MEDICATION RECONCILIATIONGLOBAL TRIGGER TOOL

DSRIP

Doing Common Things uncommonly well

June 7, 2011

Shideh Ataii, Pharm.D.

Director of Pharmacy Services

Contra Costa Regional Medical Center

Martinez, California

OBJECTIVES

1) Medication Reconciliation How the approach over the years What the process Tools the forms Pearls of wisdom & Lessons learned

2) Global Trigger Tool

3) CA 1115 Waiver – Delivery System Reform Incentive Payments (DSRIP)

OBJECTIVES

Contra Costa Regional Medical Center & Health Centers

MartinezCalifornia

San FranciscoBay Area

County hospital with 163 staffed beds 8 owned & operated health centers Public Health, Mental Health, and Health plan Teaching Hospital Hospital & clinics still using paper records Pharmacy: Inpatient Pharmacy, three

Outpatient/Clinic Pharmacies Meditech

About CCRMC……

• We serve a population of approximately 100,000 individuals

• 450,000 outpatient visit/year

• 65,000 emergency visits/year

• 12,000 hospital discharges each year

• We deliver 22% of Contra Costa County’s babies/year

• Payor mix is 45% Medicaid, 18% Medicare, 30% managed care and 7% other

• We employ 450 physicians and train 39 family medicine residents/year

• Pharmacy is consists of ~80 employees and we’re a training site for all major Pharmacy schools in CA

• Services include: Emergency Department, hospital, hospital-based outpatient clinics, and freestanding health centers.

About CCRMC……

Our mission Statement: “Care for and improve the health of all people in Contra Costa County with special attention to those most vulnerable to health problems.”

CCRMC Mission Statement

CCRMC’s Recognition

• IHI Mentor Hospital since 2006• IHI Innovation Award Winner (Dec 2007)• Agency for Healthcare Research & Quality (AHRQ)

Innovation Exchange (www.ahrq.org)Our Innovation Profile per AHRQ: “Low -Tech Medication Reconciliation process emphasizing standardized, easy to execute roles significantly reduces rates of unreconcilied medications…”

• Multiple publications on Medication Reconciliation• Published case study in Joint Commission Resources’

Medication Reconciliation Toolkit for Implementing NPSG 8

Improve Medication Safety

Reduce rates of unreconciled medications

Implement an effective admission, discharge and transfer reconciliation process

Model for Improvement Source: Institute for Healthcare Improvement (IHI)

Recommendations and Tips

Segment pieces of the improvement process in bite size increments.

Allows for small scale tests of change Allows for customization where necessary Improves likelihood of success

Our Med Rec Team membersCORE:• Physician champion (Internist)• Resident• Nursing champion (Medicine unit staff RN)• Pharmacists (2) Pharmacy Tech (1)• Clinical Informaticist (RN)• LeadersAd hoc :• Forms expert (JD/risk management)• Nursing rep for every service as we expanded• MD rep for every service as we expanded

Pearls

Multi-disciplinary team Physician champion essential Pharmacy Champion essential Nursing Champion essential Best to have a strong leader who is well

respected by the organization

Short (45 minutes) weekly team meetings Maintains momentum Promotes engagement

Recommendations and Tips

Med Reconciliation Timeline –Historical data

YearMonth J A S O N D J F M A M J J A S O N D J F M A M J J A S O N

Pilot unit (4A)

Admission Reconciliation Implemented

Transfer Reconciliation ImplementedDischarge Reconciliation Implemented

2007

Pediatrics unitOB Unit

Medicine Unit (4B)

Surgical UnitPsychiatry Unit

KEY:ICU/IMCU

IMCU/ICU

Transfer Rec live (all areas)Pediatrics unit

2005 2006

Medicine unitsSurgical units

Pilot unit (4A)OB unit

Transfer Rec pilotPsychiatry units

Pearls

Identify & Mitigate Failures Admission reconciliation failure causes

discharge reconciliation failure Develop workflows to identify key failure

points so they can be fixed immediately

Example Daily report in Pharmacy for identifying admitted patients w/o AMROF

Test measurement tool thoroughly

insures that the data collection process will produce the information you are seeking

Recommendations and Tips

Recommendations/Tips

“Measurement is for learning, not for judgment”

“Use data to generate light not heat!”

