Making A Title Slide

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Medications At Transitions and Clinical Handoffs
(MATCH) Multi-disciplinary Team Approach to
Medication Reconciliation
Presented to AHRQ Attendees AHRQ 2007 Annual
Conference September 27, 2007 By Kristine
Gleason, RPh Quality Leader, Clinical Quality and
Patient Safety
Supported by a grant from the Agency for
Healthcare Research and Quality (AHRQ) 5 U18
HS015886
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Discussion Overview
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.

• 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

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What is Medication Reconciliation?
Medication reconciliation impacts all patients at
NMH who receive medications

• A systematic process to decrease medication
  errors and associated patient harm by
• Obtaining, confirming and documenting the
  patients 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

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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 Womens Hospital Opening October 20,
  2007

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Getting Started or Moving Forward

• Organizational Risk Assessment
• Operational Component
• Research Component
• Collaboration
• Support

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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
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Designing a Multi-Disciplinary Approach
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Medication Reconciliation Improvement Initiative
Multi-disciplinary team approach - physicians,
nurses and pharmacists

• 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 gt90 compliance at admission and
  discharge to meet
• The Joint Commission requirement

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Medication Reconciliation One Source of Truth
for All Medications (Inpatient and Outpatient)
HEALTHCARE PROFESSIONAL
PATIENT
MEDICAL RECORD
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Built in Forcing Functions - Admission Order Set
Med Rec Integrated within Physician Admission
Order Set
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Built in Forcing Functions Physician PowerForm
Example
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Built in Forcing Functions Cont. Nurse /
Pharmacist PowerForm Example
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Standardized Process - Procedural Areas and the
Emergency Department
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Education, Training and Feedback
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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

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Critical Thinking Clarifying Discrepancies
Identified During Reconciliation
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. Patients 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 patients plan of care i.e., information gathered during rounds, based on a review of the physicians history and physical (HP) and progress notes, based on communication/handoffs in preparation for discharge, etc. Antibiotics started for infection As needed medications ordered for pain/fever Pre-admission doses of patients blood pressure medications changed due to hypotensive episodes Warfarin and aspirin held for a procedure Formulary substitution No
Unintended Discrepancy Discrepancies exist and require clarification of intent because there is no supporting documentation or explanation based on the patients current clinical condition or care plan. The patient takes her blood pressure medication twice daily at home but its ordered only once daily in the hospital. No indication for frequency change and patients current blood pressure slightly elevated. Patients 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.
Adapted from Gleason et al. Am J Health-Syst
Pharm. 2004 611689-95.
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Medication Reconciliation Results Adherence to
Process
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Medication Reconciliation Results - Admission
Mandatory Training Program
Definition Documented compliance with
recommended Medication Reconciliation upon
inpatient admission (physician, nurse, and/or
pharmacist)
Definition Documented compliance with
recommended Medication Reconciliation upon
outpatient arrival (includes 20 departments)
A
D
M
C
I
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Medication Reconciliation Results - Discharge
Definition Documented compliance with
recommended Medication Reconciliation upon
discharge (physician and nurse)
Definition Documented compliance with
recommended Medication Reconciliation at
discharge (physician and nurse)
A
D
M
C
I
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Medication Reconciliation ResultsMulti-disciplina
ry Team Approach at Admission
Medication Reconciliation Electronic Audit Medication Reconciliation Electronic Audit Medication Reconciliation Electronic Audit Medication Reconciliation Electronic Audit Medication Reconciliation Electronic Audit Medication Reconciliation Electronic Audit
Randomly 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
A
D
M
C
I
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Continued Focus on Patient Safety
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Assessing the Quality of Medication
Reconciliation
Goal To eliminate avoidable adverse drug events
and associated patient harm due to medication
discrepancies.

• 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).
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MATCH Toolkit - www.medrec.nmh.org
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Questions, Answers and Discussion
Kristine Gleason, RPh Quality Leader, Clinical
Quality and Patient Safety Northwestern Memorial
Hospital, Chicago, IL kmgleaso_at_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