Making a p di f-ference - results of the pdif quality improvement initiative

www.saferhealthcarenow.ca

Making a PDiF-ference –

Results of the PDiF Quality

Improvement Initiative

March 2014


Welcome also to our

francophone attendees

Bienvenue à nos participants

francophones

Hélène Riverin

Conseillère en sécurité et en amélioration

Safety Improvement Advisor

Bienvenue!

www.saferhealthcarenow.ca 3

Objectives of today’s call

Colleen Cameron:

• Describe the PDiF initiative, its outcomes and

key lessons learned.

• A few practical “challenges” to consider.

Marg Colquhoun: The MedRec Journey from 2005 and onwards.


Please input your Questions

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Making a PDiF-ference – Results of the PDiF Quality

Improvement Initiative

Colleen Cameron, RPh, Pharm.D.

PDiF Coordinator, Grand River Hospital

ISMP Canada/Safer Healthcare Now!

April 8, 2014

Objectives

Describe the PDiF initiative, its outcomes and key lessons learned.

A few practical “challenges” to consider.

WW LHIN

(775,000 people)

Grand River

Hospital St.

Mary’s General Hospital

Cambridge Memorial Hospital

North Wellington

Health Care

St. Joseph’s Health Centre

Groves Memorial Hospital

Guelph General Hospital

PDiF = Pharmacy Discharge Facilitator

Two stories

PRE

Metformin

ASA

Atorvastatin

Ramipril

Bisoprolol

POST

Metformin

ASA

Lipitor (Brand)

Perindopril

Bisoprolol

Clopidogrel

Lantus

Rapid

Ezetimibe

Esomeprazole

Docusate

Senokot

Nitro Patch

$$$

$$$

$$$

- 63 year old male

- 3rd cardiac event.

- Discharged post-stent

insertion.

Two stories

Losartan 100mg

Irbesartan 300mg

Losartan 100mg

Irbesartan 300mg

Two stories

200

The most unpredictable variables in the entire equation

Pharmacy Discharge Facilitator Project What is it?

Quality Improvement Initiative

Uniquely included 2 local CEOs in its development Possibly helped to keep the project’s profile and

momentum

January-September 2013

Facilitate medication discharge for high-risk medicine patients with a goal of improving care and outcomes

PDiF team = pharmacist + University of Waterloo pharmacy co-op student

Pt Admitted To Hospital

BPMH Completed / AMR (Best Possible Medication

History/ Admission Med Red)

Medication Therapy

In Hospital

Discharge preparation

and coordination

Discharge

Medication Care Map in Hospital

MD

Patient

Pharmacy


BPMH Completed

(Best Possible Medication

History)

Medication Therapy

In Hospital


and coordination

Discharge

MD

Patient Pharmacy

PDiF 1 On admission –

Identify

High-Risk

Patients

Components of PDiF


BPMH Completed


History)

Medication Therapy

In Hospital


and coordination

Discharge

MD

Patient Pharmacy

Components of PDiF PDiF 2

During hospital

stay –

Modify

medications that

will be practical

and make sense

for discharge


BPMH Completed


History)

Medication Therapy

In Hospital


and coordination

Discharge

MD

Patient Pharmacy

Components of PDiF PDiF 3 At time of

discharge –

1. Communicate

with involved

health care

providers about

medication

changes and

rationale for

those changes.

2. Talk to patient/

caregiver to

ensure they

understand

directions.


BPMH Completed


History)

Medication Therapy

In Hospital


and coordination

Discharge

MD

Patient Pharmacy

Components of PDiF PDiF 4

Post-discharge -

Call patient 24-

72 hours post-

discharge to see

if they are able

to follow the

instructions we

gave them.

