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1. Coordinating Institution Wide Implementation of Medication Reconciliation: Tips, Strategies & Lessons Learned March 25, 2009Safer Health Care Now! National Webinar / Teleconference Olavo Fernandes PharmD, FCSHPPharmacy Clinical Site Leader, University Health NetworkAssistant Professor, Univ of Toronto and Safety Specialist, ISMP CanadaInterdisciplinary Members of UHN Medication Reconciliation Task Force Image: green.gps.caltech.edu/pictures_images/GreenTree.jpg

2. What has your medication reconciliation implementation journey in your ER been like ? OR

3. Objectives • Highlight strategies for overcoming challenges to successfully implement medication reconciliation at various interfaces • Share coordination tips/ lessons learned to prepare your organization to meet medication reconciliation requirements • Outline the key elements of an organizational communication plan and clinician/ leadership resource package for medication reconciliation

4. How do we Navigate the Challenges of Effectively Meeting Accreditation Requirements for Medication Reconciliation ?

5. How do we actually “get started and sustain” implementation?Five Tips & Strategies • People – Empowering Clinicians • Coordination • Communication • Leadership • Tools / Systems to Support the Clinicians

6. How do we actually “get started and sustain” implementation? Leadership Coordination Communication People Tools/ Systems Five Tips & Strategies

7. Challenges & Questions • Who does the BPMH? • Who does the reconciliation/ resolving the discrepancies? • Proactive vs. Reactive Multidisciplinary practice models ? • Proactive: BPMH → admission orders (AMO) →reconciliation check • Reactive/ Concurrent: primary history → AMO →BPMH →reactive reconciliation • Hybrid Systems • Manual vs. Electronic Processes ?

8. Structured Implementation & Rollout PlanStep-wise Milestones for each Inpatient Clinical Area • ID stakeholders/ preliminary education • Formal education to unit/clinical area champions • Baseline admission reconciliation data collection • Creation of a team practice model • Finalize practice model – input from staff • Prescriber/ Nursing/ Pharmacist In-services • Start Front line implementation- Admission reconciliation • Sustain as part of daily practice with ongoing feedback and improvement

9. Questions to Address As a Team • Who? • Who- in your local practice site, who responsible for BPMH? Reconciliation? Shared responsibility? Who does what? (MD/ RN/ Phmt/ Technician/ Students) • BPMH training: designated individuals or “organization-wide” • How? • How are medication histories currently being conducted? Does med rec implementation involve building upon pre-existing practice or a major shift in practice • Where? • Decide where the BPMH is documented (visible to all staff, only useful if everyone knows where it is, can find it, can use it). • Will it be a pre-printed form/ computerized record/ clinical notes? S. Ingram BScPhm, ACPR, ED- TGH

10. UHN Clinician Validation Program • Interactive Learning/ Education Session • Key Readings • Standardized Patient Validation Program • Obtaining BPMH from a standardized patient–actor • Admission reconciliation to identify discrepancies • Coding of discrepancies • Interactive discussion on areas of strength / improvement

11. Getting Started/ Focussed Limited ResourcesWhy is Medication Reconciliation so important in the ED ? • “Gateway” to acute care admission and transitions in care • “Opportunity” – ideally med rec performed as close to arrival/ decision to admit • Family / medication vials & lists optimally available • “Efficiency” – upstream reconciliation/ resolution improves safety/ saves times and resources downstream to subsequent transitions • “Shared Responsibility” – ED/ Admitting services; all health care professionals – physicians, nurses, pharmacists, allied health and patients S. Ingram BScPhm, ACPR, ED- TGH/

12. Synchronization Challenge of Discharge Tools at Many Institutions Patient Care System Patient schedule EMITT Letter Discharge Prescription Dear Dr Letter Patient Wallet card Manual Electronic Electronic J. Wong BScPhm

13. Multidisciplinary Practice Model RX RN MD Challenges of Medication Discrepancies

14. EMITT2: Schematic of Structured, Multidisciplinary Integrated Medication Reconciliation Strategy Primary Medication History: MD or RN ER Ward BPMH: Taken by pharmacist Admission Reconciliation BPMH medical chart note 1 Wong J. [Abstract] Pharmacotherapy 2006 ;26: 106

16. Wong J. Annals of Pharmacotherapy 2008 (in press) Medications may be altered: new, adjusted, discontinued Ward Decision to discharge patient BPMDP Best Possible Medication Discharge Plan Discharge Reconciliation Synchronized Outputs Electronically Generated Prescriptions Medication Information Transfer Letter Patient Medication Wallet Card Patient Medication Grid Home Physician Discharge Summary 2 3 4 5 6

