Medication Reconciliation: Pharmacy Integrated Model

1. Best Practice Power Hour Medication Reconciliation:Pharmacy Integrated Model Steve A. Carlson, RPh Sara E. Grove, Pharm.D. Northeast Georgia Health System (NGHS) Gainesville, Georgia

2. NGHS Private, not-for-profit, community Accredited by DNV 557 inpatient beds 261 skilled nursing beds Serves almost 700,000 people in more than 13 northeast Georgia counties

3. Inpatients 30,364 Outpatients 238,542 Surgeries Outpatient 10,801 Inpatients 7,466 Emergency Visits 99,456 Deliveries 4,087 Patients Served

4. 32.04 Pharmacists (including management) 6 Clinical Pharmacy Specialists Department of Pharmacy • Cardiology • Critical Care • Internal Medicine • Oncology • Women & Children’s Health • Emergency Medicine • 41 Technicians (3:1 ratio in GA) • Unit-Based Pharmacy Technicians • Cardiology • Critical Care • Internal Medicine • Oncology • Women & Children’s Health • Emergency Medicine (2) * Reflects staffing only at the medical center

5. Customer Service is a major focus of the facility Patient Staff Developed a Unit-Base Pharmacy Technician Model Providing Exceptional Service

6. Unit-Based Pharmacy Technician (UBT) Program Established in February 2007 Initially 4 Pairs of Technicians Goals Optimize Distribution Establish Direct Communication Provide Focused Service Qualified Staff Certified Technicians Experienced Senior Staff

7. Review of Events January 2006: Nurse Managers Interviewed March 2006: Base-Line Survey Conducted May 2006: Results Presented May 2006: Pilot on 2 Floors Conducted July 2006: Proposal Presented & Approved November 2006: Initial Deployment February 2007: Full Implementation March 2007: Survey Repeated May 2007: Results Presented July–August 2007: Focus Groups Met

8. Initial FTE Requirements 7.6 FTE’s; 10 hour shifts 7on / 7off Open pharmacist position (1 FTE) converted to 2.8 FTE’s Redeployed 2.0 FTE’s Requested a net of 2.8 new FTE’s

9. Initial UBT Assignments

10. UBT Responsibilities Delivery of medications directly to nurse or nurse server Resolution of missing medications Facilitating transfer of medications on/off unit with patient Removal/return of discontinued meds Automated Dispensing Cabinet troubleshooting/restock

11. UBT Responsibilities Delivery of cart fill to nurse server Med error/ADR reporting to pharmacist Notification of allergy/height/ weight Monthly nursing unit inspections Assistance with faxing of orders Obtain new orders from units and expedite medication needs

12. Customer Service Survey

13. Pharmacy Customer Service Survey All Nursing Units - Medical Center 2006 2007

14. Pharmacy Customer Service Survey Areas Serviced by Unit-Based Technicians - Medical Center 2006 2007

15. Survey Comments and Suggestions “These techs are the smartest thing I’ve seen around here in a long time. They are beyond measure – an asset to having quality – acceptable nursing care.” “Excellent teamwork – assists nurses to complete essential nursing tasks & focus on this vs. non-nursing duties.” “Go unit based techs! You rock.”

16. Survey Comments and Suggestions “Still have a problem with medication missing, but turn around time to get it is much better.” “The morning meds that are due before breakfast…are scheduled at 0730 and this isn’t working well. By the time we get out of report, the breakfast trays have already been passed. Can these meds please be scheduled for 0630?”

17. Reconciliation Process Communicated to Patient by Nurse Home Admission Discharge Home Med List Created Addressed by MD Reconciled by RPh Addressed & Reconciled by MD New Home Med List Created Transfer List Provided to Next Provider of Care Reconciled by MD

18. Identifying Deficiencies • Discharge Medication List • Heart Failure Core Measure HF-1 Scores • Average Fiscal Year 2008: 53.4% • TJC Average: 75.8% • Majority of failures due to transcription errors • Admission Medication List • Staff observed errors and omissions • Garbage In / Garbage Out NGHS Performance Improvement Dashboard

19. Medication Reconciliation Responsibilities Admission Interview patient at admission Document home medication list Print list for physician to address Discharge Document discharge medication list as specified by physician orders Notify nurse of discrepancies

20. Technician Training Software Demonstrate Proficiency in Entry Procedure Identify Discrepancies Communication Demonstrate Appropriate Body Language Review Principle Identify Barriers

21. Pilot: Heart Failure Pharmacist Pre-Pilot October to Mid-December 2008 Locations Emergency Department 3 Medical/Cardiac Inpatient Units Redistribution of Workload Reduced # Beds/UBT Added 3 Positions per Week

22. Pilot UBT Assignments

23. Here to Help Here to Help Rx Rx Pharmacy Tech Duties Nurse Duties Admission Discharge Pharmacy-Based Medication Reconciliation Pilot Starts December 16th Coverage from 0700-2300 Floors Participating: S3E S4D S4E ED Goals: 1) To improve patient safety and care by striving to optimize the medication reconciliation process 2) To demonstrate improvement through increased Heart Failure Core Measure scores • Interview admitted patients and document current home medication list • If medication history is needed immediately and a pharmacy technician is not available, collect and document current home medication list • Print “Admission Medication List” and attach it to the chart • Late admissions will be completed the following morning • Record “MD Discharge Medication Orders” in Clinical Profile • Resolve discrepancies with physician • Review and sign off “MD Discharge Medication Orders” • Notify nursing of any discrepancies • Counsel the patient on discharge medications and instructions • Sign “MD Discharge Medication Orders” to indicate completion • Sign “Patient Discharge Medication List”

24. Technician-Assisted Medication Reconciliation NGHS Performance Improvement Dashboard

25. Current UBT Assignments

26. Cumulative HF Scores

27. Cumulative Failure Origin

28. Opportunities for Improvement • Nurse/Technician Clarifications • Developed a formal discrepancy form • Discharge Summary • Development of electronic bridge • Improperly Completed Forms • Form revision

29. Discrepancy Reasons • Therapeutic Interchange • New Prescription • Duplicate Therapy • Medication Not Addressed • No Prescription • Inappropriate Form Completion • Inappropriate Alteration of Form

32. Best Practice Power Hour Medication Reconciliation:Pharmacy Integrated Model Steve A. Carlson, RPh Sara E. Grove, Pharm.D. Northeast Georgia Health System (NGHS) Gainesville, Georgia