Title: Medication Error Process Improvement Plan Scope/Boundaries: Collection of data relevant to PSW med errors. Review data to eliminate non PSW medication errors. Define what a medication error will be. Complete a root cause analysis on all relevant errors. Develop strategies, inc education/training for PSW’s. Team Executive Sponsor: Maggie Mercer Team Lead/Process Owner: Tiziana Pelusi Improvement Advisor: JoAnn Zomer, Steve Kavanagh, Pharmacy task force Team Members: Tiziana Pelusi, Jing Hong, Joeann Shorey, Kenisha Morales, Vanessa Young, TBD: Daniela Popivici PROBLEM STATEMENT: Current statistics shows that agency wide, PSL has on average 2-4 medication errors per month. Client satisfaction survey indicates lower satisfaction levels related to PSW knowledge and training on mediation practice. As a result, clients health and well being are negatively impacted, as is the trust relationship between PSW and Client. Aim Statement: Decrease the number of medication errors made by PSL PSW’s by 50% over the next 12 months. Measures: Outcome measures: reduction of medication errors by 50%. Process Measures: Pilot small group of clients receiving medication assistance. Provide PSW’s with additional education and training on medication process and reporting techniques. Develop specific questions on client satisfaction survey that will target medication management by PSW. Balancing Measures: - Reduction of medication errors, increased client satisfaction with PSW medication knowledge. - Discovery of Med errors that do not get properly reported. -Increasing reporting will increase average number of medication reporting errors. Root Causes of the Problem: Identified through adverse event reports and client satisfaction survey . Data shows that PSL on average experienced 2-4 PSW med errors a month, and clients requesting more PSW training on assistance with medication. Change Ideas: Education and training, closer monitoring of medication process, specific training with contacted agency staff and relief PSW’s, incorporate UCP training agency wide. Incorporate strategies to achieve 100% reporting of adverse events for med related events. Relationship to root cause and Change idea of training and education of staff which is reflected on the data base. Anticipated Barriers and Mitigation Strategies: Financial resources Back fill for front line staff involved in Learning Lab. Time required for learning lab Increase Workload Lack of QI experience among group Lack of client commitment to action plan Lack of staff commitment to action plan Piloting small group decreases the data available (resource data for the project) Funding restraints for staff training Anticipated Timeline: Project starts December 2014 and ends November 2016. Key Milestones: December: gather all information and relevant stats. February: Implementation of PSW training across 3 piloted sites (TC, WISMA, SP) And document process. Evaluate training. March: Develop client survey questionnaire. Continue documenting data. August 2015: client survey on medication program satisfaction September: evaluate the client survey November: Evaluate run charts. Decision to roll out to entire agency is made Resources Required: Budget required for staff training, Dedicated staff time, Budget for back fill for staff, previous Adverse Events report/log. Mileage costs for meetings Signatures: Executive Sponsor: _______________________________ Process Owner: __________________________________

Title: Project Title Scope/Boundaries: Indicate the beginning and end steps and the process being focused on Team List the names and positions for: Executive Sponsor (someone on senior management who will be accountable at a senior level, will remove barriers, ensure adequate resources are provided, etc) Team Lead (Person accountable for accountable for leadership of the project team and accountable for day-to-day project progress) Process Owner (often the unit manager or person in a management position accountable for the process being improved; this person often acts in the position of Team Lead) Improvement Advisor (Someone who does not necessarily have content expertise, but provides and builds QI expertise in the team; if the Process Owner is not the Team Lead, the IA may act in the position of Team Lead) Team Members (based on the SIPOC, ensure individuals from the front line who are most familiar with the process are included, and where possible, “suppliers” and “customers” who may be impacted through inputs to or outputs from the process Aim Statement: Articulate your project aim stating “How much” (amount of improvement – eg 30%) , “by when” (a month and year), “as measured by” (a big dot indicator or a general description of the indicator(s)) and/or “target population” (eg COPD patients) Problem Statement: . What is the problem and what parts of the organization does it impact/touch? . Why is this important to the organization? Is it linked to a strategic priority? . Is there data or other evidence that helps to highlight the problem? Measures: Include a Family of Measures: . Outcome Measures . Process Measures . Balancing Measures Root Causes of the Problem: How were they identified? Include any available evidence. Change Ideas: What are they? What is the hypothesized relationship between the root causes and the change ideas? Is there evidence in the literature or elsewhere for the relationship? Anticipated Barriers and Mitigation Strategies: Anticipated Timeline Over how many months will the project be conducted? If possible, specify start date by month and year, and end date by month and year Key Milestones: Identify key points over the project duration at which time you anticipate key deliverables/results Resources Required: Budget, Dedicated Staff Time (if necessary for senior management to know, especially if the dedicated time is significant) For example, if you require the team to be available a half day every week, a process owner to spend 20% of his/her time, back-fill for front line staff, etc Signatures: Signals that these individuals have read the Charter and are aware of the project focus, and at minimum, commit to and agree with the design, set up, and resource requirements at the early stages. Executive Sponsor: _______________________________ Process Owner: __________________________________