Medication Reconciliation at Hospital Admission Using a Six Sigma Approach OSF Saint Francis Medical Center Peoria, I

1. Medication Reconciliation at Hospital AdmissionUsing a Six Sigma Approach OSF Saint Francis Medical CenterPeoria, Illinois Howard Cohen MD Patient Safety Officer May 15, 2003

2. OSF Saint Francis Medical Center 721 beds, 24 patient care units Tertiary center with 425 physicians and 165 residents Level 1 Trauma Center Perinatal Center Pediatric Critical Care Center 70 admissions/day 30 via ED Involved in several Medication Safety Collaboratives In the midst of IDX rollout

4. Initial Work in Corporate Patient Safety Collaborative July, 2001-February, 2002 Focus across entire hospitalization Quantum Leaps Project Replication �IHI� methodology

5. Issues Lack of understanding of what �reconciliation� means Not sure how to measure Whether it happens How is it related to Adverse Drug Events? Broad scope Use of the form Administrative priorities not clear Accountability

7. 6 Sigma Infrastructure Green beltsGreen belts

8. Comparison of Different QI Terms

9. Project Goals Collect a complete list of medications that each patient was taking before admission � Target 75% Physician will document reconciliation of each medication on admission that the patient takes at home � Target 75% Reconciliation Process will be complete by 6 hours after admission � Target 50% Timeline to complete project in conjunction with 6 sigma training Started February, 2002

10. Operational Definition Medication History Complete and accurate record of medications taken at home. For each item it includes: name of drug, dose, frequency, route and last dose taken. For Pediatric patients: concentration for elixir medications and mg/kg/dose

11. Project Scope Includes: All inpatient and observation admissions, including children and adults Excludes: Newborns and outpatients Process Start: Arrival on patient care unit Process Stop: Completed medication history list and each medication is reconciled

12. Medication Reconciliation Process Medication history is complete Includes name, dose, frequency & route Dose last taken (date and time) Physician Reviews and acts upon prior medications Documents response Writes medication orders Pharmacy Reviews medication history Verifies physician orders Enters the order in the computer

14. Meetings Team Meetings Bi-weekly 2 hours each Leadership Meetings Weekly Deployment Champion Business Leader Project Sponsor Process Owner Black Belt Project Update Meeting Weekly Project Sponsor Black Belt

15. Initial Project Findings Process is diffuse Patient is asked the same question multiple times�this has a link to patient satisfaction Multiple forms are used Medication history is found in multiple areas on the chart Lacks consistency in what is documented related to medication history Medication reconciliation process really does not exist in the hospital

19. 6 Sigma and the Voice of the Customer Surveyed MDs, RNs, Pharmacists Design a process that is �Easy to Do Business With� Wanted process complete within 2 hours Wanted formulary substitutions to be visible at time of discharge

20. Process Design Partnership with OSFMG & Sister�s Community Clinic Wallet cards Medication Bags to bring pill bottles to hospital �Know Your Medications� Posters Developed Medication Reconciliation and Amendment Forms Developed �Scripting & Tips� sheet One Form in One Location Emergency Department �Know Your Medications� Poster Send patient�s pill bottles to the nursing units Wallet Cards

21. Process Design: other aspects Survey of other institutions FMEA

26. Pilots TIHU Emergency Department

27. 6 Sigma Medication Reconciliation ProjectPilot Data Medication History Complete

28. 6 Sigma Medication Reconciliation ProjectPilot DataDose Last Taken Documented

31. Implementation (and Control) Identified Process Owner and Sub-Process Owners House-wide implementation Control Plan Project Turnover Measurement Contingency Plan IDX Implementation Incorporation of Medication Reconciliation Next reconciliation Projects

32. Implementation On Hospital Units Nursing & Unit Staff Unit posters Education provided to managers and educators of each patient care unit Detailed education packet Educational poster display Educational flyers in staff restrooms

33. Implementation Medical Staff and Pharmacy Physician Presentations at Medical Staff Committee Meetings Educational flyers Dictation cubicles & Restrooms Mailbox Offices Pharmacy Staff meetings Educational poster display Educational information mailbox and email

34. 6 Sigma Medication Reconciliation Project-TIHUMedication History CompleteControl Phase Measurement

35. 6 Sigma Medication Reconciliation ProjectPilot DataDose Last Taken Documented

37. Cycle Time Measurement

38. Conclusions Six Sigma Process allowed us to successfully implement new process of medication reconciliation on admission More complete medication history Viewed favorably by all Allows pharmacy new view of patient�s home meds Labor and resource intensive

39. Barriers Resources Pharmacy Resources in the ED Culture Bureaucracy Complexity of Communication Issues of accountability Lack of teamwork

40. Lessons Learned 1. Would have used small workgroups to work on pieces of the project�then have the workgroup report back to the team during team meetings. We lost a lot of time in team meetings debating and discussing issues that we could have handled this way. 2. Keep VOC survey small (don�t ask too many questions, overwhelming to the customer) 3. Set longer team meeting times 4. Could have been ready with discharge piece sooner so team could continue with work 5. Should have included Nursing Leadership more intimately

41. Unanswered Questions How accurate is the information? Will reconciliation improve the accuracy of the information? Are there better models? Will reconciliation help prevent medication errors and ADEs?