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Applying DMAIC Methodology to Medication Reconciliation

DMAIC Provides An Easily Managed Systematic Process To Deliver Measurable Results and Accelerate Change

Process Improvement Methodology (DMAIC)

Who are the customers and what is the problem from their perspective?

How is the process performing today and how is it measured?

What are the most important drivers of poor performance?

How do we remove the drivers of poor performance?

How do we ensure that we sustain the improved performance?

Define Measure Analyze Improve Control

Improvement Teams

Project Sponsor

Improvement Leader Process Owner

Improvement Team

Proper Team Establishment Increases Probability For Success

Project Executive Sponsor

Clinical / Academic Sponsor(As Required)

Defining Problem: Analysis of Root Causes

AdministerMedication

History, Reconcile

Order, Transcribe,

Clarify

Dispense, Deliver

MonitorEducate,

Discharge

Identified root causes

• Incomplete/inaccurate medication history (omission, different dose, route or frequency, look alike-sound alike)

Patient’s ability to recall, especially upon admission

Time constraints

Interview skills of clinician

• Multiple locations to document (free text)

• Pharmacist not formally integrated in process

Identified failure modes (FMEA)

• Incomplete and/or incorrect medication orders on admission

• Inadequate or missing information on the patient's admission profile

• No formalized approach/process to obtaining and documenting a medication history

D M A I C

Defining Problem: Challenges to Obtaining Medication Histories

• Patient’s and/or surrogate’s ability to recall medications, doses and/or frequency of use

• Stress of transitioning through the healthcare system

• Health literacy

• Language barriers; cultural beliefs

• Relationship with healthcare clinician obtaining history

• Interview skills of clinician

• Time constraints

• Accuracy and completeness of medication histories obtained from other resources; accessibility

D M A I C

Medication History / Reconciliation: Pilot ResultsDirect Admits to Med/Surg Units*

(N=204)

• 54% of patients had at least one medication discrepancy • 42% of the discrepancies requiring intervention was complete

omission of a medication• 35% of the discrepancies requiring intervention was a different

dosage, route or frequency with what the patient reported taking before admission

• Of the discrepancies requiring clarification, in the absence of a pharmacist intervention, 22% may have resulted in patient harm during hospitalization and 59% may have resulted in patient harm if continued beyond discharge

D M A I C

* Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C and Noskin GA. Reconciliation of Discrepancies in Medication Histories and Admission Orders of Newly Hospitalized Patients. Am J Health-Syst Pharm. 2004; 61:1689-95

Medication History / Reconciliation: Most Effective Interventions

• Single source of truth: Medication list with technology support• Reconciliation process with technology support• I/T design and continuous monitoring

– Compliance, sustainability of new process

– Identify rate, etiology and potential harm of medication discrepancies for process improvements

• Active patient involvement• Active pharmacist involvement

D M A I C

AdministerMedication

History, Reconcile

Order, Transcribe,

Clarify

Dispense, Deliver

MonitorEducate,

Discharge

MATCH Improvement Initiatives

Implement a system that achieves the below:

• Increase accuracy and completeness of medication history– Create “one source of truth”

– Complete medication description (drug name, dose, route or frequency – no free text)

• Reconcile home medications with patient and/or family

• Reconcile all medications (home and current medication orders) at admission, transfer and discharge– Multi-disciplinary approach with physicians, nurses and pharmacists

ID M A C

Approaches to Evaluate Medication Reconciliation Process

• Determining compliance rates

• Type and etiology of medication discrepancies requiring interventions

• Medications / medication classes involved in discrepancies requiring interventions

• Potential harm averted through intervention

• Retrospective v/s prospective review

Questions and Discussion