MEDICATION RECONCILIATION GLOBAL TRIGGER TOOL DSRIP

1. MEDICATION RECONCILIATIONGLOBAL TRIGGER TOOLDSRIP Doing Common Things uncommonly well June 7, 2011 Shideh Ataii, Pharm.D. Director of Pharmacy Services Contra Costa Regional Medical Center Martinez, California

2. OBJECTIVES • Medication Reconciliation • Howthe approach over the years • What the process • Tools the forms • Pearlsof wisdom & Lessons learned

3. OBJECTIVES 2) Global Trigger Tool 3) CA 1115 Waiver – Delivery System Reform Incentive Payments (DSRIP)

4. Contra Costa Regional Medical Center & Health Centers Martinez California San Francisco Bay Area

5. County hospital with 163 staffed beds 8 owned & operated health centers Public Health, Mental Health, and Health plan Teaching Hospital Hospital & clinics still using paper records Pharmacy: Inpatient Pharmacy, three Outpatient/Clinic Pharmacies Meditech About CCRMC……

6. About CCRMC…… • We serve a population of approximately 100,000 individuals • 450,000outpatient visit/year • 65,000emergency visits/year • 12,000 hospital discharges each year • We deliver 22% of Contra Costa County’s babies/year • Payor mix is 45% Medicaid, 18% Medicare, 30% managed care and 7% other • We employ 450 physicians and train 39 family medicine residents/year • Pharmacy is consists of ~80 employees and we’re a training site for all major Pharmacy schools in CA • Services include: Emergency Department, hospital, hospital-based outpatient clinics, and freestanding health centers.

7. CCRMC Mission Statement Our mission Statement: “Care for and improve the health of all people in Contra Costa County with special attention to those most vulnerable to health problems.”

8. CCRMC’s Recognition IHI Mentor Hospital since 2006 IHI Innovation Award Winner (Dec 2007) Agency for Healthcare Research & Quality (AHRQ) Innovation Exchange (www.ahrq.org) Our Innovation Profile per AHRQ: “Low -Tech Medication Reconciliation process emphasizing standardized, easy to execute roles significantly reduces rates of unreconcilied medications…” Multiple publications on Medication Reconciliation Published case study in Joint Commission Resources’ Medication Reconciliation Toolkit for Implementing NPSG 8

9. Improve Medication Safety Reduce rates of unreconciledmedications Implement an effective admission, discharge and transfer reconciliation process Model for Improvement Source: Institute for Healthcare Improvement (IHI)

10. Recommendations and Tips Segment pieces of the improvement process in bite size increments. Allows for small scale tests of change Allows for customization where necessary Improves likelihood of success

11. Our Med Rec Team members CORE: Physician champion (Internist) Resident Nursing champion (Medicine unit staff RN) Pharmacists (2) Pharmacy Tech (1) Clinical Informaticist (RN) Leaders Ad hoc : Forms expert (JD/risk management) Nursing rep for every service as we expanded MD rep for every service as we expanded

12. Pearls Multi-disciplinary team Physician champion essential Pharmacy Champion essential Nursing Champion essential Best to have a strong leader who is well respected by the organization

13. Short (45 minutes) weekly team meetings Maintains momentum Promotes engagement Recommendations and Tips

14. Med Reconciliation Timeline –Historical data

15. Pearls Identify & Mitigate Failures Admission reconciliation failure causes discharge reconciliation failure Develop workflows to identify key failure points so they can be fixed immediately Example  Daily report in Pharmacy for identifying admitted patients w/o AMROF

16. Test measurement tool thoroughly insures that the data collection process will produce the information you are seeking Recommendations and Tips

17. Recommendations/Tips “Measurement is for learning, not for judgment” “Use data to generate light not heat!” Use data to learn where your process is failing Data collection should be frequent, small samples

18. Measurement Tool

19. Admission Reconciliation Paper process Originally: Admitting provider hand-wrote the list of medications patient was taking at home on AMROF. Now: Admitting provider prints an eAMROF form which is pre-populated with the current med list and uses same form to order medications on admission. Process being used >99% of the time.

20. Our paper Admission Medication Reconciliation Order Form (AMROF)

21. Our electronic Admission Medication Reconciliation Order Form (eAMROF) Page 1

22. Pearls Use “What’s-In-It-For-Me” (WIFM) approach in workflow design Admitting MD  new process was less work Admitting MD  eAMROF was less work (pre-populated list meant less writing) Admitting RN  new process was less work (stopped capturing a med list from scratch) Pharmacy  ? Pearls

23. Pearls Customize where necessary; Standardize where possible Allows for unique workflows Promotes buy-in from staff Examples  OB (currently), and Psychiatry and PES units for about 2 years post implementation

24. Manual Admission and Discharge Medication Reconciliation Order Form For L&D

25. Pearls Make it easy for staff to use the new process & difficult or impossible to use the old process Key for achieving high compliance with use of the process Example  Attached Admission Med Rec form as page 1 of all admit order forms already in use & Removed the medication list part of H&P, to have prescriber comply with the standards.

26. Transfer Reconciliation Electronically printed form contains list of all active meds as of that moment in time. Provider uses form to order medications on transfer within the facility. Process being used >99% of the time.