18. Medication Information Transfer Letter A. Cesta et al. Ann Pharmacother 2006;40:1074-81.

19. Medication Information Transfer Letter

20. Horizontal : Patient Medication Grid

21. Vertical : Patient Medication Grid

22. Patient Wallet Card

23. Safer Health Care Now! National Measure For Discharge Medication Reconciliation Team Target 80% %eligible patients discharged * Graph does not include patients discharged without prescriptions 2007 TGH GIM * Sample Feb7 – May 17

24. n= 6976 Patient Admissions

26. CPOE-BASEDMED REC PRACTICE MODEL Baseline Data Evaluation Literature Review Multidisciplinary Feedback

27. UHN Implementation & Rollout Plan • Admission Reconciliation • Main priority for ALL inpatient areas • Transfer Reconciliation • Discharge Reconciliation • Ambulatory Clinics

29. Organization Wide : Leadership and Clinician Communication Formal Training of Champions • Education/ learning session, required readings, standardized patient validation/ certification training Front-line education in-services: • nurses, medical residents, medical staff Other communication tools: • Paper or electronic chart notification of reconciliation status, promotional video testimonials, hospital intra-net website, posters Leadership presentations: • Accreditation team lead meetings, site operations meetings/ leadership forum, business units, selected medical rounds, multidisciplinary med rec task force • Board, Senior Management MAC, P&T, UHN Ops…..

31. UHN Medication Reconciliation Resource Package Includes: • UHN Medical Staff Bulletin • UHN Organization Wide Roll Out Plan for Inpatient and Ambulatory Areas • Admission, Internal Transfer, Discharge, Ambulatory Clinics • Step-wise implementation plan for each inpatient ward (admission reconciliation) • Medication Reconciliation Fact Sheets (accreditation ROPs and current overall status at UHN) • Communication tools : poster, medication reconciliation website on UHN intranet, link to educational video .....Continued Next Slide

33. Hospital Internet Communication

34. Hospital Internet Communication (continued)

35. UHN Medication Reconciliation Resource Package Includes: • Patient Information on Medication Reconciliation • Screen Shots: EMITT (electronic medication information transfer tool) • Sample documentation/ outputs: EMITT (electronic medication information transfer tool) • EPR Medication Reconciliation Status/ BPMH note • Electronic reconciled discharge prescription, patient medication schedule, wallet card, medication information transfer letter • Clinician Tools: • BPMH Tip sheet; Clinician BPMH Interview Guide • Prescriber/ Nursing In-service Presentation Slides

36. How do we actually “get started and sustain” implementation? Leadership Coordination Communication People Tools/ Systems Five Tips & Strategies

37. Sample Tools in Guide

45. Tools & Strategies on CoP • BPMH guides/ trigger sheets • BPMH Forms • BPMH leading to admission order forms • Patient Risk Assessment / Scoring • Instructional Videos • Empowering patients as part of the BPMH process

46. Medication Reconciliation in the Ambulatory Clinics ISMP Canada / O. Fernandes UHN

47. Ambulatory Clinic Medication Reconciliation Meetings with Ambulatory Clinic Leaders/ Clinicians • Review models/ tools already in place • Most clinics do not have pharmacists- will need to consider mainly nursing/ prescriber based models • Nephrology model – recently updated • Presented to UHN Med Rec Task Force & Ambulatory Working Group for feedback • Recognition: different types of clinics (chronic care, procedural, different health care professional mix)

48. Considerations: UHN Ambulatory Medication Reconciliation Practice Model Nurse Clinic Chart Med List Client BPMH on visit As applicable Other Healthcare Professional Phmt • Discrepancies identified • Review and follow up where indicated • Tools: • Paper? (e.g. HD clinic model) • Electronic? (e.g. OTTR) • Other? Updated Clinic Chart Med List

50. Practical Tips to Sustain Med RecKim Streitenberger RN, The Hospital for Sick Children, Oct 2008 • Consider sustainability & spread from the moment you start developing the med rec process in your pilot area • Consider change fatigue & competing local & corporate initiatives • Embed intervention in existing processes e.g. med rec form doubles as order form • Identify frontline med rec champions to provide direct implementation support • Make it difficult for people to revert to “old ways” of doing things • Provide visible leadership support • Share results with patients, families & staff