Use data to learn where your process is failing Data collection should be frequent, small samples

Measurement Tool

MRN: Unit:

Patient Name: Reviewer:

C DC M C DC MPre-Admit (HX) Meds

Meds Pt is Taking Day of D/C

No PRNs No Insulin sliding scale No Heparin SQ No antibiotic ointments No IV Chemo No one dose only drugs

Data Summary Med order to C, DC, M on discharge?

Med

NO

T R

econ

cile

d

Total # of pre-discharge meds

NOT reconciled on discharge

Does DMOF contain all at home meds?

Med order to C, DC, M on admission?

Med

NO

T R

econ

cile

d

Med

not

rec

; but

cl

inic

ally

obv

ious

Step 1:List Meds on MAR on day of d/c with exceptions:

AD

MIS

SIO

N R

EC

ON

CIL

IATI

ON

DIS

CH

AR

GE

RE

CO

NC

ILIA

TIO

N

Was DMOF Used?

Medication Reconciliation Worksheet: Admission & Discharge Reconciliation (Contra Costa Regional Medical Center)

Admit Date:

Discharge Date:

Comments

Did any med order consist of "continue pre-admit meds" or "continue home meds" without detailing the specific medication? (Y/N)

Admission Discharge

Was Admit MROF Used?

Audit Inclusions: Any admission to the service; A least one pre-admit med in hx.

Med

not

rec

; but

cl

inic

ally

obv

ious

Drug

Step 2: Does documentation specify that each drug is C, DC, M upon discharge? If not, it's unreconciled.

Audit Instructions

If MROF used, no need to list drugs (just do summary). If no MROF, list all pre-admit drugs, including OTCs, vitamins, herbals & supplements

Patients selected for audit must have at least 1 pre-admit med.

Do not mark an herbal as unreconciled upon admission (not continued, per policy).

Total # of Pre-Admit Meds

Total # of Pre-Admit meds NOT reconciled on admission

Total # of Pre-Admit meds NOT reconciled on discharge

Total # of pre-discharge Meds

Admission Reconciliation

Paper process• Originally: Admitting provider hand-wrote the list of

medications patient was taking at home on AMROF.

• Now: Admitting provider prints an eAMROF form which is pre-populated with the current med list and uses same form to order medications on admission.

• Process being used >99% of the time.

Our paper Admission Medication Reconciliation Order Form (AMROF)

Our electronic Admission Medication Reconciliation Order Form (eAMROF)

Page 1

Pearls

Use “What’s-In-It-For-Me” (WIFM) approach in workflow design

Admitting MD new process was less work Admitting MD eAMROF was less work (pre-

populated list meant less writing) Admitting RN new process was less work (stopped

capturing a med list from scratch) Pharmacy ?

Pearls

Pearls

Customize where necessary; Standardize where possible

Allows for unique workflows Promotes buy-in from staff

Examples OB (currently), and Psychiatry and PES units for about 2 years post implementation

Manual Admission and Discharge Medication Reconciliation Order Form

For L&D

Pearls

Make it easy for staff to use the new process & difficult or impossible to use the old process

Key for achieving high compliance with use of the process

Example Attached Admission Med Rec form as page 1 of all admit order forms already in use & Removed the medication list

part of H&P, to have prescriber comply with the standards.

Transfer Reconciliation

• Electronically printed form contains list of all active meds as of that moment in time.

• Provider uses form to order medications on transfer within the facility.

• Process being used >99% of the time.

Our Transfer Medication Reconciliation Order Form (TMROF)

Pearls

Use “What’s-In-It-For-Me” (WIFM) approach in workflow design

Receiving RN Less work (no more “continue previous meds)

Harness Informal Champions Receiving RN Constant reminders to

physicians who didn’t use the new processCreate a Pharmacy-Nurse liaison to educate the

Medical as well as the Nursing staff

Discharge Reconciliation (DMROF)

• Electronically printed form contains list of all pre-admit meds and active inpatient meds as of discharge.

