Presented to: HRET Patient Safety Learning Network Participants By Kristine Gleason, MPH, RPh Helga Brake, PharmD,

1. Medication Reconciliation Using the MATCH Toolkit – Measure / Analyze Presented to: HRET Patient Safety Learning Network Participants By Kristine Gleason, MPH, RPh Helga Brake, PharmD, CPHQ Northwestern Memorial Hospital

2. Acknowledgements • This program is supported by the U.S. Agency for Healthcare Research and Quality (AHRQ) through a contract with the Health Research and Educational Trust (HRET). • HRET is a charitable and educational organization affiliated with the American Hospital Association, whose mission is to transform health care through research and education. • AHRQ is a federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

3. New Resources to Stay Connected To access the online Patient Safety Learning Network HCAHPS community: http://www.psl-network.org Username: hcahps Password: psln (Note: case-sensitive) 2. To join the HCAHPS ListServ, send an email to Jenny Shaw, jshaw@aha.org 3

4. HCAHPS and HEN Priority Challenges: Care Transitions and Adverse Drug Events Top four HCAHPS Priorities of over 430 hospitals participating in 18 HCAHPS PSLNs: • RN Communication • Responsiveness • Medication Communication* • Discharge Information* * HCAHPS domains addressed by a patient-centered discharge process

5. New CMS-Proposed HCAHPS Care Transitions Questions Scale: Strongly Disagree, Disagree, Agree, Strongly Agree • During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. • When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. • When I left the hospital, I clearly understood the purpose for taking each of my medications.

6. Timing of HCAHPS Integration • New care transitions questions available in HCAHPS on a voluntary basis beginning with July 1, 2012 discharges • New care transitions questions proposed to become mandatory in HCAHPS beginning with January 1, 2013 discharges • Suggest hospitals ask their vendors to include the proposed questions and seek expedited data

7. Northwestern Memorial HospitalChicago, Illinois • 894-bed Academic Medical Center • Primary Teaching Affiliate of Northwestern University Feinberg School of Medicine • Magnet Recognition for Nursing Excellence • Honored with the National Quality Health Care Award • One of two national finalists in the American Hospital Association’s McKesson Quest for Quality award • Affiliated with Northwestern Lake Forest Hospital, a community hospital serving northern Illinois, in February 2010 7 Feinberg and Galter Pavilions Prentice Women’s Hospital

8. Acknowledgements • Agency for Healthcare Research and Quality (AHRQ) • MATCH grant supported by AHRQ (Grant No. 5 U18 HS015886) • Knowledge transfer / toolkit dissemination supported by AHRQ through a contract with Island Peer Review Organization, Inc. (IPRO) (Contract No. HHSA2902009000 13C) and through a contract with the Health Research and Educational Trust (HRET). • IPRO • Vicky Agramonte, RN, MSN – Project Manager, QIO Learning Collaborative • Carrie Perfetti, Esq. • HRET • David Schulke – Vice President, Research Programs • Ashka Davé – Research Specialist • Northwestern Memorial Hospital and Northwestern University Feinberg School of Medicine • Gary Noskin, MD – Chief of Staff, Medical Director Clinical Quality and Patient Safety • Cindy Barnard, MBA, MJS, CPHQ – Director, Quality Strategies and Patient Safety • Physicians, Nurses, and Pharmacists • The Joint Commission

9. Today’s Objectives • Summarize highlights from the first webinar and office hour held June 25th and July 13th, respectively. • Provide an overview of the MATCH Toolkit for implementing a sustainable medication reconciliation process. Today’s focus: • Measure • Analyze

10. Where Do We Begin? Care Transitions Order, Transcribe, Clarify Procure, Dispense Deliver Educate, Discharge Med History, Reconcile Administer Monitor Phases of Medication Management Measurement / Analysis Harm Estimate/Evidence from Literature Harm Estimate/Evidence from Organization Prioritize / Implement Evidence-Based Interventions Measure Improvements / Monitor for Sustainability 10

