Go the Distance with MedRec Emerging Ideas and Success Stories To Keep You Going March 3, 2011 Alice Watt, ISMP Canada

Outline 1.MedRec is the right thing to do 2.Doing MedRec the right way 3.Measurement – quality vs. quantity 4.Pass the Baton

3 Elements of Safer Care 1. Identifying what works (efficacy) 2. Ensuring that the patient receives it (appropriate use) 3. Delivering it flawlessly (no errors) What practices will most improve safety? Evidence-based Medicine Meets Patient Safety Leape, L. JAMA July24/ – Vol 288, No.4

Clinical evidence for optimal care Clinical trials MedRec prevents potential ADEs Clinical practice level 1 – “Doing the right things” Process Measure: Percentage Reconciled at admission, transfer, discharge Goal: Target population Clinical practice level 2 – “Doing things right” Outcome Measure: Mean number of unintentional discrepancies per patient Mean number of undocumented intentional discrepancies per patient. Number of patients with at least one unintentional discrepancy. Gap #1: MedRec not done for everybody who needs it. Examples: patients who slip through the cracks who did not get a BPMH at admission or BPMDP at discharge. Gap #2: MedRec not carried out properly Examples: MedRec was done, but outstanding discrepancies still exist because of poor BPMH quality. Evidence: Establishing the problem: Clinical studies Characterization of the problem: Clinical studies, qualitative research. High quality patient care Evidence: Establishing the problem: e.g., IOM reports Characterization of the problem: e.g. Outstanding discrepancies found after MedRec is completed. Reference: Leape, L. What Practices will most improve safety Evidence based medicine meets patient safety. JAMA July 24, 2002 Vol 288, No.4

Question To determine the quality of MedRec you would measure the discrepancies found: A. During the MedRec Process B. After the MedRec Process is complete. C. I don’t know

Question To determine the quality of MedRec you would measure the discrepancies found: B. After the MedRec Process is complete.

Question To determine the impact of MedRec you would measure the discrepancies found: A. During the MedRec Process B. After the MedRec Process is complete. C. I don’t know

Question To determine the impact of MedRec you would measure the discrepancies found: A. During the MedRec Process

“Reconciliation means that you recognize that there are differences. If there weren’t any differences there would be no need for reconciliation. So because there are differences, we are very well aware of the necessity for reconciliation.” Ref: Aung San Suu Nobel Laureate who has become an international symbol of peaceful resistance in the face of oppression in Burma. Press conference Yangon, Myanmar. ( )

Ideal BPMH – Gold Standard Admission Orders GAP- Reconciliation of discrepancies RetroactiveProactive Quality

What’s Reality BPMH Admission Orders Reconciliation - discrepancies found during MedRec RetroactiveProactive Quality BPMH (Clinician) What’s the Gap? – Outcome Measures

When to Measure Everyday reconciliation process and measurement process are actually distinct and different activities After baseline, team needs to measure after reconciliation in order to measure the improvement

When should you measure ?

– Independent of clinician who has done the main reconciliation – Resource requirements - meant to be low intensity – Performed on a small sample monthly for a finite period of time only. Who Measures?

– Can be from same clinical area, different clinical area, quality / patient safety staff member – Aim is to measure the quality of medication reconciliation To ensure medication discrepancies have all been identified No need to count discrepancies team has identified and are in the process of being resolved. Who Measures?

Its like an independent double check Look at all available patient information - no need to repeat BPMH, clarify with MedRec team as necessary

Reached its 1) measurement goal (original relative target definition) or 2) reached 0.3 unintentional discrepancies per patient (absolute target- average 75 th percentile for MedRec 2 for calendar 2008) Held its gains for 3 consecutive data points (months) in a 3-6 month period is considered to be “At Goal”. Teams at goal can start/ continue to measure % of patients with formal reconciliation at admission (regularly) Should then ensure quality is maintained by reinstituting discrepancy measurement quarterly or bi- annually. When to Stop/ Change Frequency of Measuring?

Added to align / synchronize with Accreditation Canada performance indicators (same definitions) % patients receiving formal medication reconciliation on admission Denominator is total admissions (can be by unit or institution) Sampling now allowed for AC (20 patients) Measure for Admission Medication Reconciliation

Note: average of 100 Teams reporting data /month Measure: MedRec Mean Number of Undocumented Intentional Discrepancies per PatientMeasure: MedRec Mean Number of Undocumented Intentional Discrepancies per Patient Measure: MedRec Mean Number of Undocumented Intentional Discrepancies per PatientMeasure: MedRec Mean Number of Undocumented Intentional Discrepancies per Patient Acute care - Mean Undocumented Intentional Discrepancies

Acute Care – Mean Unintentional Discrepancies per patient

Pass the Baton Silo mentality must change. It is our responsibility to pass the baton and ensure that our patients and their care providers have the baton and can run with it.

Spring Training begins March 22 Register today!

Questions? Alice Watt