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

1. Medication Reconciliation Using the MATCH Toolkit 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. You’re Invited:  CMS Web Conference on HCAHPS and VBP for all PSLNs • June 28, 2012, 12:30-2pm EDT—Special CMS Web conference on HCAHPS and Value-based Purchasing (VBP) • Elizabeth Goldstein and William Lehman of CMS will talk about HCAHPS, the new care transitions questions, and the changing relationship of HCAHPS to VBP. • Registration URL: • http://event.on24.com/r.htm?e=461086&s=1&k=05322FB79924399145DFD0A9C0097299 • Dial-In Information: 1-866-710-0179 / Passcode: 954 683

8. Today’s Objectives Understand the importance of conducting medication reconciliation Link medication reconciliation with current initiatives to improve the patient experience and reduce adverse drug events and readmissions Provide an overview of the MATCH Toolkit for implementing a sustainable medication reconciliation process Describe tools for successful implementation of any improvement project

9. 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 9 Feinberg and Galter pavilions Prentice Women’s Hospital

10. A Focus OnMedication Reconciliation A process to decrease medication errors and patient harm by: • Obtaining, verifying, and documenting patient’s current prescription and over-the-counter medications; including vitamins, supplements, eye drops, creams, ointments, and herbals • Comparing patient’s pre-admission/home medication list to ordered medicines and treatment plans to identify unintended discrepancies • Discussing unintended discrepancies (e.g., those not explained by the patient’s clinical condition or formulary status) with the physician for resolution • Providing and communicating an updated medication list to patients and to the next provider of service at discharge Adapted from The Joint Commission National Patient Safety Goal 03.06.01 10

11. Why Focus on Medication Reconciliation? Statistics on U.S. Prescription Drug Use Source: Centers for Disease Control and Prevention. FastStats. Available at http://www.cdc.gov/nchs/fastats/drugs.htm. Accessed 6/20/2012. • Based on 2005-2008 data, the question “In the past month, percent of persons using at least X prescription drug (s)” revealed: • Use of one prescription drug: 47.9% • Use of three or more prescription drugs: 21.4% • Use of five or more prescription drugs: 10.5% • Based on 2008 data, the table below provides statistics stratified by type of medical visit: 11

12. Institute of Medicine Findings“Preventing Medication Errors” • At least 1.5 million preventable adverse drug events (ADEs) occur in the U.S. annually in all settings, not including errors of omission. • Errors and ADEs are a “very serious cause for concern” in hospitals. Phases with the highest errors: prescribing & administration. • Estimated 400,000 in-hospital preventable ADEs / year. Cost per ADE: $8,750 (2006 dollars) • Cost increases when extrapolated to 2012 dollars Preventing Medication Errors: Quality Chasm Series (2007). Committee on Identifying and Preventing Medication Errors, Philip Aspden, Julie Wolcott, J. Lyle Bootman, Linda R. Cronenwett, Editors. 12

13. Avoiding Readmissions: Preventable ADEs After Hospital Discharge • Study of 400 consecutive hospitalized general medicine patients discharged home. • 19% of patients had an adverse event (AE) within 3 weeks of discharge. • 66% of AEs were adverse drug events (ADE). • Most ADEs were preventable or ameliorable. • System modifications recommended by study authors: • Evaluate patients at time of discharge to identify unresolved problems • Educate patients about drug therapies, side effects, and what to do if new or worsening signs/symptoms • Improve monitoring of therapies • Improve monitoring of patients’ overall condition Source: Forster et al. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Ann Intern Med. 2003;138:161-167. 13

14. Current Evidence to Reduce Readmissions: Implementing Bundled Interventions Note: Individual components of these change packages have not been tested by themselves and might not reduce the risk for 30-day rehospitalization Source: Hansen et al. Interventions to Reduce 30-Day Rehospitalization: A Systematic Review. Ann Intern Med. 18 October 2011;155(8):520-528. 14

15. Does Medication Reconciliation Impactthe Patient Experience? *Impacted by Medication Reconciliation Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Domains: • Communication with Nurses • Communication with Doctors • Responsiveness of Hospital Staff • Pain management* • Communication about medicines* • Discharge information* • Cleanliness of hospital environment • Quietness of hospital environment • Overall rating of hospital • Willingness to recommend hospital Source: HCAHPS Fact Sheet. Available at: http://www.hcahpsonline.org/facts.aspx (accessed 2012 June 20 15

