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 – 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.

2


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]

3

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

4


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

5


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


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


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

8


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


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

10

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.org11


12

Highlights from the 2nd Webinar (Aug 3) & Office Hour (Aug 31)

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

Sustainability13



Strategy

Measure

14


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


15


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


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


Design/Redesign the Process

Analyze

18


Flow Chart Prior to

ReDesign

19

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


Newman Regional Health Center Current Process Map

20

Nurse takes Medication History

from the patient and/or family upon

admission


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

21


Flow Chart After

ReDesign

22


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


Strategy

Design/ Redesign the

Process


Assess and Evaluate

Build the Project

Foundation

Identify Team Members

Process Map

Develop a Charter


Collect Data

Identify Key Drivers

Flow Chart

Gap Analysis

Process Design

Implementation Plan

Pilot Test

Education / Training

Monitor Performance

Address low compliance

Sustainability23



Improve

24


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

25


– 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

26

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


27

Create and Execute the Communication Plan

Communication (Message)

Audience Delivery Method

Delivery Frequency Delivery Date Assigned To

27

• 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?”


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

28

When Piloting ensure the scope of the pilot is represented, it can be reproduced on a larger scale, and it is measureable


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

29

– 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


30

Train:Responsibilities and Expectations


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

31


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)

32


Go-Live!

33

• 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


Assess and Evaluate

Control

34


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

35

Goal: 95%


Report Results

36

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



Medication List at Discharge

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




37

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


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

38


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

39


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

40


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

Documents