• Provider uses form to order discharge meds• Patient is provided with a “patient friendly”

list of discharge medications.• Copy of list is sent to next provider of care.

Our Discharge Medication Reconciliation Order Form (DMROF)

Page 1

Our Discharge Medication Reconciliation Order Form (DMROF)

Final Page

Our [electronically generated] “patient friendly” Discharge Medicine List

Pearls

Use “What’s-In-It-For-Me” (WIFM) approach in workflow design

Discharging MD Less work (home & inpatient meds print on a report)

Patient Now has a concise med listRemember: Make it easy for staff to use the

new process & difficult or impossible to use the old process

Discharge Reconciliation:Who Does What…….

• MD– Reviews and sign the DMROF. Updates RXM as

needed– Generates prescriptions in RXM

Discharge Reconciliation:Who Does What…….

• Nursing Staff– Print Patient Home Medicine List from RXM (aka Patient

Friendly Med List)– Complete the STOP medication section on the Med List– Review Patient Home Medicine List with patient (aka Pt

Friendly), make a copy for the chart.– Indicate on Patient Home Medicine List, the time the next dose

of any medication is due.– Write Patient Home Medicine list if not generated from RXM

Importance of Patient Education…

Discharge Reconciliation:Who Does What…….

• Clerk– Fax prescriptions (DMROF) to Retail Pharmacy of

choiceOR– CCRMC Pharmacy

PHARMACY: Closed the service for all discharged meds in March, 2007

Exclusion criteria: Injectables, PES, and psych units

• TECHs: enter the order into RXM, pull meds and prepare

• Pharmacists: Checks techs’ work and Dispense

Discharge Reconciliation:Who Does What…….

Where We are today and where we are Going…

Future Conversion to EPIC, Go live

7/2012

ED visit Inpatient Admission

(Admit, Transfer, Discharge)

Outpatient Visit

Electronic prescribing to Retail or CCRMC

Pharmacies vs printed copy (RXM)

Meditech 2011

Pt friendly form

Pt friendly form

MeasurementORIGINALLY1) Outcome Measures• % unreconciled meds (Goal = 0%)• % of patients with ALL meds reconciled (Goal = 100%)2) Process Measure• % Compliance with use of the forms/process (Goal = 100%)

NOW1. % compliance: Med Rec Form (DMROF) Matches Home Med

List2. whether or not D/C’d meds at the Discharge are noted on

patient friendly list3. % compliance with Med list being provided for the next level

of care (SNF, rehab…)

Results

• We’ve reduced our rates of unreconciled home medications……from 26% to 0.6% on ADMISSION…from 23% to ~7% on DISCHARGE

• We’ve reduced our rates of unreconciled medications……from 12% to 4% on TRANSFER

• Improvement has been sustained with slight variations for 5 years.

2005 (Base-

line)

Q1 06 Q2 06 Q4 06 Q1 07 Q2 07 Q3 07 Apr-09 Oct-09 Apr-100%

20%

40%

60%

80%

100%

Medication Reconciled on Admission

Measurement (IHI website)

Feb Mar2011

0%

20%

40%

60%

80%

100%100%

90%

0%

94%100%

94%

Medication Reconciliation at the Discharge by Month (Feb and March of 2011)

% Med Rec Form Matches Home Med List% of Meds Discontinued on Discharge that are Noted on Patient's List% Med List was Provided to the Next Level of Care

Examples of Admission challenges:• Incomplete data collection despite one’s best attempt, poor historian and a new

patient, etc... (Much less of a problem in a closed system for majority of pts) Examples of Transfer challenges:• When an order is printed and faxed to the RX early, while additional orders are

actively being written for the same floor prior to the actual transfer• When the stop date on a time sensitive medication is not cited and the pt is

transferred with prolonged treatment period, erroneouslyExamples of Discharge challenges:• CII’s are written on a Blank by law. However, RXM (i.e., Meditech) is not updated

electronically 100% of the time throughout the system (time consuming and burdensome)

• MD may accidentally forget to DC duplication of therapy. Example: Pt comes in with a Med (documented on AMROF). The dose gets modified during the admit. Upon discharge, Meditech compiles home med in addition to inpatient meds to prepare DMROF and if not caught, it may create duplication of therapy. DMROF is faxed to retail pharmacy and this may or may not be identified as an error outside the organization

Medication Reconciliation, a continuous improvement process

Lessons Learned/Challenges

• Improvements must resonate with staff

• Make the improvement easy to do!

