1. 1 The Center for Health and Health Care in Schools A Systems Approach to Reducing Risk and Strengthening Quality in School Medication Management Nancy Eichner, MUP, Senior Program Manager Julia Graham Lear, PhD, Director Center for Health & Health Care in Schools, GWU School of Public Health and Health Services, NASBHC, June 17, 2005.

2. 2 The Center for Health and Health Care in Schools Being trained to give medication is not the critical issue -- The critical issue is having time to give it right and give the students the care they deserve. Secretaries have a full-time job and the care we give students is haphazard, not because we are not responsible or do not want to give good care -- it’s because we are already over-extended. The long and short of it, we are an accident waiting to happen! Elementary school secretary Seattle Public Schools March 29, 2001

3. 3 The Center for Health and Health Care in Schools Schools, Medicine, and Children: Basic Facts In school year 2000 - 2001, 50 million children between ages 5 and 19 attended elementary or secondary school in the U.S. A significant number have health problems that require medication or other medical treatment during the school day. Federal, state and local laws mandate that schools make care available. Assuring safe management of medications given during the school day will require system changes.

4. 4 The Center for Health and Health Care in Schools Common Health Problems of School-Age Children, 5 - 17, 1997

5. 5 The Center for Health and Health Care in Schools Policies & Practices Related to Medication Administration 64% of states and 94% of school districts have requirements regarding school administration of medications 74% of schools have a medical supply cabinet with a lock 65% have a separate medicine cabinet with a lock 57% have a refrigerator reserved for health services

6. 6 The Center for Health and Health Care in Schools Staffing for Medication Management in Schools Current staff who provide meds in schools: School nurses: an estimated 70,000 for 115,000 elementary & secondary schools UAPs (unlicensed assistive personnel) includes health aides as well as school secretaries. Unknown number

7. 7 The Center for Health and Health Care in Schools State and District Required Mandates

8. 8 The Center for Health and Health Care in Schools Legal Requirements - Federal Section 504 of the Rehabilitation Act of 1973 Declares that discrimination on the basis of disability is prohibited in federally funded programs. Individuals with Disabilities Education Act, as amended For students whose disabilities may interfere with learning, school systems must make accommodations. Americans with Disabilities Act (ADA) extends protections of 504 to private schools.

9. 9 The Center for Health and Health Care in Schools Legal Requirements - States Different approaches Generally admonitory rather than regulatory language, e.g. “an effective medication policy will assure etc.” Best practice recommendations, e.g. AL guidelines for LEAs on medication administration Recommended rather than required language, e.g. MN state law says “Drugs and medicine…must be administered, to the extent possible, according to school board procedures.”

10. 10 The Center for Health and Health Care in Schools Barriers to Safe, High Quality Medication Management in School Until their child gets sick, most parents do not know their school’s medication practices. Many school board members do not know their system’s medication management practices. Health services generally receive limited attention from school system policymakers. The people who know policies & practices -- school nurses & other school staff -- have limited input into the school system’s policy & budget process.

11. 11 The Center for Health and Health Care in Schools Improving Medication Management Safety & Quality: Lessons From IOM Studies Designing systems to prevent error by reducing reliance on memory and vigilance. To design for safety means to think about work hours, work loads, appropriate training and to have systems that include procedures that make errors visible and that in the case of error, mitigate harm.

12. 12 The Center for Health and Health Care in Schools Improving Medication Management Safety & Quality: Applying Lessons from Crossing the Quality Chasm System design using 80/20 principle: design for the usual, plan for the unusual. Develop simple low-cost process for performing routine work Examples: Using photos attached to medications to assure accurate student identification Using electronic entry of medication admin information to track documentation & problems Designing system to improve safety requires a learning environment, not a blame & reprisal culture

13. 13 The Center for Health and Health Care in Schools THE GOAL To reduce errors and improve performance in the administration of medications at school for the more than 50 million American children between ages 5 and 19 who attend an elementary or secondary school in the United States

14. 14 CHHCS Project on Medication Management at School Funded by Agency for Healthcare Research and Quality, Fall 2003 - Summer 2004 Issue Brief Invitational workshop involving key stakeholders Content: focus on systems issues -- policy guidance, delegation, documentation, process, security, and quality Case studies: comparison of two school health programs (Boston, MA; Austin, TX)

15. 15 Key Points from Issue Brief Assumptions we make in our approach to strengthening medication management in schools are as follows: Research from IOM Reports: to Err is Human and Crossing the Quality Chasm is applicable System development is the strategy for improving what is done School environment impact your results – both physical and social

16. 16 Key Points from Issue Brief Systems to Reduce Risk—Factors to Address Policy Delegation Documentation Process Security Quality Self-medication Privacy Prescribing Standards Communication with medical professionals

17. 17 Key Questions from Issue Brief Are these approaches to improving patient safety, quality of care applicable to medication management in schools? What research is needed to create a knowledge base sufficient to make recommendations for system changes? What are the downsides of assuming that a safer system can be created when unlicensed personnel perform medical functions?

18. 18 Key Questions from Issue Brief What are the politics that will affect the ability of community, state, and national institutions to implement any recommendations? Are there strategies that could be developed to build a foundation for quality improvement in medication management in school?

19. 19 Case Studies: Two City School Districts & Their School Health Services Boston –63,000 students –Sch system managed sch health program –# SN: 93.5 FTE – Students with IHPs - 3.8% –Direct student contacts, 721,300 –Medication assistance: 227,114 Austin –78,000 students –Children’s hospital- managed sch health program –# SN: 65 FTE –UAPs: 52 FTE –Direct student contacts, 543,259* –Medication assistance: 188,519

20. 20 Case Studies: Two City School Districts & Their School Health Services Boston –Episodic care - 416,650 –Medication - 227,114 –Procedures - 44,369 –Screenings - 36,645 Total 721,300 Austin –Episodic care - 338,489 –Medication - 187,897 –Screenings - 61,786 Total: 588,172

21. 21 Workshop Findings: Barriers to Action Limited risk reduction work in pediatric ambulatory care makes it hard to jumpstart system improvement efforts in school-based medication management. Focus on staffing issues in school health make it difficult to focus on other system components that might be strengthened to improve medication management at school. Other important issues include: psychotropic drugs, data collection & use, accountability & liability, parental involvement.

22. 22 Workshop Findings: Opportunities Develop criteria that could be used to identify measures or standards for assessing safety of school medication management practices. Focus on key areas such as the “hand-off” from community provider to parent or parent to school. Engage community pharmacists in efforts to improve medication management safety.

23. 23 The Center for Health and Health Care in Schools Contact Information The Center for Health and Health Care in Schools 2121 K Street, NW, Suite 250 Washington, DC 20037 202-466-3396 202-466-3467 fax www.healthinschools.org