Outcomes

Qualitative

Patient / caregiver satisfaction

Primary Care Provider satisfaction

Community Pharmacist satisfaction

Hospitalist satisfaction

Quantitative

7, 30 and 90 day ER visits

7, 30 and 90 day readmissions

Conservable Bed Days…unexpected

Demographics

# of patients seen – 148 (+)

Average age – 74.2 years

7 patients died during index hospital admission

0

5

10

15

20

25

30

35

40

45

50

20-40 41-60 61-80 81-96

Age Ranges

%

79%

Age

Range

% of

Patients

Heart

Failure

(# of pts)

Diabetes

(# of pts)

Warfarin

(# of pts)

20-40 3.4%

(N=5)

0 2 2

41-60 17.6%

(N=26)

5 16 9

61-80 35.1%

(N=52)

14 23 26

81-96 43.9%

(N=65)

20 22 39

Total 148 pts 26% 43% 51%

Qualitative Outcomes

Did we achieve Patient / Caregiver

satisfaction?

Did we achieve Primary Care Provider

satisfaction?

Did we achieve Community Pharmacist

satisfaction?

Did we achieve Hospitalist satisfaction?

Quantitative Outcomes (#, $)

ER/Readmission Rates

7, 30 and 90 day ER visits

7, 30 and 90 day hospital readmission rates

Data disclaimer

Historical =

All comers –

young

patients, DKA,

pneumonias,

acute

ingestions,

dialysis

PDiF patients

GRH Readmission Rates - Historical

0

2

4

6

8

10

12

14

16

7 day 30 day 90 day

FY 09-10

FY 10-11

FY 11-12

FY 12-13

%

CIHI 13.3%

GRH Readmission Rates

0

2

4

6

8

10

12

14

16

7 day 30 day 90 day

FY 09-10

FY 10-11

FY 11-12

FY 12-13

PDiF

%

CIHI 13.3%

ER Visit Rates - Baseline

0

5

10

15

20

25

30

7 day 30 day 90 day

FY 09-10

FY 10-11

FY 11-12

FY 12-13

%

ER Visit Rates

0

5

10

15

20

25

30

7 day 30 day 90 day

FY 09-10

FY 10-11

FY 11-12

FY 12-13

PDiF

%

What do these numbers have the statistical power to prove?

Anything? – probably not

Causality? – certainly not

Benchmarking? - maybe

Is that the only information that matters?

What if patients subsequently go elsewhere for care?


Hospital Readmissions and ED Visits

At first glance, our PDiF numbers look great…


Hospital Readmissions and ED Visits

At first glance, our PDiF numbers look great… BUT

This is

bigger than

GRH…


Conservable Bed Days

Definition…relevance

Over 9 months, PDiF realized 8 weeks of conservable bed days

Medications involved – Warfarin, Methadone

Unexpected, but fascinating

Consequently – have started targeting patients on medications that are more likely to delay discharge

Warfarin / NOACs

Insulin

Top 5 lessons learned…

1. Dare to look at your patients’ experience post-discharge.

Are they seeing their family doctor post-discharge?

Are they getting their prescriptions filled as expected?

Are they going to other local hospitals for subsequent visits?

Follow-up phone calls are quick, and incredibly valuable!


2. Drugs delay discharge Warfarin, LMWHs, insulins, methadone

We now assess 100% of patients on warfarin for timely and safe discharge from Medicine program Assist with LMWH coordination post-discharge

Educate injection technique while in hospital

Phone call follow ups

Anticoagulation summary of INRs & warfarin doses,

Ensure patient has appt with PCP as well as plans to go to lab


2 ½ . Where there is warfarin (or NOACs) there are other medication misadventures looming

Warfarin and NOACs are predictors of other high-risk medications (insulin, digoxin, spironolactone, amiodarone etc)

Most computer systems can search for certain medications.

This is the best place to start!


3. Use the hospital admission to optimize chronic medications

Clinical inertia

Look for adherence issues!!!

ODB DPV has picked up on MANY misadventures

Incorporate practical medication discharge assessment upstream


4. Medication knowledge transfer contributes to efficient and safe patient care GRH has an electronic discharge prescription

but….

PCPs and Community Pharmacists need information about medications, including rationale and plans of care.

What is your eHealth system? Fusion software (transcription software)

Clinical Connect (LHIN EHR)

Medication-Focused Discharge Summaries

Medication-Focused Discharge Summary

One of the most valuable interventions from the PDiF project!

