Medication Reconciliation Using the MATCH Toolkit “Presented to” Georgia Hospitals July 31, 2013 Kristine Gleason, MPH, RPh - Clinical Quality Leader, Northwestern Memorial Hospital Vicky Agramonte, RN, MSN - Project Manager, Healthcare Quality Improvement Program , IPRO 4 2

Today’s Objectives Provide an introduction of the MATCH Toolkit Discuss pre-work requirements to participate in the MATCH-lite Collaborative Discuss strategies to link medication reconciliation with current initiatives

MATCH “lite” Collaborative Timeline July 17, 2013 HAC Call to introduce collaborative July 31, 2013 Introduction to the MATCH toolkit and Collaborative Pre-work August 20, 2012 Regional Meeting – Savannah August 27, 2013 Regional Meeting – Atlanta September/October Coaching Calls – Date/Time TBD https://members.gha.org/source/Calendar/

A Focus On Medication Reconciliation A process to decrease medication errors and patient harm by: Obtaining, verifying, and documenting patient’s current prescription and over-the-counter medications; including vitamins, supplements, eye drops, creams, ointments, and herbals Comparing patient’s pre-admission/home medication list to ordered medicines and treatment plans to identify unintended discrepancies Discussing unintended discrepancies (e.g., those not explained by the patient’s clinical condition or formulary status) with the physician for resolution Providing and communicating an updated medication list to patients and to the next provider of service at discharge 4 Adapted from The Joint Commission National Patient Safety Goal 03.06.01

Bridging Interventions Post-Discharge Intervention Current Evidence to Reduce Readmissions: Implementing Bundled Interventions Pre-Discharge Intervention Bridging Interventions Post-Discharge Intervention Patient education Medication Reconciliation Discharge planning Scheduling follow-up appointment Transition coaches Physician continuity across settings Patient-centered discharge instruction Follow-up telephone calls Patient-activated hotlines Timely communication with next provider of service Timely follow-up with ambulatory provider Note: Individual components of these change packages have not been tested by themselves and might not reduce the risk for 30-day rehospitalization. 5 Source: Hansen et al. Interventions to Reduce 30-Day Rehospitalization: A Systematic Review. Ann Intern Med. 18 October 2011;155(8):520-528.

Does Medication Reconciliation Impact the Patient Experience? Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Domains: Communication with Nurses Communication with Doctors Responsiveness of Hospital Staff Pain management* Communication about medicines* Discharge information* Cleanliness of hospital environment Quietness of hospital environment Overall rating of hospital Willingness to recommend hospital *Impacted by Medication Reconciliation 6 Source: HCAHPS Fact Sheet. Available at: http://www.hcahpsonline.org/facts.aspx (accessed 2012 June 20)

Opportunities to Educate and Communicate Use Medication Reconciliation as an opportunity to educate patients on their medications throughout their hospital stay Home medications that are continued during the hospitalization Home medications that were discontinued and why Ordered medications, include indication and possible side effects Ordered as-needed (PRN) medications that are available to them by asking Empower patients to ask questions and become active partners Trace patients through hospital stays to identify opportunities for interaction ED Admission Intra-hospital Transfer Discharge Post-Discharge 7

“Bundling” Medication Reconciliation with Current Initiatives 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 8

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 9

YOUR Mission (to implement a successful med rec process) if YOU Choose to ACCEPT It Webinar 1 July 11 Webinar 2 July 31 Regional Meetings August 20 OR August 27 2 Office Hours Calls Date/Time TBD 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 10

A 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

Build the Project Foundation Define 12

EVERYONE Is Involved and Accountable! Assemble Your Team Executive Sponsor Project responsibilities: provide overall guidance and accountability, remove barriers, provide strategic oversight and appropriate resources, review progress Sponsors Project responsibilities: accountable for success, responsible for implementation of recommendations, provide tactical oversight, reach clinical consensus Improvement Leader Project responsibilities: Accountable for using DMAIC to manage project and complete deliverables in a timely manner, partner with Process Owner Process Owner Project responsibilities: Accountable for implementing, controlling and measuring the project outputs and improvements Team Members: Make significant and focused contributions to timely and successful implementation 13 EVERYONE Is Involved and Accountable!

