1. 1 MEDICATION RECONCILIATION in a Pre-Admission Clinic CRITICAL SUCCESS FACTORS Cynthia Turner, B. Pharm, R.Ph. Medication Reconciliation Pharmacist Vancouver Island Health Authority (VIHA)

2. 2 What It Takes To Produce Successful Results At the end of this presentation: IF you are looking for ideas to improve your results THEN complete the checklist to guide where your team might need to focus their continuous improvement efforts

3. 3 VIHA Serving all of Vancouver Island, British Columbia, population 730,000 15 acute care hospitals 1461 acute care beds 4760 long term care beds Royal Jubilee Hospital

4. 4 Med Rec Process Overview See Same Day Surgical Admission pts., Royal Jubilee Hospital In Pre-Admission Clinic (PAC) Document BPMH Use multiple sources of medication information Involves Multidisciplinary Team Reconcile meds on wards < 24h post-op

5. 5 The Results tell the Story Implemented: Aug 06 – 1 ward Now – 4 surgical wards involved Our Results are: Sustainable [month to month] Reproducible [ward to ward] Consistently  goal Consistently  national average

6. 6 Sample size small Discrepancies occurred over weekend Royal 2; 1 st ward – Sustainability Unintentional Discrepancies

7. 7 West 3; 3 rd ward - Reproducibility Unintentional Discrepancies

8. 8 Unintentional Discrepancies Local Teams better than National average

9. 9 Unintentional Discrepancies “Then and Now” – < Target Goal

10. 10 Med Rec Steering Group Bob Clark - Executive Director, Pharmacy, Diagnostic & Surgical Services Dr. Con Rusnak - Executive Medical Director, Pharmacy, Diag. & Surgical Services Leslie Moss - Executive Director, Quality & Patient Safety Michele Babich - Director of Pharmacy David McCoy – Director, Post-Surgical Care Programs Dr. Richard Bachand – Manager, Clinical Pharmacy Services Ev Pearce – Manager, Quality and Safety Andrea Bentley – Manager, Booking and Pre-Admission

11. 11 Team Members Cynthia Turner - Medication Reconciliation Pharmacist Lori Brodie - Facilitator Alyse Capron - Quality Improvement Consultant Dr. Hans Cunningham - Chief of Surgery; Surgical Services Sarah Crawford - Clinical Nurse Leader, Royal 2 Robyne Maxwell - Clinical Nurse Educator, Royal 2/Royal 3, BU Andrea Taylor - Clinical Nurse Leader, Royal 3 Kristie Waterman – Clinical Nurse Leader, West 3 Marian Chalifoux - Clinical Nurse Educator, West 3 Rhonda Porter - Clinical Nurse Leader, Surgical Daycare Claire Fisher- RN, Pre-Admission Clinic Dr. Richard Bachand- Manager, Clinical Pharmacy Services

12. 12 CRITICAL SUCCESS FACTORS 1.Documentation 2.Communication 3.Education 4.Program Sustainability 5.Spread Mentor

13. 13 CRITICAL SUCCESS FACTORS 1.Documentation a)Build in process to double check BPMH b)BPMH same place in chart every time c)Accuracy of medication information TRUST is KEY

14. 14 1. Documentation a)Build in process to double check BPMH  if BPMH not used right away  keeps info. current  our process: SDC Nurse notifies both Physician and Med Rec Pharmacist of med. changes

15. 15 1. Documentation b)BPMH in same place in chart every time  Ensure the physician can find the BPMH  Process to alert physicians to presence of BPMH  Reminder notice where to find  Form in Physician Order section of chart PDSA cycles REMINDER Please Complete Home Medication Reconciliation Physician Order Form

16. 16 1. Documentation c) Accuracy of BPMH Use multiple sources of info.  Family Physician History  Patient Clinic Questionnaire  B.C. PharmaNet profile (14 mos)  Pt. Interview ~ 100%

17. 17 Case Study NEW PROCESS: Pharmacist involved Home Medication List Family Physician Patient Clinic Questionnaire B.C. Pharma-Net Profile Patient Interview Metformin500 mg tid Ramipril2.5 mg daily 5 mg daily2.5 mg daily Atorvastatin10 mg daily20 mg daily10 mg daily Pantoprazole40 mg daily ? Metoclopramide10 mg tid? Magic m/wash?20 mL tid Oxycontin??30 mg q12h Source Accuracy: 68% 79% 76% BPMH 100 % (Based on 49 pt.)

