Applying DMAIC Methodology to Medication Reconciliation Prepared For [Date] By 4 2

Process Improvement Methodology (DMAIC) DMAIC Provides An Easily Managed Systematic Process To Deliver Measurable Results and Accelerate Change 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

Proper Team Establishment Increases Probability For Success Improvement Teams Proper Team Establishment Increases Probability For Success Project Executive Sponsor Clinical / Academic Sponsor (As Required) Project Sponsor Improvement Leader Process Owner Improvement Team

Medication History, Reconcile Order, Transcribe, Clarify Defining Problem: Analysis of Root Causes Administer Medication History, Reconcile Order, Transcribe, Clarify Dispense, Deliver Monitor Educate, Discharge 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 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 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 Results Direct 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 * 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 D M A I C

Medication History / Reconciliation: Most Effective Interventions Administer Medication History, Reconcile Order, Transcribe, Clarify Dispense, Deliver Monitor Educate, Discharge 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

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 D M A C I

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