1. FRHS Kaizen Workshop #1 Medication Reconciliation (MRR) Admission / Discharge Only October 3-5, 2007

2. Kaizen #1: Medication Reconciliation Admit / Discharge Mission: To improve the process of medication reconciliation to assure patient safety. Objectives: 1. Achieve a 50% improvement in accuracy of medication information upon admission. 2.Reduce nursing time spent by 12.5%/day. 3.Reduce delays in medication administration by 50%. 4.Reduce medical errors by 80% 5.Support the new hospitalist program. Train-the-Trainer objectives 6.Learn Lean tools as process improvement method. 7.Diffuse improvement mindset throughout the hospital. 8.Reduce waste throughout all major processes.

3. Medication Reconciliation KaizenTeam

4. Kaizen Team Work David, Beth, Steve, John, Rhonda, Beth H, Melissa, Carol, Mark, Missy, Vicky, Gloria, Alison, Patsy

5. ER Direct Admit External Transfer Obtain list of current meds  ; Contact physician  Contact external pharmacy  How to get? Review initial orders  Contact admitting physician to identify meds  Reconcile meds  Review external facility list  15 min Nurse write out med list (if needed);  Fax order to internal pharmacy  1-2 hours 30 – 60 min Nurses temp orders are cancelled and re-entered Physicians don’t write full admit med’s list; Nurses act on med’s list 15 min 20 sec to 15 min ADMISSION Get and/or Give meds Physicians don’t respond Process Efficiency: 100% max, 31% min Admit/PCP don’t agree on med list for patient Total Admission times: Min: 97.2min Max: 2.5 hr All pre-op meds discontinued when going to surgery/transfer; Pharmacy out of loop; No auto discharge between units. Discharge form placed on each chart at each location Create standing orders Computer versus manual documentation system for meds (ED gets but another area enters) Standardized process for FRHS physician offices in relaying med list. Nursing making decisions outside scope of practice. Collaboration with pharmacy. incomplete orders are not written and relayed to pharmacy – i.e. no dose, route. Education improvement s for new people. VALUE STREAM MAP – MEDICATION RECONCILIATION

6. Physician discharge order form and signs  Print Discharge Instructions   DISCHARGE Are meds complete?  Calls physician to complete list  Physician task to write meds, activity, diet, etc. Enter full info into CPSI  No Yes DONE Incomplete physician meds; Or continue home meds; Physicians don’t respond till later. Discharge order about not on all charts. Educate nurses and physicians on location. Process Efficiency for discharge: 56% Best 30% Worse Case 15 min 2 min to 1 hr Redo 2 min Physicians not writing complete list of meds for patient to continue to take. Computer generated list of all home meds and meds taken while hospitalized. Should list only meds active on day of discharge.  : Value Added  : No value added Total Time: Min: 41 min Max: 112 min Complete separate forms as needed for transfers. Redo work to getting transfer forms completed. VALUE STREAM MAP – MEDICATION RECONCILIATION

7. FUTURE STATE - ADMISSION

8. FUTURE VALUE STREAM DISCHARGE

9. PROCESS IMPROVEMENTWHOWHEN 1Physician order form Patsy & Beth W. 2At discharge bring file…. ? 3Modification of medication reconciliation report to highlight or subtract Rhonda & Vickie 4Standing order based on diagnosis. Alison and Gloria 5Go back 90 days in computer system for hospital meds Rhonda and Vickie 6Computerized physician orders Missy & Beth H 7Standard time or procedures for salary FRHS to respective physician list. John and Steve 8ER enter medication list in CPSI Mark and Carol 9All FRHS docs enter meds into CPSI – EMR, nurses pull OP list upon admission. 10Chart link for nurses to view past medical history 11Education Physicians and nurses regarding medication reconciliation Carol and Mark 12Pharmacy contacts physician directly to clarify “missing dose or frequency”Missy & Beth H 13 Pharm “D” goes to floor / or review electronic chart for clinical monitoring, interactions on home & in-house medications. 14 Problem solve why all Pre-op meds are not “stopped” at pre-op, transfer 15Why pharmacy is out of loop on patient transfer and times to stop drugs?Missy & Beth H 16IMI to associate standards of care for medication reconciliation into physicians pay 17Require PCP to fax current medications on admission Week #1 – Medication Reconciliation Process Improvement

