Western Node Collaborative WINNIPEG REGIONAL HEALTH AUTHORITY MEDICATION RECONCILIATION PROJECT TEAM (team picture)

Background Six acute care sites (two tertiary care hospitals and four community hospitals) Two primary care clinics and two home care sites Trial period from October 2005 to December 2006 Team is comprised of physician sponsor, two co-leaders, project manager, two pharmacists (1.6FTE), twelve nurses (0.4FTE each), one project evaluator

Rationale for project To develop and implement a regional Medication Reconciliation Process throughout the continuum of care including: admission to an acute care unit, referral to home care and within primary care by December 2006

GOALS AND OBJECTIVES To develop a Medication Reconciliation Admission Order Form for use in the acute care sites To maintain an up-to-date medication record in the client’s chart in the primary care and home care setting To educate clients in the primary care and home care setting to maintain a current medication list and provide tools for documenting home medications

Aims for Acute Care 1. Decrease the mean # of undocumented intentional discrepancies by 75% by December 31, Decrease the mean # of unintentional discrepancies by 50% by December 31, Increase the MedRec Success Index by 50% by December 31, Spread the MedRec admission process to 100% of Medicine/Family medicine acute care units by December 31, The MedRec Process is completed within 24 hours in 90% of patients upon admission to acute care units by December 31, 2006

Aims for Primary Care 1. Increase the number of primary care patients in the pilot sites who have a current medication list with them on clinic visit by 50% by June 30, 2006 –Long term goal of 100% by December 31, Decrease the mean number of undocumented intentional discrepancies in the pilot sites by 25% by March 31, 2006 –Long term goal to decrease by 75% by December 31, Decrease the mean number of unintentional discrepancies in the pilot sites by 25% by March 31, 2006 –Long term goal to decrease by 50% by December 31, Increase the Med Rec Success Index in the pilot sites by 25% by March 31, 2006 –Long term goal to increase by 50% by December 31, Spread the MedRec process to two other primary care sites by December 31, 2006

Aims for Home Care 1.Increase the number of home care clients in the pilot sites who have a current personal medication to 50% by September 30, –Long-term goal to 95 % by December 31, Visiting nurses will complete medications reviews and reconciliation every 6 months, or with any medication changes on 50% of their clients by December 31, Spread Medication Reconciliation to the Transcona and Inkster visiting nurses by September 30, Home care case coordinators will complete medication reviews and reconciliation with every review visit on 95% or their clients by December 31, 2006.

Aims for Home Care 5.Decrease the mean # unintentional discrepancies in the pilot site by 25 % by September 30, –Long term goal to decrease by 50 % by December 31, Increase the MEDRec Success Index in the pilot sites by 25 % by September 30, –Long term goal to increase by 50 % by December 31, Spread to all other Home Care offices by December 31, 2007.

Team Members Jan Currie (Executive Sponsor) Rob Robson (Project Sponsor) Nick Honcharik (Project Co-Lead) Marilyn Kilpatrick (Project Co-Lead) Lorraine Ogilvie (Project Manager) Beatrice de Rocquigny (Pharmacist) Lora Jaye Gray (Pharmacist)

Team members Acute care Nurses: Diane Fillion Shelly Ripley Brenda Gawryluk Angela Roy Leilani Clarete Mary Ann Driver Tracey Mastromonaco Natalie Nordin Primary care Nurses: Gail Roberts Ruth Byquist Home Care Nurses: Joan Ernst Drosdoski Lori Chartrand Project Evaluator Keir Johnson

Changes Tested in Acute Care Format and content of the physician admission order form Use of the form in medical admissions from Emergency (4 sites) Use of the form upon admission to a medical unit (1 site but abandoned due to re-work and does not conform to current process) Use of a medication list instead of an order form (1 site but abandoned due to need for standardization across region) Pharmacist facilitated medication history taking (1 site) Use of discharge order form for selected group of home care patients (1 site) Use of an addendum form for capturing variances from admission form

Changes Tested in Primary Care Patient population targeted Compliance with primary care assistants in informing clients to bring in medications at scheduled appointment Compliance with patients told to bring in medications Use of different tools for clients to record home medications Impact of posters in clinic rooms

Changes Tested in Home Care Accuracy of client’s medication list in the chart/database kept by the visiting nurse or case coordinator Accuracy of the client’s personal medication list Impact of educating client on importance of carrying an up-to-date medication list (follow-up) Scheduling medication histories every 6 months using software program Accuracy of medication list in patients recently discharged from hospital

St. Boniface General Hospital Jan 06 – Baseline audit Feb 06 – Draft form shown to physicians Apr 06 – Baseline audit results distributed Apr 06 – Form initiated in Emerg for medicine admissions May 06 – Form completed by night screening residents June 06 – Forms completed for all medicine admissions Introduction of form and process to medical staff Audits results distributed Form completed by medical residents Form completed by night screening medical residents Nephrologists informed New ward residents Form not used Compliance audit completed by Chief Medical Officer June 06 – Nephrologists informed to use the form July 1/06 – New ward residents and interns July 27-Aug 9 – form not used Aug 1-15 – form not used due to cross-coverage Aug 23 – compliance audit conducted by chief medical officer

Keys to Success and Lessons Learned Physician involvement at the onset Ongoing communication with management and direct care staff Support from senior management Buy-in from front-line staff Circulating audit results with interpretation of measurements (lay man terms) Development of site implementation teams to sustain gains and facilitate spread

Keys to Success and Lessons Learned Involve all stakeholders (physicians, nurses, ward clerks, pharmacists, medical information) in decision making Update sites on progress with the utilization of the form (compliance audits) Frequent communication amongst the team regarding role clarity and responsibilities

Steps for implementation Acute care Complete education to staff on all medical wards, Emergency and pharmacy Attain full support from attending physicians, chief residents, director of family medicine and chief medical officer Solidify process for using the order form at various sites Finalize the form content and layout

Next Steps and Plans for Spread Meet with physicians and unit nurse managers of remaining medical units in all acute care sites Meet with home care nursing directors and management team to spread to other diads within the region Spread to additional pods within a primary care facility and to other primary care sites within the region Continue developing and preparing site teams in anticipation of project closure Phase II of project– January 2007 to December 2007 involving 7 patient safety officers (6 acute care, 1 long term care) and one pharmacist

Contact Information Marilyn Kilpatrick, RN, MN, Co-lead Nick Honcharik, Pharm D, FCSHP, Co-lead Beatrice de Rocquigny, BScPharm Lora Jaye Gray, BScPharm Lorraine Ogilvie RN, BN CQM, Project Manager Rob Robson, MD, Project Sponsor Keir Johnson. Program Evaluator