• Change should not be “extra work”

• Short, goal-directed meetings

• Define your “aim” before you start

• Set attainable goals, reach them and then expand

• No room for bias, be honest

• Plan the “spread” wisely• Identify your metrics early-

you can’t fix what you can’t measure

• Conduct small tests of change

• Collect valid, reliable, actionable data

• Interdisciplinary teams: Talent not Title!

• Invaluable: Include a patient in your team as a member (FMEA perspective)

IHI Global Trigger Tool• Harm vs Error• What is Harm?

“ Less than 4% of all adverse drug events involving use of rescue drugs are reported.”

Studies of medical services suggest that only 1.5% of all adverse events result in an incident report.

Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death. (Examples: post op infections, PCN-induced anaphylactic shock, etc… )

INCIDENT REPORTING

HARM

How do you measure harm?

1) Random chart sampling after the patient has been discharged 2) Clues

Global Trigger Tools Clues

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)

E Temporary harm, intervention required

F Temporary harm, initial or prolonged hospitalization

G Permanent patient harm

H Life sustaining intervention required

I Contributing to Death

CCRMC’s Pharmacy’s position

• 100% review of all rescue med use and formal report to MSC, P&T, PIC, and MEC separate from the IHI global trigger tool data

“So what?”• Trend, DUE’s, system redesign or system

changes, departmentally or institution wide, if and when necessary

What is the significance of Global Trigger Tools?

* It is used as a strategy to improve system in multitude of projects.

* This method will help us• DECREASE preventable hospital-acquired

conditions by the end of 2013, by 40%AND • Reduce hospital readmissions by 20% by the

end of 2013

Pledge of support-a CMS initiativeIn April of 2011, at the Region IX launch of the Obama Administration new initiative, the partnership for patient, our organization shared our accomplishments with public in presence of our Congressman George Miller,7th District of California Herb K. Schultz, Regional Director, HHS, Region IX, David Sayen, CMS Regional Administrator, HHS, and Joseph McCannon, Senior Advisor, Centers for Medicare & Medicaid Services, HHS

We Pledged that CCRMC and Health Centerswill: • Decrease by 40%, preventable hospital-acquired conditions by the end of 2013 • Reduce by 20% hospital readmissions by the end of 2013.

Delivery System Reform Incentive Payments

(DSRIP)

• Delivery System Reform Incentive Pool (DSRIP): The waiver includes the opportunity for public hospitals to receive up to $3.3 billion over five years through the Delivery System Reform Incentive Pool (DSRIP). This pool will be a subset of the Safety Net Care Pool.

• The DSRIP is intended to support California’s public hospitals’ efforts to enhance the quality of care and the health of the patients and families they serve

• CCRMC plan submitted to California Department of Health Care Services and Center for Medicare and Medicaid Services in Feb ,2011

• Participants: 17 public hospitals• A copy of all participants’ plans available on California Department

of Public Health website:Http://www.dhcs.ca.gov/provgovpart/Pages/DSRIP1.aspx

Delivery System Reform Incentive Payments (DSRIP)

Following our mission, we have developed the Delivery System Reform Incentive Payment Plan (DSRIP) to:

• Accelerate the building of an integrated approach to care that will improve the patient and caregiver experience

• Build a coordinated system of care

• Improve patient safety

• Reduce harm

• Increase preventative care services

• Improve care of at-risk-populations that are most vulnerable to health problems in our communities.

