1. 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

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

3. MATCH “lite” Collaborative Timeline
July 17, 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

4. 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

5. 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):

6. 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: (accessed 2012 June 20)

7. 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

8. “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

9. A Step-by-Step Guide to Improving the Medication Reconciliation Process
MATCH Toolkit, with customizable, actionable information, is available at: 9

10. 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

11. 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 11

12. Build the Project Foundation
Define 12

13. 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!

14. 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

15. 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

16. 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

17. 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, )
# Define Phase July
# 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

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

19. 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

20. Establish a Measurement Strategy20

21. 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
All visits 21

22. 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

23. 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

24. Design/Redesign the Process
Analyze 24

25. 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

26. 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

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

28. 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

29. 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

30. 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

31. 31

32. Questions and Discussion
Vicky Agramonte, RN, MSN
Project Manager
Healthcare Quality Improvement Program 
Island Peer Review Organization, Inc. (IPRO)
 Albany, NY
(518) X115
Kristine Gleason, MPH, RPh
Clinical Quality Leader
Northwestern Memorial Hospital
Chicago IL 60611
THANK YOU!
If you want to learn more about IPRO, please visit our website at:
If you want to learn more about Northwestern Memorial Hospital, please visit our website at