Medication Reconciliation: whose job is it anyway?

1. Medication Reconciliation:whose job is it anyway?

2. Why a Multidisciplinary approach? Limitations identified in ‘pharmacists only’ approach • Baseline data from June 2010 showed pharmacists could reconcile medications for 35% of patients within 48 hours (gold standard is within 24 hours) • Insufficient pharmacists to complete and sustain medRec • If pharmacist’s sole focus could compromise other medication safety activities. • Gaps in medRec process would occur after hours and weekends • Address by targeted intervention of complex patients only?

3. Initial Training: January 2011 • Pharmacy High 5 team developed a presentation • Presented to pharmacists and High 5 core group: • “Train the trainer” • Best Possible Medication history taking • Med Rec process • Compulsory attendance • Resources provided to train/teach ward staff. • Training Road shows – ward based training • Identified unit-specific processes • Grand/ ICU rounds

4. Ongoing Training • JMO, Registrar and Resident training • Occasional ward based training • Secured additional training slots in orientation program • Medical Intern Pre-registration workshop • Pharmacist orientation • New grad nursing awareness training

5. Patient Safety Culture in our hospital

6. 2014 Survey: Objectives: Question Design Primary: Do clinicians understand the importance of Medication Reconciliation: who, how and why? Secondary: • Were there any barriers to implementing this change • Can these barriers be overcome or resolved?

7. Method • 2 Study sites: POWH, Redlands • Study group: Doctors, pharmacists and nurses • Collected data for 7 days via • Paper forms • Email ‘Survey monkey’ link • Supported by Directors of Clinical Services/Nursing/Pharmacy • Survey respondents remained Anonymous

8. Results: Demographics

9. Results: Education/Training • Sample Comments/suggestions: • “I thought this was the role of the pharmacist? Any training would be useful” (Intern) • “Wasn’t able to attend” (Registrar) • “Online training, inservice, verbal discussion?” (RN)

10. Who is responsible for completing the Medication Management Plan (MMP) form?

11. What do you understand to be the main reason/s for Medication Reconciliation?

12. Safety Culture *Medication Management Plan Form = a tool used at POWH to conduct Medication Reconciliation

13. Overall Comments

14. Discussion • Identified barriers: • Education reaching all stakeholders (frontline up) • Time • Documentation (electronic vs paper) • Identified improvements: • Patient safety culture awareness • Multidisciplinary approach identified • Limitations

15. Factors identified required for future success • Dedicated resources • Strong multidisciplinary leadership • Physician champion engagement • Software that supports the High 5 SOP and • Ongoing comprehensive staff education plan • Change readiness of organisation

16. A Doctor’s perspective

17. Doctors’ attitudes • ‘We’re very busy’ • ‘Can’t the pharmacists do it?’ • ‘It means writing everything out multiple times’ • ‘What’s the point of it?’ • ‘Why don’t we just wait until electronic prescribing comes in?’

18. Issues • Capturing the correct audience to educate them that its everyones responsibility • We are missing the middle level (staff specialists, VMOs etc) • IT systems don’t speak to each other (or a mixture of paper and electronic notes) • It requires a change in attitude- but support for change • Senior staff don’t realise the importance of the process

19. Problem: • Professional boundaries and established hierarchies may result in disagreements about where the responsibility for medicines reconciliation lies Solution: • Focus on reducing the risk for patients and increasing the availability of timely, accurate information • Any potential professional or hierarchical differences should be put aside to enable appropriately trained and competent healthcare professionals to take the lead

20. Problem: • Competing demands and the common response that ‘the problem is too big — ‘we don’t know where to start’’ can be overwhelming for staff • This can lead to delays in getting medicines reconciliation off the ground Solution: • People need to be supported by managers to enable them to prioritise their workload • simple structures should be put in place so that medicines reconciliation becomes part of the organisation’’s everyday work

21. There are no quick fixes, but this is a far from insurmountable problem A possible five-level hierarchy approach:

22. There are no shortcuts to breaking down silos. • You can’t fix the environment if the organization doesn’t understand the problem. • You can’t improve the development process if the right environment doesn’t exist to enable healthy guidelines. • Climb the pyramid brick by brick to the ultimate goal: better clinical outcomes through true collaboration.

23. Practicalities • How do we ensure senior physicians care? • IIMS categorised into ‘med rec’ errors? • Statistics on IIMS, Med rec compliance to individual departments/teams? League tables?? • Grand rounds? • Presentations of RCAs concerning medication errors? • Using Accreditation- Standard 4 as a bargaining chip?

24. Involving Patients • The value of involving patients and/or their carers in the medicines reconciliation process should not be underestimated • Patients are a valuable source of information about the medicines they take and, with support, they can be encouraged and enabled to take a fuller and more active part in the process

25. Organisational approach • The profile of medicines reconciliation needs to be raised in all healthcare organisations • The Chief Executive, senior management lead and board members of an organisation can help by promoting the uptake of medicines reconciliation • Collaborative approach with other Australian hospitals involved • Get process right before instituting eMM- detrimental to put bad stuff into a good system

26. Guess what?Its YOUR job!

27. Acknowledgements • Survey question design & data collection: Ketty Rivas (Safety and Health Outcomes Officer) , Selina Boughton (Pharmacist) • Survey promotion: POWH Pharmacists