About DSRIP……

DSRIP (executive summary)Improvement Projects (Cateogory 1) 1. Increase Primary Care Capacity

2. Increase Training of Primary Care Workforce

3. Enhanced Interpretation Services and Culturally Competent Care

4. Collection of Accurate Race, Ethnicity, and Language (REAL) Data to Reduce Disparities

Improvement Projects (Category 2)5. Expand Medical Homes

6. Patient Experience of Care

7. Integrate Physical and Behavioral Health Care

8. Conduct Medication Management (Medication Reconciliation at Discharge)

Improvement Projects (Category 3)Undefined at the moment. TBA per CMS.Improvement Projects (Category 4)1. Improve Severe Sepsis Detection and Management2. Central Line-Associated Bloodstream Infection (CLABSI) Infection Prevention3. Surgical Complications Core Processes (SCIP)4. Hospital-Acquired Pressure Ulcer Prevention5. Stroke Management6. Venous Thromboembolism (VTE) Prevention and Treatment7. Falls with Injury Prevention

DSRIPDSRIP

DSRIP (Medication Management-MED REC at Discharge)

Contact Information

Shideh Ataii, Pharm.D.Director of Pharmacy ServicesContra Costa Regional Medical Center and ClinicsHealth Services Departmentsataii@hsd.cccounty.us(925) 370-5601

Extra Materials and resources

Elements of Performance for NPSG.03.06.011. Obtain information on the medications the patient is currently taking when he or she is admitted to the hospital or is seen in an outpatient

setting. This information is documented in a list or other format that is useful to those who manage medications.Note 1: Current medications include those taken at scheduled times and those taken on an as-needed basis. See the Glossary for a definitionof medications.Note 2: It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information

from the patient and/or other sources will be considered as meeting the intent of the EP.Define the types of medication information to be collected in non–24-hour settings and different patient circumstances. Note 1: Examples of non–24-hour settings include the emergency department, primary care, outpatient radiology, ambulatory surgery, anddiagnostic settings. Note 2: Examples of medication information that may be collected include name, dose, route, frequency, and purpose.2. Compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital in order

to identify and resolve discrepancies.Note: Discrepancies include omissions, duplications, contraindications, unclear information, and changes. A qualified individual, identified by

the hospital, does the comparison. (See also HR.01.06.01, EP 1)3. Provide the patient (or family as needed) with written information on the medications the patient should be taking when he or she is

discharged from the hospital or at the end of an outpatient encounter (for example, name, dose, route, frequency, purpose).Note: When the only additional medications prescribed are for a short duration, the medication information the hospital provides may includeonly those medications. For more information about communications to other providers of care when the patient is discharged or transferred,refer to Standard PC.04.02.01.4. Explain the importance of managing medication information to the patient when he or she is discharged from the hospital or at the end of an

outpatient encounter.Note: Examples include instructing the patient to give a list to his or her primary care physician; to update the information when medications

are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information at all times in the event of emergency situations. (For information on patient education on medications, refer to Standards MM.06.01.03, PC.02.03.01, and PC.04.01.05.)

TJC standards on Med Rec (effective 7/1/2011)

ReliabiityNolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)

Joint Commission Resources

(www.jcrinc.com)

SummaryContra Costa Health Services launched a medication reconciliation process at its county-owned hospital based on Institute for Healthcare Improvement (IHI) concepts for redesigning work to achieve a high degree of reliability. Contra Costa Health Services uses a process in which Providers, Pharmacy, and Nursing staff have standardized, easy-to-understand, and easy-to-execute roles related to medication reconciliation. Before instituting the program, it was "everyone's job" to collect information on a patient's home medications, which led to confusion, and often home medication information "fell through the cracks." The program has allowed Contra Costa Health Services to nearly reach its stated goals of having no unreconciled medications at transition points (admission, transfer, discharge) and achieving 100 percent adherence with form usage. Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics related to medication reconciliation, with baseline and post-implementation data coming from chart audits.

