presented to: hret patient safety learning network participants by kristine gleason, mph, rph

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 – Measure / Analyze

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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http://www.psl-network.org/

mailto:[email protected]


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.

New CMS-Proposed HCAHPS Care Transitions Questions

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New care transitions questions available in HCAHPS on a voluntary basis beginning with July 1, 2012 discharges

New care transitions questions proposed to become mandatory in HCAHPS beginning with January 1, 2013 discharges

Suggest hospitals ask their vendors to include the proposed questions and seek expedited data

Timing of HCAHPS Integration

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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 Hospital7


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


Today’s Objectives

1. Summarize highlights from the first webinar and office hour held June 25th and July 13th, respectively.

2. Provide an overview of the MATCH Toolkit for implementing a sustainable medication reconciliation process. Today’s focus:

• Measure• Analyze

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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

10Measure Improvements / Monitor for Sustainability


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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http://www.ahrq.gov/qual/match/match.pdf




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.org12


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Highlights from the First Webinar (June 25th) & Office Hour (July 13th)

Recap


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

Sustainability14


Build the Project Foundation

Define

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Recap: Progress to Date


Recap: Mapping the Process

A High Level Process Map is a simple picture of a complex process represented by

4-8 key steps. It is essential to better understand the process being improved

and to gain agreement on project scope.

Physician places discharge order

Physician writes new prescription

Physician prepares d/c instructions

Nurse collects the d/c instructions and prescription and counsels the patient

Patient discharged16


Recap: How to construct a high level process map:

1. Get Team together - include all stakeholders

2. Define and agree to a process

3. List all participants of the process – depts., mgrs, and job performers

4. Define beginning and end points

5. Brainstorm key process steps

6. Determine order of process steps

7. Validate by physically walking through process17


• Clearly ties the project to organizational goalsStrategic Linkage

• Concise description of the issuesProblem Statement

• Describes planned accomplishmentsGoal

• Area to be covered – avoid scope creepScope

• Tangible end-products, must align with goalDeliverables

• Necessary requirements for project successResources

• Objective measurement of progressMetrics

• Used to monitor progress and maintain focusMilestones

Recap: Develop a Charter

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Keep it simple … anyone should be able to review your charter and know what you are looking to do and why it is important

Include data … If you do not have initial data, use placeholders

Identify where the project “Starts – Stops” Ensure your scope reflects your time horizon Try to avoid projects over 12 months long Estimate where necessary, refine over time …

‘something’ provides a guide, ‘nothing’ causes delays Focus on outcomes

Recap: Tips for Successful Chartering

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High Level Process Map, courtesy of: Bon Secours, St. Francis Medical Center, Midlothian, VA

AHRQ-HRET PSLN Project Team:• Margaret

Cavanaugh, RPh • Jen Scholtz,

Clinical Coordinator - St .Francis Medical Center

• TuLinh Le, Director of Pharmacy

• Shakil A. Khan, MD., FACC

• Khoi B. Do, MD, (Hospitalist and Internal Medicine)


OUR Mission if YOU Choose to ACCEPT It

DEFINE MEASURE ANALYZE IMPROVE CONTROL

Webinar 1June 25

Office HourJuly 13

Office HourAugust 31

Office HourOctober 19

Webinar 2August 3

Webinar 3September 21


Strategy

Design/ Redesign the

Process

Implement the Process

Assess and Evaluate

Build the Project

Foundation

Identify Team Members

Process Map

Develop a Charter


Collect Data


Flow Chart

Gap Analysis

Process Design

Implementation Plan

Pilot Test

Education / Training

Monitor Performance

Address low compliance

Sustainability21



Strategy

Measure

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To understand performance, you have to measure it. To measure performance, you have to collect data:

To collect data…1. Understand the data that is available2. Determine how it will be used3. Identify how it should be collected

And then collect it!

Measuring Performance

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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


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Comparison of Measurement Techniques

Electronic Reports Retrospective Review Concurrent/Prospective Review

Easy, efficient Time-consuming Time-consuming

All Patients Manual Sampling of Patients

Manual Sampling of Patients

Quantity (% Compliant)

Quality data may or may not be available


Quality (number of interventions, drug, drug class, type of discrepancy, harm averted)


Quality (number of interventions, drug, drug class, type of discrepancy, harm averted)

Opportunity to intervene may have passed

Opportunity to intervene has passed

Intervention and real-time feedback


Percent of inpatient records with documented disposition of all home medications and inpatient orders within PowerChart’s Med Rec screens

Numerator: # Inpatient Records with PowerChart Discharge Green Status CheckmarkDenominator: # Records Reviewed; exclusions: Expired in hospital, Left hospital against medical advice, Neonatology or newborn

Example: Records reviewed (n) = 1000• 850 records have the correct HER-generated discharge status checkmark• 120 are missing the identified tool• 30 records have exclusion criteriaReport: 88% (850/970) compliance with patient records with completed discharge medication reconciliation within the identified tool.