Medication-Focused Discharge Summaries

Standardized document including Date of Admission/Discharge

Adherence Issues Identified**

Drug Cost Issues Identified

Numerical List of medications comment if same, increased, decreased or new

Medications discontinued or held

Additional information Commentary including plan of care, monitoring plans,

concerns

My name and telephone extension


5. Discharge medication reconciliation is time consuming! Track outcomes/stories to strengthen your

argument for more funding Go to your program director with proposal Develop a business case?

Dr. Schnipper’s data

Be creative in staffing Pharmacist : patient ratio Pharmacy students Pharmacy Technicians

Financially:

1 pharmacist ≈ 2 technicians ≈ 4 co-op students

Summary

Was the PDiF project successful? Did we improve outcomes?

Unequivocally

Are there simple strategies every hospital can implement to help these patients?

Absolutely

Medication misadventures

We don’t even know the magnitude

of the problem yet

[email protected]

©2014 Institute for Safe Medication Practices Canada (ISMP Canada)

The MedRec Journey

Margaret Colquhoun, B.Sc.Phm., FCSHP, R.Ph.,

Project Lead, ISMP Canada

http://www.ismp-canada.org/medrec/

http://www.ismp-canada.org/medrec





Objectives

• To talk about the MedRec from 2005 – 2014

• Highlight SHN tools and resources

• Highlight your accomplishments

• To announce changes in 2014-2015


Thanks to………

• Canadian Patient Safety Institute

• 2005 MedRec Intervention

MedRec 2005 • Unknown – did

not know what we did not know

• Systems not in place

• Measures not in place

• Studies not driving practice change


Things I am Proud of!!!

• Creation of new language and knowledge

• Being used around the world

• Whole country worked together and learned together as a team

• Tools and Resources

• Webinars, kits, questions

• Unbelievable sharing though our network of MedRec teams across Canada


Action for Safer Medical Care – Medication Reconciliation, CMPA/ACPM, 2103


www.ismp-canada.org/medrec www.saferhealthcarenow.ca




http://www.saferhealthcarenow.ca/


www.ismp-canada.org/medrec





http://www.saferhealthcarenow.ca/


National Team Sharing through Webinars

200-400 lines for each webinar

Showcase the Success of our Teams

Well received by attendees

Relevant and Timely


London Health Sciences Centre describes:

The challenging elements of MedRec implementation in one of Canada's largest, acute care teaching hospitals

1. How LHSC overcame these challenges by focusing on interdisciplinary collaboration

2. How LHSC is evaluating and sustaining the process

The Stepping Stones to MedRec Success


Square Peg in a Round Hole: MedRec in Ambulatory Clinics Requires a Different Model

Vancouver Health Authority and University Health Network, Toronto

• Describe how ambulatory clinic patients require a different system to enable medication reconciliation & review.

• Understand the longitudinal team approach to improve accuracy & error reduction through regular review.

• Describe two approaches to medication reconciliation in the ambulatory clinic setting.

• Identify opportunities of a patient registry as it relates to patient care (medication reconciliation), the organization (drug usage review) and outcomes research.

• To share the findings of medication discrepancies and drug therapy problems identified in a post discharge medication reconciliation pilot study.

http://www.saferhealthcarenow.ca/EN/events/NationalCalls/2009/Pages/National Call - Med Rec - November 24, 2009.aspx


Different Strokes: Engaging Pharmacy Technicians in MedRec

The Moncton Hospital, The Ottawa Hospital, Trillium Health Centre, Peterborough Regional Health Centre

Describe the medication reconciliation model developed for pharmacy technicians

• Review the training process involved for pharmacy technicians in medication reconciliation

• Highlight the role of the pharmacy technician in the Emergency Department and/or the pre-admission clinic


Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS)

Dr. Jeffrey Schnipper

Results of a funded research study into what works and what is the impact of MedRec

All past and future webinars available from: SHN website: http://www.saferhealthcarenow.ca/EN/events/NationalCalls/Pages/default.aspx ISMP Canada website: http://www.ismp-canada.org/medrec/ (Education & Training)

http://www.saferhealthcarenow.ca/EN/events/NationalCalls/Pages/default.aspx





Slide Courtesy of Dr.Jeff Schnipper Safer Healthcare Now! Webinar Jan, 2014


All past and future webinars available from:

