presented to: hret patient safety learning network participants by kristine gleason, mph, rph
DESCRIPTION
Medication Reconciliation Using the MATCH Toolkit – Improve / Control. Presented to: HRET Patient Safety Learning Network Participants By Kristine Gleason, MPH, RPh Helga Brake, PharmD, CPHQ Northwestern Memorial Hospital. Acknowledgements. - PowerPoint PPT PresentationTRANSCRIPT
Agency for Healthcare Research and QualityAdvancing Excellence in Health Care • www.ahrq.gov
Presented to:
HRET Patient Safety Learning Network Participants By Kristine Gleason, MPH, RPh
Helga Brake, PharmD, CPHQ Northwestern Memorial Hospital
Medication ReconciliationUsing the MATCH Toolkit – Improve / Control
Advancing Excellence in Health Care
Acknowledgements
This program is supported by the U.S. Agency for Healthcare Research and Quality (AHRQ) through a contract with the Health Research and Educational Trust (HRET).
HRET is a charitable and educational organization affiliated with the American Hospital Association, whose mission is to transform health care through research and education.
AHRQ is a federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.
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New Resources to Stay Connected
1. To access the online Patient Safety Learning Network HCAHPS community:
http://www.psl-network.org Username: hcahps
Password: psln (Note: case-sensitive)
2. To join the HCAHPS ListServ, send an email to Jenny Shaw, [email protected]
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Top four HCAHPS Priorities of over 430 hospitals participating in 18 HCAHPS PSLNs:
1. RN Communication2. Responsiveness3. Medication Communication*4. Discharge Information*
* HCAHPS domains addressed by a patient-centered discharge process
HCAHPS and HEN Priority Challenges: Care Transitions and Adverse Drug Events
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Scale: Strongly Disagree, Disagree, Agree, Strongly Agree
During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
When I left the hospital, I clearly understood the purpose for taking each of my medications.
Mandatory beginning with January 1, 2013 discharges.
New HCAHPS Care Transitions Questions
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Northwestern Memorial HospitalChicago, Illinois
894-bed Academic Medical Center
Primary Teaching Affiliate of Northwestern University Feinberg School of Medicine
Magnet Recognition for Nursing Excellence
Honored with the National Quality Health Care Award
One of two national finalists in the American Hospital Association’s McKesson Quest for Quality award
Affiliated with Northwestern Lake Forest Hospital, a community hospital serving northern Illinois, in February 2010
Feinberg and Galter Pavilions Prentice Women’s Hospital6
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MATCH Acknowledgements
Agency for Healthcare Research and Quality (AHRQ)− MATCH grant supported by AHRQ (Grant No. 5 U18 HS015886)− Knowledge transfer / toolkit dissemination supported by AHRQ through a contract with Island
Peer Review Organization, Inc. (IPRO) (Contract No. HHSA2902009000 13C) and through a contract with the Health Research and Educational Trust (HRET).
IPRO− Vicky Agramonte, RN, MSN – Project Manager, QIO Learning Collaborative− Carrie Perfetti, Esq.
HRET− David Schulke – Vice President, Research Programs− Ashka Davé – Research Specialist
Northwestern Memorial Hospital and Northwestern University Feinberg School of Medicine
− Gary Noskin, MD – Chief of Staff, Medical Director Clinical Quality and Patient Safety− Cindy Barnard, MBA, MJS, CPHQ – Director, Quality Strategies and Patient Safety− Physicians, Nurses, and Pharmacists
■ The Joint Commission
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Today’s Objectives
1. Summarize highlights from the second webinar (held August 3) and office hour (held August 31).
2. Provide an overview of the MATCH Toolkit for implementing a sustainable medication reconciliation process. Today’s focus:
• Improve / Implement• Control
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Where Do We Begin?
Harm Estimate/Evidence from Literature Harm Estimate/Evidence from Organization
Med History, Reconcile
Order, Transcribe, Clarify
Procure, DispenseDeliver
Administer Monitor Educate, Discharge
Phases of Medication Management
Measurement / Analysis
Prioritize / Implement Evidence-Based Interventions
ED AdmissionIntra-
hospital Transfer
Discharge Post-Discharge
Care Transitions
9Measure Improvements / Monitor for Sustainability
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A Step-by-Step Guide to Improving the Medication Reconciliation Process
MATCH Toolkit, with customizable, actionable
information, is available at: http://
www.ahrq.gov/qual/match/match.pdf
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Identify the problem and goal
Measure current performance
Validate key drivers of error
Fix the drivers of poor performance
Use mechanisms to sustain improvement
Analyze
Systematic Approach to Improvement
Define Measure Improve Control
DMAIC is a step by step process improvement methodology used to solve problems by identifying and addressing root causes
For more DMAIC information, including free access to a toolkit and project templates, visit the Society for Healthcare Improvement Professionals website at www.shipus.org11
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Highlights from the 2nd Webinar (Aug 3) & Office Hour (Aug 31)
Recap
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RECAP
DEFINE MEASURE ANALYZE IMPROVE CONTROL
Webinar 1June 25
Office HourJuly 13
Office HourAugust 31
Office HourOctober 19
Webinar 2August 3
Webinar 3September 21
Establish a Measurement
Strategy
Design/ Redesign the
Process
Implement the Process
Assess and Evaluate
Build the Project
Foundation
Identify Team Members
Process Map
Develop a Charter
Data Collection Plan
Collect Data
Identify Key Drivers
Flow Chart
Gap Analysis
Process Design
Implementation Plan
Pilot Test
Education / Training
Monitor Performance
Address Low Compliance
Sustainability13
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Establish a Measurement
Strategy
Measure
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What to Measure
Operational Definition
Collection Method
Sampling Plan
What Where When How ManyQuestion the
data will answerSpecific
DefinitionSystem, existing
forms, new handwritten forms, etc.