16. Opportunities to Educate and Communicate • Use Medication Reconciliation as an opportunity to educate patients on their medications throughout their hospital stay • Home medications that are continued during the hospitalization • Home medications that were discontinued and why • Ordered medications, include indication and possible side effects • Ordered as-needed (PRN) medications that are available to them by asking • Empower patients to ask questions and become active partners • Trace patients through hospital stays to identify opportunities for interaction 16

17. “Bundling” Medication Reconciliationwith Current Initiatives 17 • Care Transitions • ED • Admissions • Intra-hospital Transfer • Discharge • Post-Discharge • Phases of Medication Management • Med History, Reconcile • Order, Transcribe, Clarify • Procure, Dispense,Deliver • Administer • Monitor • Educate, Discharge • Measurement/Analysis • Prioritize/Implement Evidence-Based Interventions • Measure Improvements/Monitor for Sustainability • Harm Estimate/Evidence from Literature • Harm Estimate/Evidence from Organization

18. 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 18

19. YOUR Mission (to implement a successful med rec process) if YOU Choose to ACCEPT It Build the Project Foundation Implement the Process Design/ Redesign the Process • Establish a Measurement Strategy Assess and Evaluate 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 19

20. 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 Use mechanisms to sustain improvement Identify the problem and goal Validate key drivers of error Measure current performance Fix the drivers of poor performance A 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 20

21. Define  Build the Project Foundation 21

22. Executive Sponsor Project responsibilities: provide overall guidance and accountability, remove barriers, provide strategic oversight and appropriate resources, review progress Sponsors Project responsibilities: accountable for success, responsible for implementation of recommendations, provide tactical oversight, reach clinical consensus Improvement Leader Project responsibilities: Accountable for using DMAIC to manage project and complete deliverables in a timely manner, partner with Process Owner Process Owner Project responsibilities: Accountable for implementing, controlling and measuring the project outputs and improvements Team Members Make significant and focused contributions to timely and successful implementation Everyone is involved and accountable! Assemble Your Team 22

23. Map the Current Process 23 • 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. • Physician places discharge order Physician writes new prescription  Physician prepares d/c instructions  Nurse collects the d/c instructions and prescription and counsels the patient  Patient discharged

24. How to construct a high level process map: 24 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

25. Develop a Charter 25 • Strategic Linkage: Clearly ties the project to organizational goals • Problem Statement: Concise description of the issues • Goal: Describes planned accomplishments • Scope: Area to be covered – avoid scope creep • Deliverables: Tangible end-products, must align with goal • Resources: Necessary requirements for project success • Metrics: Objective measurement of progress • Milestones: Used to monitor progress and maintain focus

26. Medication Reconciliation Phase III • Linkage to NMH Goal: Best Patient Experience – Deliver care that is safe and without error. • Problem Statement: NMH has made significant strides in developing and implementing a Medication Reconciliation process organization-wide. Through close measurement and monitoring, we have identified the need for additional efforts including: process reassessment and refinement (SDS, Prentice, Discharge). With the proposed 2009 revision to The Joint Commission standard we are presented with new process design opportunities (ED, Outpatient Areas); and, a renewed focus on transfers (internal and external). • Goal/Benefit: 1)To measurably decrease the number of discrepant medication orders (both inpatient and outpatient) and the associated potential and actual patient harm. 2) Fully meet the Joint Commission’s National Patient Safety Goal #8, documentation and reconciliation of all medications at admission, transfer and discharge for all inpatients, ED visits and outpatient encounters and external transfers. • Scope: Focus on outpatient Same Day Surgery, Prentice, ED, and procedural areas, transfer and discharge processes • Deliverables: • Improved compliance of medication reconciliation through refined processes in areas stated above. • A sustainable measurement and monitoring approach to be embedded in current reporting infrastructure. • Resources Required: • We will need leadership to prioritize med rec work and facilitate manager involvement in design and implementation efforts Exec Sponsor: C Watts Sponsors: DDerman-MD, CPayson-RN, DLiebovitz–IS, NSoper-SurgerySubject Matter Expert: K GleasonProcess Owner: H BrakeJFoody, KOLeary–Medicine, KNordstrom–Pharmacy Improvement Leader: ML Green Milestones: DescriptionDate (month, 2008-9) #1 Define Phase July #2 Measure/Analyze August #3 Improve December #4 Control January • Key Metric(s): • % inpatient Med Rec compliance at admission, transfer and discharge by discipline (MD, RN, RPh) • % inpatient Med Rec compliance by service • % outpatient Med Rec compliance at admission and discharge 26

