Medication Reconciliation Using the MATCH Toolkit – Improve / Control Presented to: HRET Patient Safety Learning Network Participants By Kristine Gleason, MPH, RPh Helga Brake, PharmD, CPHQ Northwestern Memorial Hospital

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. AHRQ is a federal agency within the U.S. Department of Health and Human Services (DHHS) whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. HRET is a charitable and educational organization affiliated with the American Hospital Association whose mission is Transforming health care through research and education. HRET’s vision is to leverage research and education to create a society of healthy communities, where all individuals reach their highest potential for health.

New Resources to Stay Connected 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, jshaw@aha.org 3

HCAHPS and HEN Priority Challenges: Care Transitions and Adverse Drug Events Top four HCAHPS Priorities of over 430 hospitals participating in 18 HCAHPS PSLNs: RN Communication Responsiveness Medication Communication* Discharge Information* * HCAHPS domains addressed by a patient-centered discharge process

New HCAHPS Care Transitions Questions 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.

Northwestern Memorial Hospital Chicago, 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 6 Feinberg and Galter Pavilions Prentice Women’s Hospital

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 1

Today’s Objectives Summarize highlights from the second webinar (held August 3) and office hour (held August 31). Provide an overview of the MATCH Toolkit for implementing a sustainable medication reconciliation process. Today’s focus: Improve / Implement Control

Intra-hospital Transfer Where Do We Begin? Care Transitions ED Admission Intra-hospital Transfer Discharge Post-Discharge Phases of Medication Management Med History, Reconcile Order, Transcribe, Clarify Procure, Dispense Deliver Administer Monitor Educate, Discharge Measurement / Analysis Harm Estimate/Evidence from Literature Harm Estimate/Evidence from Organization Prioritize / Implement Evidence-Based Interventions Measure Improvements / Monitor for Sustainability 9

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

Systematic Approach to Improvement DMAIC is a step by step process improvement methodology used to solve problems by identifying and addressing root causes Define Measure Analyze Improve Control Identify the problem and goal Measure current performance Validate key drivers of error Fix the drivers of poor performance Use mechanisms to sustain improvement For more DMAIC information, including free access to a toolkit and project templates, visit the Society for Healthcare Improvement Professionals website at www.shipus.org 11

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

RECAP Webinar 1 June 25 Office Hour July 13 Webinar 2 August 3 September 21 Office Hour October 19 DEFINE MEASURE ANALYZE IMPROVE CONTROL Build the Project Foundation Establish a Measurement Strategy Design/ Redesign the Process Implement the Process Assess and Evaluate 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 Sustainability 13

Establish a Measurement Strategy 14

Operational Definition Data Collection Plan What to Measure Operational Definition Collection Method Sampling Plan What Where When How Many Question the data will answer Specific Definition System, 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

Involvement of Frontline Staff is KEY Key Drivers The backside of the baseline data collection form: Identifying (& addressing) the problematic issues that drive outcomes will lead to lasting improvement Involvement of Frontline Staff is KEY 17

Design/Redesign the Process Analyze 18

Flow Chart Prior to ReDesign 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 Nurse takes Medication History from the patient and/or family upon admission Nurse enters the medication data into Meditech Admission screen Allergies are entered into RXM Physician obtains the pt’s list of current medications from his office After admission, nurses attempt to clarify any discrepancies by calling pharmacies, doctors office, nursing home, etc. Physician writes medication orders. Some medications are substituted because not on formulary Physician selects PRN medications from a list Upon discharge: 3 lists are printed for the physician to review and select meds on for discharge: Home Meds, Inpt Medications, New Rx’s. Nurse calls med changes and new medications to pharmacy Nurse types discharge med list, compiled from the 3 lists of meds Nurse reviews meds and d/c instructions w patient

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

OUR (YOUR) Mission Continues Webinar 1 June 25 Office Hour July 13 Webinar 2 August 3 Office Hour August 31 Webinar 3 September 21 Office Hour October 19 DEFINE MEASURE ANALYZE IMPROVE CONTROL Build the Project Foundation Establish a Measurement Strategy Design/ Redesign the Process Implement the Process Assess and Evaluate 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 Sustainability 23

Implement the Process Improve 24

Implementation Plan Improvement Planning To implement solutions successfully, five areas must be carefully considered and planned for: Interventions Communication IT Training Measurement Be sure to always include… Detailed actions Team member assignments Completion dates 50% of the work begins now 25

The Intervention Work Plan Activity Task Responsible Role Dependency Expected Completion Actual Completion Status 1-Feb 8-Feb 15-Feb 22-Feb 1-Mar 8-Mar 15-Mar 22-Mar Implement home med documentation process Team   Have plan approved by Nursing Practice Committee Sue 4-Feb Place IT request for new home med form   John Create Form content 6-Feb Pilot test new home med form John Form is completed Educate clinicians on how to collect a complete/accurate home med list Nancy Develop education  21-Mar Educate clinicians on new process David Key for Status   - Behind Schedule - At Risk of Falling Behind Schedule - On Target 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

Communication (Message) Create and Execute the Communication Plan Communication (Message) Audience Delivery Method Delivery Frequency Delivery Date Assigned To 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?” 27

Pilot Test 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 When Piloting ensure the scope of the pilot is represented, it can be reproduced on a larger scale, and it is measureable 28

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 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 29

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

Tips For Obtaining A Complete Medication 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)

Go-Live! 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

Monitor Performance Goal: 95% 35 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 35

Report Results 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

Post-Implementation Strategies to 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

Take Med Rec on the Road 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 ]

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

Determine your pre/post-implementation metrics HOMEWORK Based on your gap analysis and identified improvement strategies, create a Work Plan to implement your interventions 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, RPh Clinical Quality Leader Northwestern Memorial Hospital Chicago IL 60611 312.926.9172 kmgleaso@nmh.org Helga Brake, PharmD, CPHQ Patient Safety Leader Northwestern Memorial Hospital Chicago IL 60611 312.926.2034 hbrake@nmh.org If you want to learn more about Northwestern Memorial Hospital, please visit our website at http://www.nmh.org