Achieving Compliance with Medication Reconciliation Utilizing Improvement Methods Tuesday, July 1, :00 – 1:00 p.m. EDT © American Academy of Pediatrics 2008

Moderator: Uma Kotagal, MD, MBBS, MSc, FAAP Vice President for Quality and Transformation Director, Center for Health Policy and Clinical Effectiveness Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

DISCLOSURES Financial Relationships One individual involved in this webinar: Melissa A. Singleton, M.Ed., Project Manager-Consultant has disclosed a financial relationship with an entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Her husband is employed by Walgreen Co. as a Workforce Administration Manager (technology position) for the company’s call centers. The AAP determined that this financial relationship does not relate to the educational assignment. None of the other involved individuals (Speakers, Moderators, Project Advisory Committee members, or Staff) has disclosed a relevant financial relationship. Refer to full AAP Disclosure Policy & Grid available below for download.

DISCLOSURES Off-Label/Investigational Uses None of the individuals (Speakers, Moderators, Project Advisory Committee members, or Staff) has disclosed that they intend to discuss or demonstrate pharmaceuticals and/or medical devices that are not approved. Refer to full AAP Disclosure Policy & Grid available below for download.

This activity was funded through an educational grant from the Physicians’ Foundation for Health Systems Excellence.

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CME CREDIT Live Webinar Only The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAP designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. This activity is acceptable for up to 1.0 AAP credits. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Members of the American Academy of Pediatrics.

OTHER CREDIT Live Webinar Only This program is approved for 1.0 NAPNAP contact hours of which 1.0 contain pharmacology (Rx) content per the National Association of Pediatric Nurse Practitioners Continuing Education Guidelines. The American Academy of Physician Assistants accepts AMA PRA Category 1 Credit(s) TM from organizations accredited by the ACCME. Important Note: You must have been pre-registered for this webinar in order to claim CME or other credit for your participation.

Speaker: Maria Etris, RN, BSN Project Manager, Division of Patient Safety Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

Speaker: Jason Olivea, MS, MPA Quality Improvement Consultant Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

Speaker: Christine White, MD, MAT Pediatric Chief Resident Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

LEARNING OBJECTIVES Upon completion of the webinar, participants will be able to: Cite the requirements of medication reconciliation and one hospital’s compliance prior to implementing improvement strategies. Describe improvement strategies that were tested and implemented to achieve success with completing medication reconciliation within 24 hours of admission. Apply improvement strategies to sustain success with medication reconciliation compliance.

Achieving Compliance with Medication Reconciliation Utilizing Improvement Methods Safer Health Care for Kids Webinar July 1, 2008 Maria Etris, RN, BSN Project Manager, Patient Safety Jason Olivea, MS, MPA Quality Improvement Consultant Christine White, MD, MAT, Pediatric Chief Resident

Medication Reconciliation Endorsed as a Safe Practice throughout the nation.

Medication Reconciliation & The Joint Commission… 2005: “New” National Patient Safety Goal with 1 year phase in period to be implemented by January ’ 06 Included: Creating the Medication List Reconciling the list at admission, transitions in care, & at discharge Providing list to family 2006: Many FAQ’s and varied interpretations of Goal 2007: Additional Expectation Provide list to next care provider 2008: No Change

CCHMC’s Historical Performance with Medication Reconciliation 2006 Baseline 2007 Improvement Phase Implementation & Spread Phases 2008 Sustainability Phase

Chartering our Improvement Team I.Team Name: Inpatient Medical Services Medication Reconciliation Team (Steering & Improvement Teams) II.Date we started & Median Performance: 12/06 & 60% III.Date we finished & Median Performance: 1/08 & 94% IV.Keys for Team Successes:  Have the right people at the table  Well defined project & start small  Pick an area where you have buy-in with support & commitment to testing  Pick an area where you can see & measure the change V.Project Constraints:  Technical availability (Currently, Information Services focus is on EPIC, questions surround the ability to provide timely enhancements to MRT.)  Resources for data collection at Admission & Discharge.  Multiple Medication Reconciliation Tools are being utilized (i.e. paper & electronic versions)

