Presented to:

AHRQ Attendees

AHRQ 2007 Annual ConferenceSeptember 27, 2007

By

Kristine Gleason, RPhQuality Leader, Clinical Quality and Patient Safety

Medications At Transitions and Clinical Handoffs (MATCH): Multi-disciplinary Team Approach to Medication Reconciliation

Supported by a grant from the Agency for Healthcare Research and Quality (AHRQ) 5 U18 HS015886

Discussion Overview

• Multi-Disciplinary Approach for Medication Reconciliation

• Designing a Process within Inpatient and Outpatient / Procedural Areas

• Education and Team Training – “Med Rec Roadshow”

• Measurements for Improvement

Session Objectives - To describe patient-centered tools and re-engineering of processes to improve the effective and safe delivery of medications across the healthcare continuum.

What is Medication Reconciliation?

• A systematic process to decrease medication errors and associated patient harm by:

− Obtaining, confirming and documenting the patient’s complete list of medications upon admission

− Comparing and screening this list against the medications prescribed

− Reconciling (resolving) unintended medication discrepancies

− Communicating an updated medication list, highlighting any changes, to the patient and next provider of service upon discharge

• The Joint Commission National Patient Safety Goal #8

Medication reconciliation impacts all patients at NMH who receive medications

Northwestern Memorial Hospital - Chicago, Illinois • 744-bed Academic Medical Center

• Fiscal Year 2006:– 43,000 Admissions

– 10,000 Deliveries

– 74,000 ED Visits

– 430,000 Outpatient Registrations

• NMH Strategy:– Provide the Best Patient Experience

– Recruit, Develop and Retain the Best People

– Achieve Mission and Vision through Exceptional Financial Performance

• Recipient of 2005 National Quality in Healthcare Award

• New Prentice Women’s Hospital Opening October 20, 2007

Getting Started or Moving Forward

• Organizational Risk Assessment

• Operational Component

• Research Component

• Collaboration

• Support

MATCH - Specific Aims• Aim 1: Implement the MATCH program utilizing an integrated,

multidisciplinary process (NPSG – operational component)

• Aim 2: Analyze the implementation and compliance of MATCH program (NPSG – operational component)

• Aim 3: Determine the rate and etiology of medication reconciliation failures within the general medicine service after MATCH implementation (research question)

• Aim 4: Identify risk factors frequently responsible for inaccurate medication reconciliation (research question)

• Aim 5: Produce and disseminate a toolkit based on MATCH (implementation / research summary)

Supported by a grant from the Agency for Healthcare Research and Quality (AHRQ) 5 U18 HS015886

Designing a Multi-Disciplinary Approach

Medication Reconciliation – Improvement Initiative

• Increase accuracy and completeness of medication history− Create “one source of truth” (Med Profile)− Complete medication description (name; dose; route; frequency)− Validate home medications with patient, family and/or other sources

• Prompt clinicians to complete medication reconciliation

• Reconcile all medications (home and current medication orders) during transitions in care

• Achieve >90% compliance at admission and discharge to meet The Joint Commission requirement

Multi-disciplinary team approach - physicians, nurses and pharmacists

Medication Reconciliation: “One Source of Truth” for All Medications (Inpatient and Outpatient)

Physician Medication

Reconciliation

PatientInteraction

Pharmacist Medication

Reconciliation

Nurse Medication

Reconciliation

PATIENT HEALTHCARE PROFESSIONAL

MEDICAL RECORD

Built in Forcing Functions - Admission Order Set

Med Rec Integrated within Physician

Admission Order Set

Built in Forcing Functions –Physician PowerForm Example

Built in Forcing Functions Cont. – Nurse / Pharmacist PowerForm Example

Standardized Process - Procedural Areas and the Emergency Department

Education, Training and Feedback

Medication Reconciliation “Roadshow”

• Significant Technology Enhancements

• 60+ Computer Classroom Training Sessions Conducted– 341 physicians trained (focused on residents)– 450 Nurses, APNs, NPs– 51 Pharmacists

• Unit-by-Unit In-services

• Prioritization and support reinforced by Medication Reconciliation Leadership Team

• Weekly audits to identify areas for improvement and to provide feedback

CATEGORY DEFINITION EXAMPLE REQUIRES PHYSICIAN

FOLLOW-UP? (Yes/No)

“One-to-One” Match

Medications ordered for patient during episode of care or upon discharge match what patient was taking prior to admission (entry) to the organization

Patient takes furosemide 40 mg by mouth twice daily at home; ordered upon admission. Patient’s pre-admission dose of simvastatin 40 mg by mouth every evening is continued during the hospital stay and at discharge.

