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

1. Medication Reconciliation Using the MATCH Toolkit – Improve / Control 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 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. Mandatory beginning with January 1, 2013 discharges.

6. 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 6 Feinberg and Galter Pavilions Prentice Women’s Hospital

7. MATCH 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

8. Today’s Objectives • Summarize highlights from the second webinar (held August 3) and office hour (held August 31). • Provide an overview of the MATCH Toolkit for implementing a sustainable medication reconciliation process. Today’s focus: • Improve / Implement • Control

9. 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 9

10. 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 10

11. 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 11

12. Highlights from the 2nd Webinar (Aug 3) & Office Hour (Aug 31) Recap

13. 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 13

14. Measure Establish a Measurement Strategy 14

15. Data Collection Plan 15

16. Data Collection • Work with the team and staff to identify potential drivers and build a data collection form • Identify metrics to be measured pre- and post-implementation to monitor compliance to the new process. Ex: Numerator: # Patient Records with List of Home Medications. Denominator: # Records Reviewed • Graph the data you intend to collect to (1) confirm how you plan to use the data and (2) identify any missing data elements

17. 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 17

18. Analyze Design/Redesign the Process 18

19. Flow Chart Prior to ReDesign • 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

20. Newman Regional Health Center Current Process Map

21. Gap Analysis 21 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

22. Flow Chart After ReDesign

23. OUR (YOUR) Mission Continues 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 23

24. Improve Implement the Process 24

25. Implementation Plan • Be sure to always include… • Detailed actions • Team member assignments • Completion dates 50% of the work begins now 25 Improvement Planning To implement solutions successfully, five areas must be carefully considered and planned for: • Interventions • Communication • IT • Training • Measurement

26. The Intervention Work Plan • Create, update, and share the work plan with all team members • Use the Status column to communicate to the team if the activities / tasks are On Target , At Risk of Falling Behind Schedule, or Behind Schedule • Reassign and update tasks as needed to stay on track • Update due dates based on dependencies • Manage to deadlines

27. Create and Execute the Communication Plan • Ask “how best can we communicate with you?” • Diversify the methods to ensure widespread distribution • Know your audience – customize the messages – “what’s in it for me?” 27

28. Pilot Test When Piloting ensure the scope of the pilot is represented, it can be reproduced on a larger scale, and it is measureable 28 Piloting solutions helps to ensure they 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 implement People are sensitive to the change Unintended consequences may result as part of the change

29. Educate and Train • 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 29 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

30. Train: Responsibilities and Expectations

31. An Opportunity to Educate and Communicate At Admission and throughout the patient’s stay: Educate your patient about: • Home medications that are continued during the hospitalization • Home medications that were discontinued and why • Ordered medications, include indication and side effects • Ordered as-needed (PRN) medications that are available to them by asking At Discharge: Educate your patient to: • Give a list to his/her primary care physician • Update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added • Carry medication information at all times in the event of emergency situations

32. Tips For Obtaining A CompleteMedication History Whether you obtain a complete medication history or not is dependent in large part on the patient’s memory. You can ensure that you are getting the entire list only by asking for medications in a variety of ways. Trigger patient’s memory by asking these questions which address items not commonly thought of as medications but can still adversely interact with them: • What prescription or prescription samples are you taking at home? • What over-the-counter drugs are you taking at home? • What vitamins are you taking at home? • What herbals are you taking at home? Ex. Gingko, Ginger, St Johns Wart • What nutritional supplements are you taking at home? Ex. Green Tea • What inhalers are you using at home? Also, incorporate probing questions to help the patient remember. Ask about: • routes of administration other than oral medications • medications they take for their medical condition(s) • types of physicians who prescribe medications for them • times they take their medication (daily, weekly, monthly)

33. Go-Live! • Implementation is a process, you only get one chance at a successful “go-live” • To maximize the chance for success • Evaluate solutions • Manage the Work Plan • Communicate • Educate/Train

34. Assess and Evaluate Control 34

35. Monitor Performance Goal: 95% Inpatient Metric: Numerator: # of patient records that have Home Medications documented . Denominator: # of records of patients discharged within the noted time period Definitions: Documented Home Med: Home Medications documented in the EMR‘s Home Medication List, verified by status checkmark, during the encounter Exclusions: Expired or left hospital against medical advice within 24 hours, newborn 35

36. Report Results

37. Post-Implementation Strategiesto Increase Compliance • Hold small focus groups on the pilot tested/go-live floors/units: • 15 – 30 min • Focus discussion on the new process – what worked, what didn’t, how can it be improved • Thank those who agreed to participate • Make changes based on the feedback

38. Take Med Rec on the Road Ensure process works as designed Blast notification communications Tell med rec success/failure stories Celebrate and disseminate successes Enlist Champions Engage Leadership in walkarounds Unblind compliance audits Elevate med rec to an annual organizational goal to maintain focus ]

39. A Final Note: High Risk Situations • Additional Challenges/Barriers to Addressing Effective Medication Reconciliation: • Health Literacy • Implement Teach-back • Cognitive Impairment • Use “Universal Precautions” • External Transfers • Ensure Robust Hand-offs 39

40. HOMEWORK • Based on your gap analysis and identified improvement strategies, create a Work Plan to implement your interventions • Determine your pre/post-implementation metrics **We’ll review these and answer your questions during the interactive Med Rec Office Hour on October 19 40

41. 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