A Kick Start to Medication Reconciliation

1. A Kick Start to Medication Reconciliation Dr. Hilary AdamsQuality Improvement Physician, Family Medicine Calgary Health Region Judy Schoen Pharmacy Patient Care Manager, Calgary Health Region

2. The team • Multidisciplinary • Champions/opinion leaders • QI support if possible • Don’t forget frontline staff! • Distinct group with common focus (e.g. nursing unit, specific service etc)

3. Getting Started • GSK from SHN • PDSA quality improvement model • FOCUS • Find an opportunity • Organize a team • Clarify current process • Understand variability • Sustain results

4. Why baseline data • We don’t know what we don’t know • Recognize size of problem • Get buy in early • Helps show improvement • Makes it a priority

5. Baseline Measures Success Index: 56.9% Mean # of Undocumented Discrepancies: 0.6/patient Mean # of Unintentional Discrepancies: 1.7/patient 5

6. Current process and Variability • Analyze current process for gaps and drops • Understand variability • ? multiple locations for data

7. Incomplete med list Past Process: Hospitalist History and Physical Form 7 Source(s) of Information

8. Past Process: Hospitalist History and Physical Form No med list 8 8 Source(s) of Information

9. Past Process: Nursing Medication History No med list 9

10. Variety of processes Unclear roles Concerns about duplication Rework in locating information in chart Key Learnings 10

11. Variety of processes Unclear roles Concerns about duplication Rework in locating information in chart Team Vision: Standard approach Clear roles Single location for home medication information in chart Collect Best Possible Medication History (BPMH) in 24 – 48 hours 11

12. Team Charter • Identify all team members • Purpose of project • Guiding principles • Scope and boundary • Goals and objectives • Ideas for change • Principles for working together • Roles and responsibilities

13. Challenges at the Onset • No clear owner. • Variety of processes. • Obtaining accurate medication information. • Limited clinical pharmacy resources. • Physician / nursing buy-in. • Difficulty in adopting new practices. • Lack of communication between interfaces. 13

14. Critical Aspects • No duplication/melds with current workflow • Prompts/cues on forms (e.g. dose) • Involvement of all disciplines • Education • Strong leadership • Monitoring our progress • Auditing the process, not individuals 14

15. An Improved Process: What things may look like • Standardized approach • Multidisciplinary • Clear roles. • Defined location for home medication information in patient chart. • Increased awareness of key questions to ask to illicit the BPMH. 15

16. An Improved Process: What things may look like • Ease of use • Flexible • Does not result in duplication • Clear communication • Close the loop • Prompts health care providers to provide BPMH

17. Step 2: Pre-Admission Medication List 17

18. Step 3 & 4: Additions/Clarifications of Pre-Admission Medication List 18

19. 19

20. Step 5: Physician Review 20

21. Challenges • Wellnet – not a complete record • “As directed” on Rx • Patient altering own medications • Limited sources of information outside of office hours • Transposing to PCIS (EMR) • Adapting learnings to the community 21

22. Lessons learned • Understand variation in current practice is critical • Multidisciplinary approach is essential • Vision of final outcome critical • BPMH auditor must be separate to the process • Clear definitions • Deal with one issue at a time • Small successes build momentum • Just do it! (when is it right enough?)

23. A nurse on Unit 62 received a phone call from a patient’s wife. She asked why her husband was on lasix. The nurse pulled the patients chart and referred to the BPMH form in which the MD had documented that lasix was to be ‘held’ due to dehydration. The nurse was able to efficiently respond to the patient’s wife. Gains 23

24. Baseline Measures Success Index: 56.9% at baseline to as high as 92.8% Mean # of Undocumented Discrepancies: 0.6/patient to as few as 0.0 Mean # of Unintentional Discrepancies: 1.7/patient to as few as 0.4 24

25. Step 1: Patient Risk Assessment Tool Step 1: Patient Risk Assessment Tool 25

26. Referrals to Pharmacy 26

27. Success Index

28. Undocumented Intentional Discrepancies

29. Unintentional Discrepancies