27. Our Transfer Medication Reconciliation Order Form (TMROF)

28. Pearls Use “What’s-In-It-For-Me” (WIFM) approach in workflow design Receiving RN  Less work (no more “continue previous meds) Harness Informal Champions Receiving RN  Constant reminders to physicians who didn’t use the new process Create a Pharmacy-Nurse liaison to educate the Medical as well as the Nursing staff

29. Discharge Reconciliation (DMROF) Electronically printed form contains list of all pre-admit meds and active inpatient meds as of discharge. Provider uses form to order discharge meds Patient is provided with a “patient friendly” list of discharge medications. Copy of list is sent to next provider of care.

30. Our Discharge Medication Reconciliation Order Form (DMROF) Page 1

31. Our Discharge Medication Reconciliation Order Form (DMROF) Final Page

32. Our [electronically generated] “patient friendly” Discharge Medicine List

33. Pearls Use “What’s-In-It-For-Me” (WIFM) approach in workflow design Discharging MD  Less work (home & inpatient meds print on a report) Patient  Now has a concise med list Remember: Make it easy for staff to use the new process & difficult or impossible to use the old process

34. Discharge Reconciliation:Who Does What……. • MD • Reviews and sign the DMROF. Updates RXM as needed • Generates prescriptions in RXM

35. Discharge Reconciliation:Who Does What……. • Nursing Staff • Print Patient Home Medicine List from RXM (aka Patient Friendly Med List) • Complete the STOP medication section on the Med List • Review Patient Home Medicine List with patient (aka Pt Friendly), make a copy for the chart. • Indicate on Patient Home Medicine List, the time the next dose of any medication is due. • Write Patient Home Medicine list if not generated from RXM

36. Importance of Patient Education…

37. Discharge Reconciliation:Who Does What……. • Clerk • Fax prescriptions (DMROF) to Retail Pharmacy of choice OR • CCRMC Pharmacy

38. Discharge Reconciliation:Who Does What……. PHARMACY: Closed the service for all discharged meds in March, 2007 Exclusion criteria: Injectables, PES, and psych units • TECHs: enter the order into RXM, pull meds and prepare • Pharmacists: Checks techs’ work and Dispense

39. Where We are today and where we are Going… Future Conversion to EPIC, Go live 7/2012 Meditech 2011 Inpatient Admission (Admit, Transfer, Discharge) OutpatientVisit ED visit Pt friendly form Pt friendly form Electronic prescribing to Retail or CCRMC Pharmacies vs printed copy (RXM)

40. Measurement ORIGINALLY 1) Outcome Measures % unreconciled meds (Goal = 0%) % of patients with ALL meds reconciled (Goal = 100%) 2) Process Measure % Compliance with use of the forms/process (Goal = 100%) NOW % compliance: Med Rec Form (DMROF) Matches Home Med List whether or not D/C’d meds at the Discharge are noted on patient friendly list % compliance with Med list beingprovided for the next level of care (SNF, rehab…)

41. Results We’ve reduced our rates of unreconciledhomemedications… …from 26% to 0.6% on ADMISSION …from 23% to ~7% on DISCHARGE We’ve reduced our rates of unreconciled medications… …from 12% to 4% on TRANSFER Improvement has been sustained with slight variations for 5years.

43. Measurement(IHI website)

45. Examples of Admission challenges: Incomplete data collection despite one’s best attempt, poor historian and a new patient, etc... (Much less of a problem in a closed system for majority of pts) Examples of Transfer challenges: When an order is printed and faxed to the RX early, while additional orders are actively being written for the same floor prior to the actual transfer When the stop date on a time sensitive medication is not cited and the pt is transferred with prolonged treatment period, erroneously Examples of Discharge challenges: CII’s are written on a Blank by law. However, RXM (i.e., Meditech) is not updated electronically 100% of the time throughout the system (time consuming and burdensome) MD may accidentally forget to DC duplication of therapy. Example: Pt comes in with a Med (documented on AMROF). The dose gets modified during the admit. Upon discharge, Meditech compiles home med in addition to inpatient meds to prepare DMROF and if not caught, it may create duplication of therapy. DMROF is faxed to retail pharmacy and this may or may not be identified as an error outside the organization Medication Reconciliation, a continuous improvement process

46. Lessons Learned/Challenges Plan the “spread” wisely Identify your metrics early- you can’t fix what you can’t measure Conduct small tests of change Collect valid, reliable, actionable data Interdisciplinary teams: Talent not Title! Invaluable: Include a patient in your team as a member (FMEA perspective) • Improvements must resonate with staff • Make the improvement easy to do! • Change should not be “extra work” • Short, goal-directed meetings • Define your “aim” before you start • Set attainable goals, reach them and then expand • No room for bias, be honest

47. IHI Global Trigger Tool • Harm vs Error • What is Harm? “ Less than 4% of all adverse drug events involving use of rescue drugs are reported.” Studies of medical services suggest that only 1.5% of all adverse events result in an incident report. Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death. (Examples: post op infections, PCN-induced anaphylactic shock, etc… )

48. INCIDENT REPORTING HARM How do you measure harm? 1) Random chart sampling after the patient has been discharged 2) Clues

49. Global Trigger Tools Clues

50. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) E Temporary harm, intervention required F Temporary harm, initial or prolonged hospitalization G Permanent patient harm H Life sustaining intervention required I Contributing to Death