Map the Current Process A High Level Process Map is a simple picture of a complex process represented by 4-8 key steps. It is essential to better understand the process being improved and to gain agreement on project scope. Physician places discharge order Physician writes new prescription Physician prepares d/c instructions Nurse collects the d/c instructions and prescription and counsels the patient Patient discharged 14

How to construct a high level process map: Get Team together - include all stakeholders Define and agree to a process List all participants of the process – depts., mgrs, and job performers Define beginning and end points Brainstorm key process steps Determine order of process steps Validate by physically walking through process 15

Develop a Charter Strategic Linkage Goal Scope Deliverables Resources Clearly ties the project to organizational goals Strategic Linkage Concise description of the issues Problem Statement Describes planned accomplishments Goal Area to be covered – avoid scope creep Scope Tangible end-products, must align with goal Deliverables Necessary requirements for project success Resources Objective measurement of progress Metrics Used to monitor progress and maintain focus Milestones 16

Medication Reconciliation Phase III Linkage to NMH Goal: Best Patient Experience – Deliver care that is safe and without error. Problem Statement: NMH has made significant strides in developing and implementing a Medication Reconciliation process organization-wide. Through close measurement and monitoring, we have identified the need for additional efforts including: process reassessment and refinement (SDS, Prentice, Discharge). With the proposed 2009 revision to The Joint Commission standard we are presented with new process design opportunities (ED, Outpatient Areas); and, a renewed focus on transfers (internal and external). Goal/Benefit: 1) To measurably decrease the number of discrepant medication orders (both inpatient and outpatient) and the associated potential and actual patient harm. 2) Fully meet the Joint Commission’s National Patient Safety Goal #8, documentation and reconciliation of all medications at admission, transfer and discharge for all inpatients, ED visits and outpatient encounters and external transfers. Scope: Focus on outpatient Same Day Surgery, Prentice, ED, and procedural areas, transfer and discharge processes Deliverables: Improved compliance of medication reconciliation through refined processes in areas stated above. A sustainable measurement and monitoring approach to be embedded in current reporting infrastructure. Resources Required: We will need leadership to prioritize med rec work and facilitate manager involvement in design and implementation efforts Key Metric(s): % inpatient Med Rec compliance at admission, transfer and discharge by discipline (MD, RN, RPh) % inpatient Med Rec compliance by service % outpatient Med Rec compliance at admission and discharge Milestones: Description Date (month, 2008-9) #1 Define Phase July #2 Measure/Analyze August #3 Improve December #4 Control January 17 Exec Sponsor: C Watts Sponsors: DDerman-MD, CPayson-RN, DLiebovitz–IS, NSoper-Surgery Subject Matter Expert: K Gleason Process Owner: H Brake JFoody, KOLeary–Medicine, KNordstrom–Pharmacy Improvement Leader: ML Green

A Word About Scope Begin by identifying all areas within your facility where patients receive medication.

Tips for Successful Chartering Keep it simple … anyone should be able to review your charter and know what you are looking to do and why it is important Include data … If you do not have initial data, use placeholders Identify where the project “Starts – Stops” Ensure your scope reflects your time horizon Try to avoid projects over 12 months long Estimate where necessary, refine over time … ‘something’ provides a guide, ‘nothing’ causes delays Focus on outcomes 19

Establish a Measurement Strategy 20

Operational Definition Data Collection Plan Caution: Jumping into data collection without a clear plan wastes time, energy, resources, etc. 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 21

Collect Data Work with the team and staff to identify potential drivers and build a data collection form Seek assistance from the team and staff in collecting the data to increase buy-in Observe the data collection process periodically to identify issues, errors 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 Identify 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 23

Design/Redesign the Process Analyze 24

Flow Chart 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 25

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 26

Design a Successful Med Rec Process Best Practice: Develop a single medication list, "One Source of Truth” 27

Guiding Principles Clearly define roles and responsibilities Standardize, simplify, and eliminate unnecessary redundancies Make the right thing to do the easiest thing to do Develop effective forcing functions, prompts, and reminders Educate workforce, and patients, families, and caregivers Ensure process design meets all pertinent local laws or regulatory requirements 28

Strategies to Overcome Lack of Resources and Time Get Leadership Buy-In Let them know why they should care: Patient Safety, Public Reporting, Financial Incentives Bundle the Work Identify similarities among projects – get 2 things accomplished for the price of 1 Identify Opportunities for “Quick Wins” Prioritize changes that may be easily developed and implemented 29

Homework Complete prior to the regional meeting: Put together a High Level Process Map for med rec. Remember: Keep it high level – No more than 8 steps With your team, create a project charter. Use the template on the next slide Adopt a plan to collect baseline data and audit 5 medical records for compliance with the current process 30

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Questions and Discussion Vicky Agramonte, RN, MSN Project Manager Healthcare Quality Improvement Program  Island Peer Review Organization, Inc. (IPRO)  Albany, NY 12211-2370 (518) 426-3300 X115 vagramonte@ipro.org Kristine Gleason, MPH, RPh Clinical Quality Leader Northwestern Memorial Hospital Chicago IL 60611 312.926.9172 kmgleaso@nmh.org THANK YOU! If you want to learn more about IPRO, please visit our website at: http://www.ipro.org If you want to learn more about Northwestern Memorial Hospital, please visit our website at http://www.nmh.org