AHRQInnovation Profile: Low -Tech Medication Reconciliation process emphasizing standardized,

easy to execute roles significantly reduces rates of unreconcilied medications

Preventing Readmissions

• Focus on preventing readmissions (CHF)• Using LEAN/Kaizen (many examples

throughout the organization)• It is NOT: hospital ‘project’• It is: system way of functioning• Goal: using best practices for rapid

adaption/adoption in our system

Our Approach

• Bundle of 5 triggered at Dx– CHF order set– Patient education process– Interdiscpilinary teaching plan– Discharge appts made at time of admission!– CHF Discharge Nurse

CHF Discharge Nurse

• Twice weekly phone calls to patients – First call within 72 hours of discharge

• Real time ongoing medication reconciliation of all meds

• Education• Transportation assistance• Triage

CHF Nurse Ask the patient: Since leaving the hospital.• How is your breathing?

Can you lay flat without shortness of breath? Are you coughing more? Have you gained weight? If yes, how many pounds Are you more dizzy or light headed?

Do you have worsening chest pain?

Green Zone All Clear – This zone is your goal. Your systems are under control

You have• No shortness of breath.• No weight gain more than 2 pounds (It may change 1 or 2 pounds).• No swelling of your feet, ankles, legs or stomach.• No chest pain.

Yellow ZoneCaution: - This zone is a warning. CALL YOUR DOCTOR’S OFFICE IF: • You have a weight gain of 3 pounds or more in 1 day or a weight gain of 5 pounds or more in 1 week.• More shortness of breath.• More swelling or your feet, ankles, legs, or stomach.• Feeling more tired. No energy.• Worsening cough. • Dizziness.• Feeling uneasy, you know something is not right.• It is harder for you to breathe when lying down. You need to sleep sitting up in a chair.

Red EMERGENCYGo to the emergency room or call 911 if you have any of the following:

• Struggling to breath. Unrelieved shortness of breath while sitting still.• Have chest pain that is different or stronger than normal or usual.• Have confusion or can’t think clearly.

CONTRA COSTA HEALTH SERVICESCONTRA COSTA REGIONAL MEDICAL CENTER

Congestive Heart Failure (CHF) Nurse ToolCHF NurseCall all new CHF referrals received by fax twice a week on Tuesday and Friday:

•Assess Clinical Condition (see attached): Red Zone Advised patient to go to ED and Notified ED (370-5973) Yellow Zone Made appointment within 24 hours ---- OR--- Do green zone assessment below and call medicine dept. on call MD to consult.

• Green Zone – Initiate discussion with patient or caretaker•Ask patient “teach back” questions:

What gain is concerning enough that you should report to your doctor? What foods should you avoid? Do you know what symptoms to report to your doctor?

•Review medications: “Were you able to get prescribed medications after you left the hospital?” “Do you have the list of medicines they gave you when you left the hospital?” “What is the name of your water pill(s)?” Does patient have medications? Yes No

Medications Refaxed /called to __________________________ pharmacy•Does patient administer own medications? Yes No

Medications reviewed with patient/family member_____________•Reinforced “Daily Activities” (daily wt., law-salt diet, activity as tolerated)•Review Appointment(s):

Patient/family member aware of follow-up appointment(s) ____________________________________________________________________________________________________________________ Referral made to Social Worker (925)370-5480 for transportation issues.

Appointment with Patient Educator made (next available):___________________________________•Other Intervention:

_________________________________________________________________________________________________________________•Follow up:

Low Risk Patient: Chart check to make sure patient made follow-up appt. High risk Patient (any patient requiring consultation with MD or not clear on any items on patient assessment): Chart check for repeat phone

call 3 to 5 days.

Our paper Pediatric Admission Medication Reconciliation Order Form

What’s wrong with just studying errors?

• “We found that less than 4% of all adverse drug events involving use of rescue drugs were reported.”

Schade, Am J Med Qual. 2006 Sep-Oct;21(5):335-41

• Studies of medical services suggest that only 1.5% of all adverse events result in an incident report.

O'Neil A,. Ann Intern Med 1993;119:370-376

Pearls

Find and tell the stories...share…….They exist….They’re powerful ….They’ll engage people

Where we were….

Medication Reconciliation: 2005 - 2007

Inpatient Admission

Admit Transfer Discharge

ED Visits Outpatient Visits