

NGHS Performance Improvement Dashboard

Medication Reconciliation Medication Reconciliation ResponsibilitiesResponsibilities Admission

• Interview patient at admission• Document home medication list• Print list for physician to address

Discharge• Document discharge medication list as

specified by physician orders• Notify nurse of discrepancies

Technician TrainingTechnician Training

Software• Demonstrate Proficiency in Entry

Procedure• Identify Discrepancies

Communication• Demonstrate Appropriate Body Language

• Review Principle

• Identify Barriers

Pilot: Heart FailurePilot: Heart Failure

Pharmacist Pre-Pilot• October to Mid-December 2008

Locations• Emergency Department

• 3 Medical/Cardiac Inpatient Units

Redistribution of Workload• Reduced # Beds/UBT

• Added 3 Positions per Week

Pilot UBT AssignmentsPilot UBT Assignments

Pharmacy-Based Medication Reconciliation PilotPharmacy-Based Medication Reconciliation PilotStarts December 16Starts December 16thth

Floors Participating: S3E S4D S4E ED

1) To improve patient safety and care by striving to optimize the medication reconciliation process2) To demonstrate improvement through increased Heart Failure Core Measure scores

Goals:

Here to Help

Rx

•Interview admitted patients and document current home medication list

•If medication history is needed immediately and a pharmacy technician is not available, collect and document current home medication list

•Record “MD Discharge Medication Orders” in Clinical Profile

•Resolve discrepancies with physician

Pharmacy Tech Duties Nurse DutiesAdmission

Discharge

•Print “Admission Medication List” and attach it to the chart

•Notify nursing of any discrepancies

•Sign “MD Discharge Medication Orders” to indicate completion

•Counsel the patient on discharge medications and instructions•Sign “Patient Discharge Medication List”

Coverage from 0700-2300Coverage from 0700-2300

•Late admissions will be completed the following morning

•Review and sign off “MD Discharge Medication Orders”

Here to Help

Rx

Technician-Assisted Technician-Assisted Medication ReconciliationMedication Reconciliation

NGHS Performance Improvement Dashboard

HF-1 Score Adjusted Score

2008 Average 53.4% --

1st Quarter 2009 75.4% 92.1%

2nd Quarter 2009 70.1% 85%

January 63.6% 77.3%

February 72.7% 86.4%

March 73.9% 91.3%

Current UBT AssignmentsCurrent UBT Assignments

Cumulative HF ScoresCumulative HF Scores

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

1st Qrt 08

2nd Qrt08

3rd Qrt08

4th Qrt 08

1st Qrt 09

2nd Qrt09

3rd Qrt09

4th Qrt 09

1st Qrt 10

2nd Qrt10

3rd Qrt10

4th Qrt 10

1st Qrt 11

HF-1 Score Pharmacy Adjusted Score

Cumulative Failure Origin

Opportunities for Opportunities for ImprovementImprovement

Nurse/Technician Clarifications Developed a formal discrepancy form

Discharge Summary Development of electronic bridge

Improperly Completed Forms Form revision

Discrepancy ReasonsDiscrepancy Reasons

Therapeutic Interchange New Prescription Duplicate Therapy Medication Not Addressed No Prescription Inappropriate Form Completion Inappropriate Alteration of Form

Medication Reconciliation:Medication Reconciliation:Pharmacy Integrated Pharmacy Integrated Model Model

Steve A. Carlson, RPhSara E. Grove, Pharm.D.

Northeast Georgia Health System (NGHS)Gainesville, Georgia

Best Practice Power HourBest Practice Power Hour