Percent of patient record with documented home medication list

Example: Records reviewed (n) = 10• 5 records have a list of home medications documented on the identified tool• 2 are missing the identified tool• 3 have the tool but one or more entries are incomplete such as lack of name, dose, route and frequencyReport: 50% (5/10) compliance with patient records with a list of home medications on the identified tool.

Example Metrics

Numerator: # Patient Records with List of Home MedicationsDenominator: # Records Reviewed


Data Collection

• Work with the team and staff to identify potential drivers and build a data collection form

• Seek assistance from the team and staff in collecting the data to increase buy-in

• Observe the data collection process periodically to identify issues, errors

• Graph the data you intend to collect to (1) confirm how you plan to use the data and (2) identify any missing data elements



28 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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Medication Reconciliation Surveillance Tool Reviewer Initials: Date of Review: Age: Gender:

Admission Orders Admission Medication History Medication History - Patient InterviewMedications Ordered Medications Listed Medications

Drug Dose Rt Freq Code Drug Dose Rt Freq Code Drug Dose Rt FreqLast Dose Code Source

Codes: 1. No discrepancy; 2. Discrepancy but no clarification: 2a) New medication; 2b) MD decision not to order or dose/rt/freq change based on clinical status; 2c) Similar or alternative drug prescribed based on formulary or clinical condition; 2d) Judged not clinically significant for hospital stay 3. Discrepancy requires clarification: 3a) Omission; 3b) Commission; 3c) Different Dose; 3d) Different Route; 3e) Different Frequency; 3f) Different Medication ordered. Source Information: 1. Pt interview; 2. Med list; 3. Family/Surrogate; 4. Old medical records; 5. Prescription vials; 6. Call to pharmacy or physician office; 7. Other (specify)

Measuring Quality


Design/Redesign the Process

Analyze

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Project Team

The medication reconciliation team may be subdivided into three core groups: (a) Leadership Team ; (b) Additional Stakeholders ; (c) Design Team

Questions to Ask When Developing Your Design Team Based on Scope1. Do you have a multidisciplinary group of frontline staff to obtain perspectives and

identify workflow issues? 2. Have you identified physician representation from Medicine, Surgery, Emergency

Department and/or specialty areas depending on scope?3. Do you have a patient safety representative on your team? 4. If your organization utilizes an EHR, do you have representation from your

information technology department? 5. If you utilize a paper process, do you have representation from medical records,

your forms committee, or others to help with form design and verbiage and to obtain final approval for use?


Develop a Detailed Flow Chart

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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


Flow Chart Prior to

ReDesign

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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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Gap Analysis/Process Map

Observations Challenges and Barriers

Design/Redesign Considerations

Next Steps/Primary Responsibility

Physicians should reconcile home medications at admission

Physicians are not remembering to conduct admission medication reconciliation

Physicians have to rely on memory

Design a prompt during the admission ordering phase that creates a forcing function for physicians to complete admit medication reconciliation

Monitor physician compliance for completing admit med rec

Subjective Analysis to InformProcess Design


Objective Analysis to InformProcess Design

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Issue 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: >90%ACTUAL: [insert current compliance]

Insert plans to close the gap between the actual compliance percentage and the goal

Medication Reconciliation on Transfer

Numerator: # of patients with medications reconciled upon transfer Denominator: # of patients transferred



Medication List at Discharge

Numerator: # of patients provided an updated home medication list at discharge Denominator: # of patients discharged




Medication Error Analysis and Classification

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Adapted from National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) http://www.nccmerp.org.

http://www.nccmerp.org/


Designing a SuccessfulMed Rec Process

Best Practice: Develop a single, shared medication list, "One Source of Truth”

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Guiding Principles

Clearly define roles and responsibilities Standardize, simplify, and eliminate unnecessary

redundancies Make the right thing to do the easiest thing Develop effective forcing functions, prompts, and

reminders Educate workforce, and patients, families, and

caregivers Ensure process design meets all pertinent local laws

or regulatory requirements

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Consider the following questions: Which discipline could start building the “One Source of Truth” upon

admission (entry) to the organization? How will information be validated applying a “good faith effort” in

building an accurate, complete medication list? What process steps are needed to perform medication reconciliation on

outpatients and inpatients upon admission (entry), intra-hospital transfers (if applicable during a patient’s stay), and discharge (exit)? – Depending on scope defined in your charter

What are the required elements for The Joint Commission’s NPSG on medication reconciliation?

What resources are available within the organization to perform required steps in the process?

Defining Roles and Responsibilities

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Develop Effective Forcing Functions, Prompts, and Reminders

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Designing to Meet Guiding Principles

Hospital Admission

Hospital Discharge


Flow Chart After

ReDesign

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HOMEWORK

1. Put together a Data Collection Plan and collect a couple weeks of data

2. Conduct a Gap Analysis between your current practice/data collection findings and best practice

**We’ll review these and answer your questions during the Med Rec Office Hour on August 31

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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

presented to: hret patient safety learning network participants by kristine gleason, mph, rph

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