1. Presented to: AHRQ Attendees AHRQ 2007 Annual Conference September 27, 2007 By Kristine Gleason, RPh Quality Leader, Clinical Quality and Patient Safety Medications At Transitions and Clinical Handoffs (MATCH): Multi-disciplinary Team Approach to Medication Reconciliation Supported by a grant from the Agency for Healthcare Research and Quality (AHRQ) 5 U18 HS015886

2. Discussion Overview Multi-Disciplinary Approach for Medication Reconciliation Designing a Process within Inpatient and Outpatient / Procedural Areas Education and Team Training – “Med Rec Roadshow” Measurements for Improvement Session Objectives - To describe patient-centered tools and re-engineering of processes to improve the effective and safe delivery of medications across the healthcare continuum.

3. What is Medication Reconciliation? A systematic process to decrease medication errors and associated patient harm by: − Obtaining, confirming and documenting the patient’s complete list of medications upon admission − Comparing and screening this list against the medications prescribed − Reconciling (resolving) unintended medication discrepancies − Communicating an updated medication list, highlighting any changes, to the patient and next provider of service upon discharge The Joint Commission National Patient Safety Goal #8 Medication reconciliation impacts all patients at NMH who receive medications

4. Northwestern Memorial Hospital - Chicago, Illinois 744-bed Academic Medical Center Fiscal Year 2006: – 43,000 Admissions – 10,000 Deliveries – 74,000 ED Visits – 430,000 Outpatient Registrations NMH Strategy: – Provide the Best Patient Experience – Recruit, Develop and Retain the Best People – Achieve Mission and Vision through Exceptional Financial Performance Recipient of 2005 National Quality in Healthcare Award New Prentice Women’s Hospital Opening October 20, 2007

5. Getting Started or Moving Forward Organizational Risk Assessment Operational Component Research Component Collaboration Support

6. MATCH - Specific Aims Aim 1: Implement the MATCH program utilizing an integrated, multidisciplinary process (NPSG – operational component) Aim 2: Analyze the implementation and compliance of MATCH program (NPSG – operational component) Aim 3: Determine the rate and etiology of medication reconciliation failures within the general medicine service after MATCH implementation (research question) Aim 4: Identify risk factors frequently responsible for inaccurate medication reconciliation (research question) Aim 5: Produce and disseminate a toolkit based on MATCH (implementation / research summary) Supported by a grant from the Agency for Healthcare Research and Quality (AHRQ) 5 U18 HS015886

7. Designing a Multi-Disciplinary Approach

8. Medication Reconciliation – Improvement Initiative Increase accuracy and completeness of medication history − Create “one source of truth” (Med Profile) − Complete medication description (name; dose; route; frequency) − Validate home medications with patient, family and/or other sources Prompt clinicians to complete medication reconciliation Reconcile all medications (home and current medication orders) during transitions in care Achieve >90% compliance at admission and discharge to meet The Joint Commission requirement Multi-disciplinary team approach - physicians, nurses and pharmacists

9. Medication Reconciliation: “One Source of Truth” for All Medications (Inpatient and Outpatient) Physician Medication Reconciliation Patient Interaction Pharmacist Medication Reconciliation Nurse Medication Reconciliation PATIENT HEALTHCARE PROFESSIONAL MEDICAL RECORD

10. Built in Forcing Functions - Admission Order Set Med Rec Integrated within Physician Admission Order Set

11. Built in Forcing Functions –Physician PowerForm Example

12. Built in Forcing Functions Cont. – Nurse / Pharmacist PowerForm Example

13. Standardized Process - Procedural Areas and the Emergency Department

14. Education, Training and Feedback

15. Medication Reconciliation “Roadshow” Significant Technology Enhancements 60+ Computer Classroom Training Sessions Conducted – 341 physicians trained (focused on residents) – 450 Nurses, APNs, NPs – 51 Pharmacists Unit-by-Unit In-services Prioritization and support reinforced by Medication Reconciliation Leadership Team Weekly audits to identify areas for improvement and to provide feedback

16. CATEGORYDEFINITIONEXAMPLEREQUIRES PHYSICIAN FOLLOW-UP? (Yes/No) “One-to-One” Match Medications ordered for patient during episode of care or upon discharge match what patient was taking prior to admission (entry) to the organization  Patient takes furosemide 40 mg by mouth twice daily at home; ordered upon admission.  Patient’s pre-admission dose of simvastatin 40 mg by mouth every evening is continued during the hospital stay and at discharge. No Intended Discrepancy (i.e., purposeful) Discrepancies exist but are appropriate based on the patient’s plan of care – i.e., information gathered during rounds, based on a review of the physician’s history and physical (“H&P”) and progress notes, based on communication/handoffs in preparation for discharge, etc.  Antibiotics started for infection  “As needed” medications ordered for pain/fever  Pre-admission doses of patient’s blood pressure medications changed due to hypotensive episodes  Warfarin and aspirin held for a procedure  Formulary substitution No Unintended Discrepancy Discrepancies exist and require clarification of intent because there is no supporting documentation or explanation based on the patient’s current clinical condition or care plan.  The patient takes her blood pressure medication twice daily at home but it’s ordered only once daily in the hospital. No indication for frequency change and patient’s current blood pressure slightly elevated.  Patient’s simvastatin was omitted from their discharge instructions without any clear indication for why. Yes- Physician should be consulted for resolution and resulting changes and/or clarifications documented. Critical Thinking – Clarifying Discrepancies Identified During Reconciliation* *Adapted from Gleason et al. Am J Health-Syst Pharm. 2004; 61:1689-95.

17. Medication Reconciliation Results: Adherence to Process

18. Medication Reconciliation Results - Admission Definition: Documented compliance with recommended Medication Reconciliation upon inpatient admission (physician, nurse, and/or pharmacist) Mandatory Training Program Definition: Documented compliance with recommended Medication Reconciliation upon outpatient arrival (includes 20 departments) D M A I C

19. Medication Reconciliation Results - Discharge Definition: Documented compliance with recommended Medication Reconciliation upon discharge (physician and nurse) Definition: Documented compliance with recommended Medication Reconciliation at discharge (physician and nurse) D M A I C

20. Medication Reconciliation Results Multi-disciplinary Team Approach at Admission D M A I C Medication Reconciliation – Electronic Audit Randomly selected sampling days8/8/078/13/078/21/078/29/079/5/07 Overall Admission Compliance95%94%93%97%99% -Physician Compliance84%86%89%90% -Nurse Compliance88%82%86%85%87% -ICU Pharmacist Compliance100%92%100% 94%

21. Continued Focus on Patient Safety

22. Assessing the Quality of Medication Reconciliation Evaluation of the medication reconciliation process post- implementation to determine: – Frequency and causes of medication reconciliation failures – Type of discrepancies involved – Potential patient harm averted – Patient and/or medication-related risk factors frequently responsible for inaccurate medication reconciliation Supported by grant number 5 U18 HS015886 from the Agency for Healthcare Research and Quality (AHRQ). Goal: To eliminate avoidable adverse drug events and associated patient harm due to medication discrepancies.

23. MATCH Toolkit - www.medrec.nmh.org

24. Questions, Answers and Discussion Kristine Gleason, RPh Quality Leader, Clinical Quality and Patient Safety Northwestern Memorial Hospital, Chicago, IL kmgleaso@nmh.org MATCH Toolkit available at: http://www.medrec.nmh.org We acknowledge the supported of the Agency for Healthcare Research and Quality (AHRQ) 5 U18 HS015886