27. Begin by identifying all areas within your facility where patients receive medication. A Word About Scope

28. Tips for Successful Chartering 28 • 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

29. Measure  Establish a Measurement Strategy 29

30. Caution: Jumping into data collection without a clear plan wastes time, energy, resources, etc. Data Collection Plan 30

31. 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 Collect Data

32. The backside of the baseline data collection form: Identifying (& addressing) the problematic issues that drive outcome will lead to lasting improvement Involvement of Frontline Staff is Key Identify Key Drivers 32

33. Analyze Design/Redesign the Process 33

34. 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 Flow Chart 34

35. Gap Analysis 35 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

36. Design a Successful Med Rec Process 36 Best Practice: Develop a single medication list, "One Source of Truth”

37. Guiding Principles 37 Clearly define roles and responsibilities Standardize, simplify, and eliminate unnecessary redundancies Make the right thing to do the easiest thing to do 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

38. Develop effective forcing functions, prompts, and reminders 38

39. Improve  Implement the Process 39

40. Implementation Plan 40 Improvement Planning To implement solutions successfully, five areas must be carefully considered and planned for: • Interventions • IT • Communication • Training • Measurement - Be sure to always include: detailed actions, team member assignments, completion dates - 50% of the work begins now

41. Pilot Test 41 Piloting solutions helps to ensure the solutions work on a small scale and allows the team to identify and resolve issues prior to a house wide roll out. A Pilot Should Be Used When Change covers a large scope Change is costly Change is difficult to reverse People are sensitive to the change Unintended consequences may result as part of the change When Piloting ensure the scope of the pilot is represented,it can be reproduced on a larger scale, and it is measureable

42. Educate and Train 42 Best Practice: Multidisciplinary training (i.e., physicians, nurses, and pharmacists attending training classes together), supported by introductions from hospital leaders, is an excellent strategic decision • Sets the tone for training and implementation • Promotes a team approach • Creates an appreciation of the interdependency of each discipline • Trains consistently on each step within the process

43. Control  Assess and Evaluate 43

44. Monitoring Performance Exceptional Care Dashboard Metric Inpatient Metric: Med Rec completed on discharge Ambulatory Surgery/Observation Patient Metric: Home Medications documented Definitions: Completed Discharge Med Rec: Documented disposition of all home medications and inpatient orders within PowerChart’s Med Rec screens, verified by status checkmark during the encounter, to render a discharge medication list. Documented Home Med: Home Medications documented in PowerChart‘s Home Medication List, verified by status checkmark, during the encounter Exclusions: Expired in hospital, Left hospital against medical advice, Neonatology or newborn 44

45. Identify Areas of Low Compliance 45

46. Post-Implementation Strategies to Increase and Sustain Compliance: Address barriers that result in low compliance Conduct focus groups Take med rec on the road Reassess, at minimum, annually When is a project “over”? Sustainability

47. Overcoming Barriers to Success 47

48. Barrier:Lack of Resources and Time ‘Lack of Staffing’ ‘Needed Resources Will Not Be Approved’ ‘Not Enough Hours in the Day’ ‘Quality Consists of One Person Here’ ‘Task Saturation’ 48

49. 1. Get Leadership Buy-In Let them know why they should care: Patient Safety, Public Reporting, Financial Incentives 2.Bundle the Work Identify similarities among projects – get 2 things accomplished for the price of 1 3.Identify Opportunities for “Quick Wins” Prioritize changes that may be easily developed and implemented Strategies to OvercomeLack of Resources and Time 49

50. Barrier: Resistance to Change ‘No Sense of Urgency’ ‘No Buy-In’ ‘People Don’t Like to Change’ ‘Lack of Enthusiasm from Staff/Physicians’ ‘Lack of New Ideas’ 50