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A Kick Start to Medication Reconciliation. Dr. Hilary Adams Quality Improvement Physician, Family Medicine Calgary Health Region Judy Schoen Pharmacy Patient Care Manager, Calgary Health Region. The team. Multidisciplinary Champions/opinion leaders QI support if possible
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A Kick Start to Medication Reconciliation Dr. Hilary AdamsQuality Improvement Physician, Family Medicine Calgary Health Region Judy Schoen Pharmacy Patient Care Manager, Calgary Health Region
The team • Multidisciplinary • Champions/opinion leaders • QI support if possible • Don’t forget frontline staff! • Distinct group with common focus (e.g. nursing unit, specific service etc)
Getting Started • GSK from SHN • PDSA quality improvement model • FOCUS • Find an opportunity • Organize a team • Clarify current process • Understand variability • Sustain results
Why baseline data • We don’t know what we don’t know • Recognize size of problem • Get buy in early • Helps show improvement • Makes it a priority
Baseline Measures Success Index: 56.9% Mean # of Undocumented Discrepancies: 0.6/patient Mean # of Unintentional Discrepancies: 1.7/patient 5
Current process and Variability • Analyze current process for gaps and drops • Understand variability • ? multiple locations for data
Incomplete med list Past Process: Hospitalist History and Physical Form 7 Source(s) of Information
Past Process: Hospitalist History and Physical Form No med list 8 8 Source(s) of Information
Past Process: Nursing Medication History No med list 9
Variety of processes Unclear roles Concerns about duplication Rework in locating information in chart Key Learnings 10
Variety of processes Unclear roles Concerns about duplication Rework in locating information in chart Team Vision: Standard approach Clear roles Single location for home medication information in chart Collect Best Possible Medication History (BPMH) in 24 – 48 hours 11
Team Charter • Identify all team members • Purpose of project • Guiding principles • Scope and boundary • Goals and objectives • Ideas for change • Principles for working together • Roles and responsibilities
Challenges at the Onset • No clear owner. • Variety of processes. • Obtaining accurate medication information. • Limited clinical pharmacy resources. • Physician / nursing buy-in. • Difficulty in adopting new practices. • Lack of communication between interfaces. 13
Critical Aspects • No duplication/melds with current workflow • Prompts/cues on forms (e.g. dose) • Involvement of all disciplines • Education • Strong leadership • Monitoring our progress • Auditing the process, not individuals 14
An Improved Process: What things may look like • Standardized approach • Multidisciplinary • Clear roles. • Defined location for home medication information in patient chart. • Increased awareness of key questions to ask to illicit the BPMH. 15
An Improved Process: What things may look like • Ease of use • Flexible • Does not result in duplication • Clear communication • Close the loop • Prompts health care providers to provide BPMH
Step 3 & 4: Additions/Clarifications of Pre-Admission Medication List 18
Challenges • Wellnet – not a complete record • “As directed” on Rx • Patient altering own medications • Limited sources of information outside of office hours • Transposing to PCIS (EMR) • Adapting learnings to the community 21
Lessons learned • Understand variation in current practice is critical • Multidisciplinary approach is essential • Vision of final outcome critical • BPMH auditor must be separate to the process • Clear definitions • Deal with one issue at a time • Small successes build momentum • Just do it! (when is it right enough?)
A nurse on Unit 62 received a phone call from a patient’s wife. She asked why her husband was on lasix. The nurse pulled the patients chart and referred to the BPMH form in which the MD had documented that lasix was to be ‘held’ due to dehydration. The nurse was able to efficiently respond to the patient’s wife. Gains 23
Baseline Measures Success Index: 56.9% at baseline to as high as 92.8% Mean # of Undocumented Discrepancies: 0.6/patient to as few as 0.0 Mean # of Unintentional Discrepancies: 1.7/patient to as few as 0.4 24
Step 1: Patient Risk Assessment Tool Step 1: Patient Risk Assessment Tool 25