Medication Reconciliation Steering Team Purpose of Team: (a) To provide strategic Direction & Feedback (b) To receive monthly Updates from the Improvement Team (C) Assist in removing organizational Barriers. Team Members: Frequency of Meetings: Monthly

Medication Reconciliation Improvement Team Purpose of the Team: Utilization of Improvement Science Methodologies to achieve 90%> Compliance re: Admission Medication Reconciliation for Inpatient Medical Services (AIM). Team Members: Frequency of Team Meetings: Bi-Weekly

January 2007 Where we started Heading……. The Utilization of Improvement Science Methodology A different way of thinking- What Are We Trying to Accomplish & How Will We Know? Focus on Improving the System and not simply ensuring compliance Pt. Safety Focus not simply a Joint Commission requirement

Do StudyAct Plan What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement?

The Improvement Approach It all Starts at the Top Organizational Support and Leadership –Cabinet Support (Steering Committee) –Cabinet Physician Champion Strategic Improvement Priority Quarterly Scorecard

Strategic Priorities Quarterly Score Card

CSI Inpatient Unit Level Quarterly Quality Dashboard

PROJECT MANAGEMENT PHASES 1.0 Define Project (D) 2.0 Measure Current State (M) 3.0 Analyze Current State (A) 4.0 Plan, Do, Study, Act Cycles (P) 5.0 Implement Improve- ment (I) 7.0 Sustain Improve- ment (S) 6.0 Spread Improvements (S)

What is the problem? What are we trying to accomplish (i.e. AIM)? What were the initial Key Drivers to achieve success? What does the Process look like? DEFINE PHASE: To Identify Problem Area, Scope of Project, Charter Team 1.0 Define Project (D)

Potential Medication Reconciliation Areas Requiring Improvement Inpatient Admission –Creating the List –Reconciling the List Inpatient Discharge Outpatient Admission Outpatient Discharge Available to Parents Available to Next Care provider 1.1 Define The Problem Area to Focus On Why Selected?

Develop a S.M.A.R.T AIM for the Project S = Specific M= Measurable A = Actionable R = Relevant T = Timebound 1.2 What are we trying to Accomplish? To increase from 57% to 90% (which includes sustained process stability) for Inpatient Medical Services Medication Reconciliation Upon Admission by 12/31/07. (% Weekly Performance on Run Chart)

Identify Key Drivers Sr. Physician & Nurse Leadership support. An effective/efficient means to capture pt. medications for reconciliation. Make each defined Clinical Area Performance Highly Visible High Reliability Med. Rec. Prescriber Practices Prioritize & standardize Updater Work Flow Up to Date Prescriber & Updater Knowledge of requirements 1.3 Key Drivers: Identified components of the system or process that are vital to Achieving the AIM

1.4 Key Driver Diagram

1.5 What does the Process look like?

MEASUREMENT PHASE: To gather data to build a quantified (data driven) understanding of the current state of the process. Operationally define measures How we used to use and share data Determine Baseline Data via Run Chart Develop Additional Charts as needed (i.e. Sustain/Process Stability) 2.0 Measure Current State (M)

Medication Reconciliation Operational Definition of Measures 2.1 Operational Definition Re: Med. Rec.

2.2 Med. Rec. Run Chart

2.3 Med. Rec. Control Chart Very High Census

ANALYZE PHASE: To assess & identify Contributing & Root Causes associated with Problem Area Team is Focused on Improving Review Data & Assess for Process Stability Conduct Simplified Failure Mode Effects Analysis Intense Reviews of Individual Failure Modes (Ask 5 Why’s) 3.0 Analyze Current State (A)

3.1 Med. Rec. Run Chart 1.What is the current performance? 2.How much variability in the data exists week to week?

Simplified FMEA: High Level version of traditional FMEA 3.2 Simplified FMEA Example of One Step Within Med. Rec. Process

3.3 Failure Mode Reviews Individual Failure Mode Identification

IMPROVE PHASE: To identify, test, and select the right improvement solutions. What changes can we make that will result in an improvement? Document Tests via PDSA Cycles Run Charts with Annotations of Changes 4.0 Plan, Do, Study, Act Cycles (P)