Elements to be collected
Physical location
Timing and frequency of
collection
Number of data points
to be collected
Was an updated medication list provided to the
patient and reviewed at discharge?
“Medication instructions
were reviewed with the patient”
checked on At-Home Meds
List form
Manual collection from existing forms
Copy of At-Home Meds
List form, reasons for
non-compliance.
Use Med Rec audit form
GI Lab 2-weeks all shifts. August
15 - 31
All visits
Data Collection Plan
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Data Collection
• Work with the team and staff to identify potential drivers and build a data collection form
• Identify metrics to be measured pre- and post-implementation to monitor compliance to the new process. Ex: Numerator: # Patient Records with List of Home Medications. Denominator: # Records Reviewed
• Graph the data you intend to collect to (1) confirm how you plan to use the data and (2) identify any missing data elements
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Key Drivers
17 Involvement of Frontline Staff is KEY
The backside of the baseline data collection form:
Identifying (& addressing) the problematic issues that drive outcomes will lead to lasting improvement
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Design/Redesign the Process
Analyze
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Flow Chart Prior to
ReDesign
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A flowchart outlines current workflow and helps identify:• Successful medication
reconciliation practices• Current roles and
responsibilities for each discipline at admission, transfer, and discharge
• Potential failures • Unnecessary
redundancies and gaps in the process
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Newman Regional Health Center Current Process Map
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Nurse takes Medication History
from the patient and/or family upon
admission
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Gap Analysis
Assess the current state of your facility’s medication reconciliation process
Identify gaps between your current process and one that comprises best practices
Collect policies, procedures, programs, metrics, and personnel that support the current process
Describe barriers and rate implementation feasibility
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Flow Chart After
ReDesign
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OUR (YOUR) Mission Continues
DEFINE
MEASURE
ANALYZE
IMPROVE
CONTROL
Webinar 1June 25
Office HourJuly 13
Office HourAugust 31
Office HourOctober 19
Webinar 2August 3
Webinar 3September 21
Establish a Measurement
Strategy
Design/ Redesign the
Process
Implement the Process
Assess and Evaluate
Build the Project
Foundation
Identify Team Members
Process Map
Develop a Charter
Data Collection Plan
Collect Data
Identify Key Drivers
Flow Chart
Gap Analysis
Process Design
Implementation Plan
Pilot Test
Education / Training
Monitor Performance
Address low compliance
Sustainability23
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Implement the Process
Improve
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Improvement Planning To implement solutions successfully, five areas must be carefully considered and planned for:
1. Interventions2. Communication3. IT4. Training5. Measurement
Implementation Plan
50% of the work begins now50% of the work begins now
Be sure to always include…• Detailed actions• Team member assignments• Completion dates
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– Create, update, and share the work plan with all team members– Use the Status column to communicate to the team if the activities / tasks are On Target , At
Risk of Falling Behind Schedule, or Behind Schedule – Reassign and update tasks as needed to stay on track– Update due dates based on dependencies– Manage to deadlines
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The Intervention Work Plan
Key for Status
- Behind Schedule
- At Risk of Falling Behind Schedule - On Target
Activity Task Responsible
Role Dependency Expected
CompletionActual
Completion Status
1-Feb
8-Feb
15-Feb
22-Feb
1-Mar
8-Mar
15-Mar
22-Mar
Implement home med documentation process Team 22-Mar
Have plan approved by Nursing Practice Committee
Sue
4-Feb 4-Feb
Place IT request for new home med form
John Create Form content
8-Feb 6-Feb
Pilot test new home med form John Form is completed
1-Mar
Educate clinicians on how to collect a complete/accurate home med list
Nancy Develop education
21-Mar
Educate clinicians on new process David 21-Mar
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Create and Execute the Communication Plan
Communication (Message)
Audience Delivery Method
Delivery Frequency Delivery Date Assigned To
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• Ask “how best can we communicate with you?”• Diversify the methods to ensure widespread distribution• Know your audience – customize the messages – “what’s in it for me?”
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Piloting solutions helps to ensure they work on a small scale and allows the team to identify and resolve issues prior to a house wide roll out.