11. A Step-by-Step Guide to Improving the Medication Reconciliation Process MATCH Toolkit, with customizable, actionable information, is available at: http://www.ahrq.gov/qual/match/match.pdf 11

12. Use mechanisms to sustain improvement Identify the problem and goal Validate key drivers of error Measure current performance Fix the drivers of poor performance Systematic Approach to Improvement DMAIC is a step by step process improvement methodology used to solve problems by identifying and addressing root causes Define Measure Analyze Improve Control For more DMAIC information, including free access to a toolkit and project templates, visit the Society for Healthcare Improvement Professionals website at www.shipus.org 12

13. Highlights from the First Webinar (June 25th) & Office Hour (July 13th) Recap

14. RECAP Build the Project Foundation Assess and Evaluate Implement the Process • Establish a Measurement Strategy Design/ Redesign the Process Webinar 1 June 25 Office Hour July 13 Webinar 2 August 3 Office Hour August 31 Webinar 3 September 21 Office Hour October 19 Identify Team Members Process Map Develop a Charter Data Collection Plan Collect Data Identify Key Drivers Flow Chart Gap Analysis Process Design Implementation Plan Pilot Test Education / Training Monitor Performance Address low compliance Sustainability 14

15. Recap: Progress to Date Define Build the Project Foundation 15

16. Recap: Mapping the Process A High Level Process Map is a simple picture of a complex process represented by 4-8 key steps. It is essential to better understand the processbeing improved and to gain agreement on project scope. 16

17. Recap: How to construct a high level process map: • Get Team together - include all stakeholders • Define and agree to a process • List all participants of the process – depts., mgrs, and job performers • Define beginning and end points • Brainstorm key process steps • Determine order of process steps • Validate by physically walking through process 17

18. Recap: Develop a Charter 18

19. Recap: Tips for Successful Chartering 19 • Keep it simple … anyone should be able to review your charter and know what you are looking to do and why it is important • Include data … If you do not have initial data, use placeholders • Identify where the project “Starts – Stops” • Ensure your scope reflects your time horizon • Try to avoid projects over 12 months long • Estimate where necessary, refine over time … ‘something’ provides a guide, ‘nothing’ causes delays • Focus on outcomes

20. AHRQ-HRETPSLN Project Team: • Margaret Cavanaugh, RPh • Jen Scholtz, Clinical Coordinator - St .Francis Medical Center • TuLinh Le, Director of Pharmacy • Shakil A. Khan, MD., FACC • Khoi B. Do, MD, (Hospitalist and Internal Medicine) High Level Process Map, courtesy of: Bon Secours, St. Francis Medical Center, Midlothian, VA

21. OUR Mission if YOU Choose to ACCEPT It Build the Project Foundation Assess and Evaluate Implement the Process • Establish a Measurement Strategy Design/ Redesign the Process Webinar 1 June 25 Office Hour July 13 Webinar 2 August 3 Office Hour August 31 Webinar 3 September 21 Office Hour October 19 Identify Team Members Process Map Develop a Charter Data Collection Plan Collect Data Identify Key Drivers Flow Chart Gap Analysis Process Design Implementation Plan Pilot Test Education / Training Monitor Performance Address low compliance Sustainability 21

22. Measure Establish a Measurement Strategy 22

23. Measuring Performance To understand performance, you have to measure it. To measure performance, you have to collect data: To collect data… Understand the data that is available Determine how it will be used Identify how it should be collected And then collect it!

24. Data Collection Plan 24

25. Comparison of Measurement Techniques

26. Example Metrics • Percent of patient record with documented home medication list Example: Records reviewed (n) = 10 • 5 records have a list of home medications documented on the identified tool • 2 are missing the identified tool • 3 have the tool but one or more entries are incomplete such as lack of name, dose, route and frequency Report: 50% (5/10) compliance with patient records with a list of home medications on the identified tool. • Percent of inpatient records with documented disposition of all home medications and inpatient orders within PowerChart’s Med Rec screens • Numerator: # Inpatient Records with PowerChart Discharge Green Status Checkmark • Denominator: # Records Reviewed; exclusions: Expired in hospital, Left hospital against medical advice, Neonatology or newborn • Example: Records reviewed (n) = 1000 • 850 records have the correct HER-generated discharge status checkmark • 120 are missing the identified tool • 30 records have exclusion criteria • Report: 88% (850/970) compliance with patient records with completed discharge medication reconciliation within the identified tool.

