Initiatives

Getting Started

Assuring that every patient gets the right medications following each transition of care requires addressing the core issues of teamwork and communication and information transfer. Success requires a cooperative effort, with caregivers sharing responsibilities across disciplines and units. You will be required to change how people do work, and will meet with resistance as a result. The case studies of successful hospital programs to implement the reconciling procedures highlight four fundamental ingredients for success:

1. Clearly-identified leadership support
2. Cross-disciplinary implementation team including strong representation from leadership of each of the three key stakeholder groups: physicians, nursing, and pharmacy
3. Highly-visible use of data, both to motivate caregivers and to show whether individual changes are leading to improvement
4. Start small, stay focused

The following links provide some tips on getting started developed over the course of the Massachusetts Coalition for the Prevention of Medical Errors’ two-year Reconciling Medications Collaborative.

Leadership Commitment
Form a Team
Collect Baseline Data
Develop Mission and Aim Statements
Choose Where to Start
Begin Testing

Leadership Commitment

Leadership engagement is a fundamental component of a successful reconciling medications implementation effort. Hospital teams participating in the Reconciling Medications Collaborative have had identified the following tasks for leadership to support the implementation teams:

1. Provide very clear directions on personal goals for your organization from the highest level of your organization (CEO/President/COO):
   Be committed, set the standard – make it clear that this is how we will practice:
   All information on patients’ pre-admission medications will be available in one highly visible place in the patient chart and new medication orders will always be checked against that list
2. Appoint an executive sponsor for the safety team; the executive sponsor can stand in for leadership in addressing some of the issues below and provide an active voice supporting the team
3. Sufficiently resource the effort: allocate sufficient time for team members to work on testing, relieving some of their other responsibilities during the testing phase, and make clear assignment for the ongoing data collection effort
4. Review the team’s monthly data and timeline regularly
   Be sure this initiative is part of the ongoing quality and safety reporting to leadership
   Build into strategic plan in way that reporting-out at Board-level happens naturally
   Ask about the project on executive walkrounds
5. Remove barriers where possible
   Develop support from all (IT, medical records, staff education, etc)
   Eliminate need for forms committee approvals during testing
6. Role of incentives???
   Should be part of management’s core mission
   Find ways to reward both management and staff

Form a Team

Identify a multidisciplinary team to direct your Medication Reconciliation effort.
using the form at the end of this document. Key voices that need to be on the team include:

• Executive sponsor
• Clinical leadership for all three primary disciplines:
  physicians, nursing, pharmacy
• Front-line caregivers: nursing all shifts
• Patient Safety Officer and/or reps from QI/RM and key committees (P&T, Medication Safety)
• Special successes from engaging hospitalists, residents, staff education, IT, VNA, medical records, care managers, physician assistants

Collect Baseline Data

Begin a risk assessment of your current processes, collecting baseline data and developing high-level flow charts of existing workflow. It can also be helpful to review any root cause analysis of recent medication errors occurring at the interfaces of care and develop a mini-FMEA identifying what can go wrong at admission relative to collecting the patient’s home medication list and ensuring that that list is accurately reflected in the admit orders.

Instructions for collecting baseline data and an accompanying Excel spreadsheet can be found in the Measures section: Forms for Baseline Data Collection

Develop Mission and Aim Statements

Example mission and aim statements are provided below. The key is to frame a mission statement that reflects the project’s goal in reducing adverse medication events for the patient, coupled with an aim statement that includes both a quantified goal and a timeframe for achieving that goal.

Broad Mission Statement

Every patient will receive all medications they have been taking at home unless they are held/discontinued by their caregiver(s) and all new medications as ordered -- correct drug, dose, route, and schedule.

The goal of reconciling is to design a process that will ensure the most accurate patient home medication list available, thus reducing the number of medication events upon admission, transfer and discharge.

AIM Statement

Short-term Aim:

• Reduce the rate of unreconciled medications at admission by 75% within 9 months

Long-term Aim:
Identify goals for both the success rate of reconciling medications for identified populations and also the expansion of the sets of patients for whom medications are being reconciled.