• SHN website: http://www.saferhealthcarenow.ca/EN/events/NationalCalls/Pages/default.aspx

• ISMP Canada website: http://www.ismp-canada.org/medrec/

(under Education & Training)

MedRec

Webinars

2009-2014

Available online

http://www.saferhealthcarenow.ca/EN/events/NationalCalls/Pages/default.aspx





2010- National MedRec Summit

To accelerate a system-wide strategy to implement medication reconciliation (MedRec)

Healthcare CEOs, senior leaders, representatives from national organizations, provincial quality councils, physicians, nurses and pharmacists identified themes that

would accelerate and optimize MedRec across the continuum of care


“Senior leadership commitment is critical to ensuring MedRec is

implemented successfully across an organization.

Accountability must rest with the CEO with clear reporting

expectations at the board level.”

REF: Optimizing Medication Safety at Care Transitions: A National Challenge, 2011

http://www.ismp-canada.org/download/MedRec/MedRec_National_summitreport_Feb_2011_EN.pdf





PR Campaign from North Bay

Regional Health Centre (ON)

Consumer Awareness and Tools


Interactive Map

Relatively few self-identified “MedRec All-Stars” who have MedRec in place

across admission, transfer and discharge


Paper to Electronic Tools/Checklists

• Organizational Readiness

• Steps to support the safe transition to eMedRec

• Ideal features of eMedRec,

• Evaluation of eMedRec


October 2013 was National MedRec Quality Audit Month

2340 patients

29% (acute care)

55% (Long Term Care)

• 1906 Acute Care

• 329 Long Term Care

• Met all 5 quality criteria

• Met all 5 quality criteria

103 Organizations


National Quality Audit Results Summary Comments

• MUST critically evaluate admission to ensure quality at discharge

• Canadian audit tool results demonstrate need for ongoing and specific improvements

• People believe they are doing MedRec but they may not be doing it well

• The foundation of the process – the BPMH needs work


In 2014 we have NOT reliably implemented MedRec!!!


Outstanding Issues in MedRec!

Getting to where we want to be

• Leadership

• Measuring and Monitoring Quality

• Role and use of technology

• Embedding roles and processes into system

• Consumer Engagement

• Primary care


Light…. at the end

of a lot of hard work

The tipping point is that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire.


Changes in 2014-2015


Questions


Questions

1. Raise your hand and we

may be able to open your

phone line

2. Send feedback via

the “chat” box • Select “All participants”

• Type message

• Click “Send”

All Participants


Please complete our poll


Upcoming MedRec Webinars

83

Thank you for attending

Join us on May 6, 2014 at 12 noon ET

for our next MedRec webinar

Safety, Sleuthing and Students: A Novel Collaborative

MedRec Event at the University of British Columbia


www.ismp-canada.org

84

We encourage you to report

medication incidents

Practitioner Reporting https://www.ismp-canada.org/err_report.htm

Consumer Reporting www.safemedicationuse.ca/

http://www.ismp-canada.org/



https://www.ismp-canada.org/err_report.htm



http://www.safemedicationuse.ca/


www.ismp-canada.org

Medication Safety Self-Assessment®

• Hospitals (acute care)(2006) – free for Ontario*

• Long-term care (2012) – free for Ontario*

• Complex Continuing Care and Rehabilitation (2008) – free for Ontario*

• Community and Ambulatory Pharmacy (2007) – free for Ontario*

• Operating Room Medication Safety Checklist (2009) – free for Ontario*

• Oncology (2012)

• Anticoagulant Safety (VTE) – free for Ontario*

• HYDROmorphone Safety Self-Assessment (2014) - $50

* Supported by the Ontario MOHLTC

For more information visit www.ismp-canada.org/MSSA or email [email protected]




http://www.ismp-canada.org/MSSA



mailto:[email protected]




Thank you for attending

Making a p di f-ference - results of the pdif quality improvement initiative

Health & Medicine

Transcript of Making a p di f-ference - results of the pdif quality improvement initiative