What changes will lead to improvement? 4.1 Interventions

Document your learnings thru Plan Do Study Act (PDSA) Cycles Key Components for Documenting your PDSA: -State Objective of Test -Make Prediction -Outline the Execution of Test = PLAN -Document the Facts/Observations of Test = DO -Assess your Results vs. Prediction & Document what was learned = STUDY -Determine if you Adopt, Adapt, or Abandon = ACT 4.2 PDSA Cycles

Example of a PDSA CYCLE

Follow Up on Failure Modes- Making changes Access from Order Writing Pt context sharing Clarity of Expectations Prompt Visible Until Reconciliation Complete

Optimize Application Functionality Clarity on Required Fields Improved Error Identification Hold, Resume, and Confidential Medication Changes Alphabetical Listings Improved Discharge Summary Integration Developed Reporting Functionality

Impact of Improvements in One Area (A7) 4.3 Annotated Run Charts Via PDSA Cycles

IMPLEMENTATION PHASE: To implement selected solution & design all necessary Support Processes for success. Use of Implementation Check List to ID the following…… a. Process Owners b. Hardwire Support Processes c. Formal Education Roll Out d. Communication Plans Developed 5.0 Implement Improve- ment (I)

Process Owners All Chief Resident are Meso-System Process Owner (They cover all Service Areas) Medical & Clinical Directors are Micro- System Process Owners 5.1 Process Owners

Support Process Developed an Algorithm Tested & showed the ability of Unit Medical Directors to mitigate failures Labeled all COW’s Provided Weekly Performance Reports 5.2 Support Process

Formal Education Roll Out for Units 5.3 Education

Communication Plans Unit Level Leadership involvement & support Unit Level Education Coordinator involvement & support Med. Rec. Posters put up throughout the Unit Worked through the Hospital’s Improvement Structure & various Councils 5.4 Communication Plan

SPREAD PHASE: To Spread the Changes that have led to an improvement to all other areas that apply to the Scope of Project. Use of IHI’s Spread Model a. Work through each of the 3 Chiefs b. Systematic with Spread Package c. Intensive monitoring of data d. Spread Education Plan 6.0 Spread Improvements (S)

IHI’s Model for Spread

Med. Rec. Spread Owners: Chief ResidentServices/TeamsMed. Rec. Ownership Dr. Christine WhiteRed, Blue, Purple, Green, Orange, Neuro Primary Owner for all of Medication Reconciliation Performance Dr. Donna ClaesA5S, RCNIC, PICU, Heme/OncSecondary Owner Dr. Brad SobolewskiCardiology, GI, YellowSecondary Owner 6.1 Spread Owners

6.2 Systematic & Monitoring Of Spread

6.3 Education Formal Education Roll Out for Units

SUSTAIN PHASE: To sustain improvement & ensure stability. Weekly Posting of Performance Reviews Algorithm to guide Process Owners Making System Visible- Performance Poster in Resident Noon Conference Room On-Going Education Plan 7.0 Sustain Improve- ment (S)

Weekly Updates 7.1 Weekly Updates

7.2 Algorithm For Process Owners

Ex: of Ownership & use of Algorithm for Sustain

7.3 Poster for Resident Noon Conf. Rm

Resident Noon Conference Room

On-Going Education Plan Annual Training of New Resident Physicians- New Resident Training will be done by a Project Manager for Patient Safety or CIS Ed team in the Spring of each year. It will include: (1) review of the application (2) the expectations Annual Training of New Fellows- Fellow Training will be done by a Project Manager for Patient Safety or CIS Ed team in the Spring of each year. It will include: (1) review of the application (2) the expectations Training for new RN’s- Incorporated into Patient Services Orientation 7.4 On-Going Education Plan

Have We Sustained Success Our? YES!

New Med. Rec. Team launched: “Inpatient Surgical Services” We have carried over many lessons learned from the previous Project which include: Strong phyisican leadership up front Understanding of process variability & performance prior to launch of new team Daily PDSA cycle testing More aggressive with ensuring the right people are at the table As a result of the above, this new team has been chartered to complete its work in 90 Days.

“Summary” Front line nurses & physicians aligned/involved Make the system visible Effective utilization of Improvement Science Methodology Committed Process Owners w/ support processes

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