27. Data Collection • Work with the team and staff to identify potential drivers and build a data collection form • Seek assistance from the team and staff in collecting the data to increase buy-in • Observe the data collection process periodically to identify issues, errors • Graph the data you intend to collect to (1) confirm how you plan to use the data and (2) identify any missing data elements

28. Identify Key Drivers The backside of the baseline data collection form: Identifying (& addressing) the problematic issues that drive outcomes will lead to lasting improvement Involvement of Frontline Staff is KEY 28

29. Measuring Quality

30. Analyze Design/Redesign the Process 30

31. Project Team • The medication reconciliation team may be subdivided into three core groups: • (a)Leadership Team ; (b) Additional Stakeholders ; (c) Design Team Questions to Ask When Developing Your Design Team Based on Scope Do you have a multidisciplinary group of frontline staff to obtain perspectives and identify workflow issues? Have you identified physician representation from Medicine, Surgery, Emergency Department and/or specialty areas depending on scope? Do you have a patient safety representative on your team? If your organization utilizes an EHR, do you have representation from your information technology department? If you utilize a paper process, do you have representation from medical records, your forms committee, or others to help with form design and verbiage and to obtain final approval for use?

32. Develop a Detailed Flow Chart • A flowchart outlines current workflow and helps identify: • Successful medication reconciliation practices • Current roles and responsibilities for each discipline at admission, transfer, and discharge • Potential failures • Unnecessary redundancies and gaps in the process 32

33. Flow Chart Prior to ReDesign

34. Gap Analysis 34 Assess the current state of your facility’s medication reconciliation process Identify gaps between your current process and one that comprises best practices Collect policies, procedures, programs, metrics, and personnel that support the current process Describe barriers and rate implementation feasibility

35. Subjective Analysis to Inform Process Design

36. Objective Analysis to InformProcess Design

37. Medication Error Analysis and Classification Adapted from National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) http://www.nccmerp.org.

38. Designing a SuccessfulMed Rec Process 38 Best Practice: Develop a single, shared medication list, "One Source of Truth”

39. Guiding Principles 39 Clearly define roles and responsibilities Standardize, simplify, and eliminate unnecessary redundancies Make the right thing to do the easiest thing Develop effective forcing functions, prompts, and reminders Educate workforce, and patients, families, and caregivers Ensure process design meets all pertinent local laws or regulatory requirements

40. Defining Roles and Responsibilities Consider the following questions: • Which discipline could start building the “One Source of Truth” upon admission (entry) to the organization? • How will information be validated applying a “good faith effort” in building an accurate, complete medication list? • What process steps are needed to perform medication reconciliation on outpatients and inpatients upon admission (entry), intra-hospital transfers (if applicable during a patient’s stay), and discharge (exit)? • Depending on scope defined in your charter • What are the required elements for The Joint Commission’s NPSG on medication reconciliation? • What resources are available within the organization to perform required steps in the process?

41. Develop Effective Forcing Functions, Prompts, and Reminders 41

42. Designing to Meet Guiding Principles Hospital Admission Hospital Discharge

43. Flow Chart After ReDesign

44. HOMEWORK • Put together a Data Collection Plan and collect a couple weeks of data • Conduct a Gap Analysis between your current practice/data collection findings and best practice **We’ll review these and answer your questions during the Med Rec Office Hour on August 31 44

45. Helga Brake, PharmD, CPHQ Patient Safety Leader Northwestern Memorial Hospital Chicago IL 60611 312.926.2034 hbrake@nmh.org Kristine M. Gleason, MPH, RPh Clinical Quality Leader Northwestern Memorial Hospital Chicago IL 60611 312.926.9172 kmgleaso@nmh.org If you want to learn more about Northwestern Memorial Hospital, please visit our website at http://www.nmh.org