18. 18 Intro. Med Rec Form: BPMH documentation/Rx at present – Draft 21 PDSA Cycle #2 To identify Form as an Order PDSA Cycle #3 To focus Physician to their area (yellow highlighting) PDSA Cycle #4 To eliminate SDC Nurses from documenting medications on Form (new process) PDSA Cycle #5 To clearly define area of responsibility on Form 18

19. 19 Documentation Summary TRUST IS KEY!!!  Physicians, nurses, pharmacists all need to TRUST the documentation is accurate  At our site – becomes a Physician Order  Time saving step for multidisciplinary team

20. 20 CRITICAL SUCCESS FACTORS 2.Communication a)Speak language of audience b)Preparation and Follow-up are critical c)Show-off your results BIGGER THAN 1 ST THOUGHT

21. 21 2. Communication a)Speak language of audience Two examples IMPACT of program on  patient safety IMPACT of program on patient admissions

22. 22 OVERVIEW of Unintentional Discrepancies 6 month review 615 patients (3570 meds reconciled) BASELINE PREDICTION: 615 WHAT REALLY HAPPENED WITH MED REC? 24 DIFFERENCE = potential avoided discrepancies: 591

23. 23 Impact of Process at RJH ALL Admissions Jan to Jun 2007 Med Rec Process 8 % Non Med Rec 92 %

24. 24 Impact of Process at RJH Non-Emergency admissions Jan to Jun 2007 Med Rec Process 18% Non Med Rec 82%

25. 25 2. Communication b)Preparation and follow-up is critical Before: Attend physician meetings, nurse staff meetings etc. After: Ensure everyone is performing their role - problems occur with new residents, physicians, nurses etc.

26. 26 2. Communication c)Show-off your results - Before & after measures on wards - Poster in Senior Executive area - Display in cafeteria, newsletter etc.

27. 27 Communication examples Patients: Brochure Fine tuned questions Pharmacy: UBC presentation RJH/VGH/Aberdeen 3-5 days training Students rotate in Senior Team: Poster VIHA Board “Big Dot” Nurses: Cafeteria Day/Newsletter Monthly staff meetings Muffin “thank you” day Physicians: Surgical Executive Presentations Chief of Surgery Dept. meetings Training Video

28. 28 CRITICAL SUCCESS FACTORS 3.Education a)On-going – new staff, new processes b)Standardize material e.g. ward package, educational video etc. c)Make use of educational moments

29. 29 CRITICAL SUCCESS FACTORS 4.Program Sustainability a)Program still functions when key personnel away b)People seek you out to be included c)Use FACTS to sell program

30. 30 … one person needs time off

31. 31 CRITICAL SUCCESS FACTORS 5.Spread Mentor Med Rec = part of VIHA Strategic Plan VGH Pre-Admission Clinic Residential Long Term Care Dialysis/renal pts. Pediatric ward Total Joint Clinic TRUST is KEY

32. Med Rec – Critical Success Factors Checklist Would you like to improve your team’s Med Rec measures? Are your measures:  Sustainable (month to month)  Reproducible as you spread to other areas  Meeting or beating your goal targets  Showing better results than the National Average? If you do not answer “Yes” in the above four boxes, then this checklist might offer guidance as to where to focus your continuous improvement efforts. Any tick in a “NO” box below indicates where improvements in this area may improve your Med Rec measures. AreaSuccess FactorYesNo D O C U M E N T A T I O N IF there is a delay between recording the BPMH and when the physician orders home medications, is there a process of review of medications on Best Possible Medication History (BPMH)? If there is a delay, has our team built in processes to double-check information entered on the BPMH? Is there a consistent location where the BPMH is placed on the patient’s chart? Is there a method of alerting physicians that a BPMH is used on a patient’s chart? Does our team use the maximum number of available medication information sources to create the BPMH (family physician, patient questionnaire, PharmaNet profile, patient interview)? Do stakeholders TRUST that the medications on the BPMH represent an accurate and complete list at the time of documentation? 32

33. 33 Med Rec – Critical Success Factors Checklist Page 2 AreaSuccess FactorYesNo C O M U N I C A T I O N Can we present our data in a more user-friendly format for the average layperson? Does our team “speak the language of the audience” when sharing information? (e.g. senior team, physicians, patients) Have we demonstrated the impact our process is making to the rest of our organization? Do we have a process for informing nurses and physicians about the medication reconciliation process BEFORE implementation in their area? Do we have a process of follow-up AFTER the physician has ordered the home medications? Do we have a process for informing new residents, physicians and/or nurses of the Med Rec process? Have we displayed our results in a public way? e.g. poster to senior exec, newsletters, on wards

34. Med Rec – Critical Success Factors Checklist Page 3 AreaSuccess FactorYesNo E D U C A T I O N Have we standardized the material we use to educate people about this process? Do we have a formal process of providing the education? (Attend physician meetings, staff meetings etc.) Do we have an informal process of providing education – to either “catch them in the act of good performance” or redirect their efforts to the intended process? Have we created any training material that can be used by multiple users e.g. web info, video etc. S U S T A I N A B I L I T Y Do our basic processes still function when key personnel are away? Do we use small tests of change (PDSA cycles) to trial our change processes? Do physicians ask to be included in your Med Rec processes? Does Senior Management enthusiastically support our program? SPREAD MENTOR Does your team act as a SPREAD MENTOR – sharing processes, tips for successes, documentation with other med rec teams? 34

35. 35 Contact Information Cynthia Turner, Med Rec Pharmacist cynthia.turner@viha.ca Lori Brodie, Facilitator lori.brodie@viha.ca Richard Bachand Manager, Clinical Pharmacy Services richard.bachand@viha.ca