No

Intended Discrepancy (i.e., purposeful)

Discrepancies exist but are appropriate based on the patient’s plan of care – i.e., information gathered during rounds, based on a review of the physician’s history and physical (“H&P”) and progress notes, based on communication/handoffs in preparation for discharge, etc.

Antibiotics started for infection“As needed” medications ordered for pain/feverPre-admission doses of patient’s blood pressure medications changed due to hypotensive episodes Warfarin and aspirin held for a procedureFormulary substitution

No

Unintended Discrepancy

Discrepancies exist and require clarification of intent because there is no supporting documentation or explanation based on the patient’s current clinical condition or care plan.

The patient takes her blood pressure medication twice daily at home but it’s ordered only once daily in the hospital. No indication for frequency change and patient’s current blood pressure slightly elevated. Patient’s simvastatin was omitted from their discharge instructions without any clear indication for why.

Yes- Physician should be consulted for resolution and resulting changes and/or clarifications documented.

Critical Thinking – Clarifying Discrepancies Identified During Reconciliation*

*Adapted from Gleason et al. Am J Health-Syst Pharm. 2004; 61:1689-95.

Medication Reconciliation Results: Adherence to Process

Medication Reconciliation Results - Admission

Compliance with Medication ReconciliationInpatient Admission

0%

20%

40%

60%

80%

100%

ComplianceFY07 GoalBaseline

Definition: Documented compliance with recommended Medication Reconciliation upon inpatient admission (physician, nurse, and/or pharmacist)

Mandatory Training Program

Definition: Documented compliance with recommended Medication Reconciliation upon outpatient arrival (includes 20 departments)

Compliance with Medication Reconciliation Outpatient

Admission/Arrival

0%

20%

40%

60%

80%

100%

May

07

Jun 07

Jul 0

7

Aug 07

ComplianceFY07 GoalBaseline

D M A I C

Compliance with Medication Reconciliation

Inpatient Discharge

0%

20%

40%

60%

80%

100%

May

07

Jun 07

Jul 0

7

Aug 07

Compliance

FY07 GoalBaseline

Medication Reconciliation Results - DischargeCompliance with Medication

ReconciliationOutpatient Discharge

0%

20%

40%

60%

80%

100%

May

07

Jun 07

Jul 0

7

Aug 07

ComplianceFY07 GoalBaseline

Definition: Documented compliance with recommended Medication Reconciliation upon discharge (physician and nurse)

Definition: Documented compliance with recommended Medication Reconciliation at discharge

(physician and nurse)

D M A I C

Medication Reconciliation ResultsMulti-disciplinary Team Approach at Admission

D M A I C

Medication Reconciliation – Electronic AuditRandomly selected sampling days 8/8/07 8/13/07 8/21/07 8/29/07 9/5/07

Overall Admission Compliance 95% 94% 93% 97% 99%

-Physician Compliance 84% 86% 89% 90% 90%

-Nurse Compliance 88% 82% 86% 85% 87%

-ICU Pharmacist Compliance 100% 92% 100% 100% 94%

Continued Focus on Patient Safety

Assessing the Quality of Medication Reconciliation

• Evaluation of the medication reconciliation process post-implementation to determine:

– Frequency and causes of medication reconciliation failures

– Type of discrepancies involved

– Potential patient harm averted

– Patient and/or medication-related risk factors frequently responsible for inaccurate medication reconciliation

Supported by grant number 5 U18 HS015886 from the Agency for Healthcare Research and Quality (AHRQ).

Goal: To eliminate avoidable adverse drug events and associated patient harm due to medication discrepancies.

MATCH Toolkit - www.medrec.nmh.org

Questions, Answers and Discussion

Kristine Gleason, RPhQuality Leader, Clinical Quality and Patient Safety

Northwestern Memorial Hospital, Chicago, ILkmgleaso@nmh.org

MATCH Toolkit available at: http://www.medrec.nmh.org

We acknowledge the supported of the Agency for Healthcare Research and Quality (AHRQ) 5 U18 HS015886