11. Discharge Orders Form Sample

13. DRAFT Policy

14. Physician List Sample

16. Reconcile Sample

17. Reconcile Sample Extra Lines

19. Standing Orders Example

20. Standardized Work Chart

25. BEFOREAFTERIMPACT Physician Order Form (#1) No consistent process for use and chart placement; physicians ask nurses to complete. Continue to use current form; education unit clerk/physician; qtrly review Increased usage and compliance - 18 of 18 Med Reconcile report: (#3) Form contained all home meds and all medications administered during the hospital stay Form can be modified so all home meds and only current medications ordered at time of discharge will show; continue or discharge boxes available for orders; nursing option for all meds or current only meds; hard- code med name/type/route Less medication errors, improved patient safety, less risk with compliance to applicable regulations. Standing Orders (#4) Some in place - 17 top 25 DRGs; patient safety and compliance not optimal Meeting 100% standards for care involving the top 25 DRGs. Improves education/awareness for new team members, thus overall by-in for use of product. Improved patient care/safety. Increases standardization which maximizes productivity and improves customer satisfaction by decreased waiting times. 90 Days (#5) System can restore after 98 days (copy-forward); current usage unknown Nursing will be educated on process for bringing information forward without having to re-type. Speeding up processes. (Unless an outpatient event) Smoother process for medication list of home medications with minimal computer data entry by nursing. Saving time and more reliable listing. Scope of Practice for Nursing (#7) Lack of physician compliance with providing med list results in nursing making medical decisions in addition to 'hunting for information' via family, pharmacy, or other resources. Develop Policy and Procedure for physician call-back from unit pages; complete listing of medications will be provided to all upon referral or transfer; external pharmacy to be used as a last resort in the event other resources unable to provide needed info. Returns nursing scope of practice to acceptable legal parameters. Decreases time for nursing, pharmacy, and physician to resolve home medication issues upon arrival. ER med list entering into CPSI (#8) Currently home meds are not being entered into the computer system by ER team. Current questions about medications are free texted rather than in electronic flow sheet. All ER patients will get home medication list started in ER. Decreases time for medication reconciliation RESULTS

26. BEFOREAFTERIMPACT Computer usage #11 – system not being utilized to its maximum potential All incoming patients would have their home medication lists started at the earliest entry point – with focus on ER. Computer system usage maximized and patient care improved via speedy medication reconciliation. Pharmacy missing does; floor review; stopped orders (#12) – medications are not being discontinued prior to transfers Pharmacy has only one terminal with trigger for transfers between floors – but no surgical trigger. Typically not looked at by the pharmacy team. Pharmacy using personal decisions on what medications to continue due to lack of new orders written by physician upon transfer. All pts will have their orders discontinued upon transferred and new orders received as the physician feels appropriate on med rec form for that patient’s continued care. Orders for transfer will be complete and include medication reconciliation between units as per the HFAP standards. Surgery to fax all post-op orders to pharmacy. Medication lists will be printed between transfers and used as a guide for which meds to continue. Ideally the physician will provide this information. Nursing and pharmacy will work in conjunction to review and assess for potential patient safety issues. Meets hospital policy and improves patient safety. Medication errors reduced. Conforms to federal guidelines. RESULTS

27. Results Summary CATEGORYRESULTSBASELINEACHIEVEDCOMMENTS Steps: Lead Time / Process Efficiency 1610 Standard works: written 0+1 QualityStandard orders improve care; Pharmacy review/process MRR; Physicians use revised MRR to confirm meds Enter ECF meds into CPS Decrease medication errors Time / ProductivityFewer pharmacy calls; Fewer nurse calls to physician; Nurses have less confusion on whose orders to follow Med orders more clearly understood; Fewer calls to physicians for discharge instructions; Discharge nurses do not have to enter into CPSI. OtherIncrease nursing morale with better work flow. Improve communication between nsg / docs