A Pilot Should Be Used When Change covers a large scope Change is costly Change is difficult to implement People are sensitive to the change Unintended consequences may result as part of the change
Pilot Test
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When Piloting ensure the scope of the pilot is represented, it can be reproduced on a larger scale, and it is measureable
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Educate and Train
Best Practice: Multidisciplinary training (i.e., physicians, nurses, and pharmacists attending training classes together), supported by introductions from hospital leaders, is an excellent strategic decision
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– Sets the tone for training and implementation– Promotes a team approach– Creates an appreciation of the
interdependency of each discipline– Trains consistently on each step within the
process
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Train:Responsibilities and Expectations
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An Opportunity to Educate and Communicate
At Admission and throughout the patient’s stay:
Educate your patient about: Home medications that are
continued during the hospitalization
Home medications that were discontinued and why
Ordered medications, include indication and side effects
Ordered as-needed (PRN) medications that are available to them by asking
At Discharge:
Educate your patient to: Give a list to his/her primary care
physician Update the information when
medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added
Carry medication information at all times in the event of emergency situations
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Tips For Obtaining A CompleteMedication History
Whether you obtain a complete medication history or not is dependent in large part on the patient’s memory. You can ensure that you are getting the entire list only by asking for medications in a variety of ways.
Trigger patient’s memory by asking these questions which address items not commonly thought of as medications but can still adversely interact with them: What prescription or prescription samples are you taking at home? What over-the-counter drugs are you taking at home? What vitamins are you taking at home? What herbals are you taking at home? Ex. Gingko, Ginger, St Johns Wart What nutritional supplements are you taking at home? Ex. Green Tea What inhalers are you using at home?
Also, incorporate probing questions to help the patient remember.Ask about: routes of administration other than oral medications medications they take for their medical condition(s) types of physicians who prescribe medications for them times they take their medication (daily, weekly, monthly)
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Go-Live!
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• Implementation is a process, you only get one chance at a successful “go-live”
• To maximize the chance for success– Evaluate solutions– Manage the Work
Plan– Communicate– Educate/Train
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Assess and Evaluate
Control
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Baseline 4/1 4/7 4/14 4/21 5/1 5/750%
60%
70%
80%
90%
100%
60%
70% 68%
75%78% 77% 77%
Inpatient Weekly Documented Home Med Compliance
Inpatient Metric: Numerator: # of patient records that have Home Medications documented . Denominator: # of records of patients discharged within the noted time period
Definitions:Documented Home Med: Home Medications documented in the EMR‘s Home Medication List, verified by status checkmark, during the encounter
Exclusions: Expired or left hospital against medical advice within 24 hours, newborn
Monitor Performance
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Goal: 95%
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Report Results
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Phase Compliance Defined as: Current Compliance as of [insert date]
Action Plan
Medication Reconciliation on Admission
Numerator: # of patients with a home medication list documented and reconciled at admission Denominator: # of patients admitted
GOAL: >95%ACTUAL: [insert current compliance]
As necessary, determine and insert strategies to improve performance to meet goal
Medication Reconciliation on Transfer
Numerator: # of patients with medications reconciled upon transfer Denominator: # of patients transferred
GOAL: >95%ACTUAL: [insert current compliance]
As necessary, determine and insert strategies to improve performance to meet goal
Medication List at Discharge
Numerator: # of patients provided an updated home medication list at discharge Denominator: # of patients discharged
GOAL: >95%ACTUAL: [insert current compliance]
As necessary, determine and insert strategies to improve performance to meet goal
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Post-Implementation Strategiesto Increase Compliance
Hold small focus groups on the pilot tested/go-live floors/units:• 15 – 30 min• Focus discussion on the
new process – what worked, what didn’t, how can it be improved
• Thank those who agreed to participate
• Make changes based on the feedback
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Ensure process works as designed Blast notification communications Tell med rec success/failure stories Celebrate and disseminate successes Enlist Champions Engage Leadership in walkarounds Unblind compliance audits Elevate med rec to an annual
organizational goal to maintain focus
]
Take Med Rec on the Road
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A Final Note: High Risk Situations
Additional Challenges/Barriers to Addressing Effective Medication Reconciliation:
Health Literacy Implement Teach-back
Cognitive Impairment Use “Universal Precautions”
External Transfers Ensure Robust Hand-offs
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HOMEWORK
1. Based on your gap analysis and identified improvement strategies, create a Work Plan to implement your interventions
2. Determine your pre/post-implementation metrics
**We’ll review these and answer your questions during the interactive Med Rec Office Hour on October 19
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Kristine M. Gleason, MPH, RPhClinical Quality Leader Northwestern Memorial Hospital Chicago IL [email protected]
Helga Brake, PharmD, CPHQPatient Safety Leader Northwestern Memorial Hospital Chicago IL [email protected]
If you want to learn more about Northwestern Memorial Hospital, please visit our website at http://www.nmh.org