• All medications will be reconciled within 24 hours for 100% of eligible patients (i.e. patient populations for whom reconciling has been initiated) within two years
  and
• The reconciling process will be expanded to cover 80% of our patient population within two years

Choose Where to Start

A lot of different ingredients have gone in to hospitals’ selection of where to start testing the reconciling procedures, and there has been a wide variation in their choices. For some, the emergence of a physician champion on a particular unit has dictated the choice. For others, a medication error has triggered activity in a specific location. Some hospitals combined their baseline data collection efforts with a mini-FMEA process to assess the areas with the greatest potential for problems.

The most common place for organizations participating in the Collaborative to start has been in pre-admission testing (PAT), where they can take advantage of the pre-admission contact with the patient to develop an accurate home medication list. For nursing units, there have been many provocative discussions about the advantages of starting on medical versus surgical units. Chronically ill patients on the medical floors are often at great risk because of multiple conditions, multiple medications. Surgical patients with underlying medical conditions are often on medications that will need to be re-started post-op, another significant safety risk.

While most hospitals are focusing on starting with the admission phase, there is lots of great evidence on the effectiveness of reconciling on transfer out of the ICU in preventing medication errors (see Pronovost P, et. al. Medication reconciliation: a practical tool to reduce the risk of medication errors. Journal of Critical Care. 2003 Dec;18(4):201-205.) Peter Pronovost’s work at Johns Hopkins on reconciling at transfer from the ICU is well documented on the www.qualityhealthcare.com WEB site, including his measurement template. Among our collaborative participants, one of our great success stories was a hospital with an extremely large mental health population that began their reconciling implementation in the ICU, with a very powerful MD champion who consistently used the evidence of the impact that failure to re-start psychotropic meds was having on their patient population!

Starting in the ED is not usually recommended, since not all patients will be admitted and the urgency of the environment results in clinician focus on other issues. However, there are opportunities to take advantage of wait times for patients who are being admitted to start the reconciling process by developing the home medication list. (Additional comments can be found at this link: Special Issues for Reconciling in the ED).

Begin Testing

Once you have identified your pilot unit, you’ll want to begin small tests of change. We strongly suggest breaking the process down into small steps, so you will have narrow, focused tests to work out the kinks in the process. You can begin with just the first step, taking the patient’s medication history, and then introduce the reconciling step, having someone compare the admit orders to the pre-admit medication list and reconcile differences, and then later on build toward having the ordering prescriber use the history when writing orders. Some ideas to help you get started:

1. Pick a pilot form to test. It’s a great idea to build on one of the sample forms provided on this WEB site, rather than investing significant time in developing your own form. In the process of running your tests of change, you’ll get lots of input from your staff that will guide you in tailor the reconciling form to meet the needs of your organization.
   See Designing a Form to Use for Reconciling Medications
2. Ask a nurse to try taking her next two-three patients’ medication histories onto the reconciling form. Identify workflow issues: How can you integrate this into her current nursing assessment? Any differences in workflow for patients coming in from different routes (ED, direct admit, transfer)? Any opportunities to engage pharmacy when medication history is particularly complex or missing information needs to be tracked down?
3. De-brief the nurse and revise the process and the form
4. Continue testing just the first step of the reconciling process, taking the home history, engaging more nurses from different shifts
5. Expand your tests to the reconciling itself, identifying workflow issues and alternative assignment of responsibilities. Be sure your physician champion is actively engaged.

A set of implementation planning tools are provided in the “Toolkit” section of this WEB site:

• Implementation Planning Checklist
• Worksheet for Reporting Tests of Change
• Examples of Tests of Change Worksheets

The most important thing is to stay focused; start small and test each step of the process:

• One or two RNs, one patient/one ordering MD, on one unit
• Test how reconciling process can be integrated most effectively with current work processes
• Thoroughly test forms in paper format before automating
• Moving too fast to spread change to other areas can be a mistake; ensure smooth process first

This collaborative is supported in part by grant number 5 U18 HS011928 from the Agency for Healthcare Research and Quality (AHRQ)

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