Medication Reconciliation at Hospital Admission Using a Six Sigma Approach OSF Saint Francis Medical

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Medication Reconciliation at Hospital
AdmissionUsing a Six Sigma Approach OSF Saint
Francis Medical CenterPeoria, Illinois

• Howard Cohen MD
• Patient Safety Officer
• May 15, 2003

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OSF Saint Francis Medical Center

• 721 beds, 24 patient care units
• Tertiary center with 425 physicians and 165
  residents
• Level 1 Trauma Center
• Perinatal Center
• Pediatric Critical Care Center
• 70 admissions/day
• 30 via ED
• Involved in several Medication Safety
  Collaboratives
• In the midst of IDX rollout

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Include Rx from All specialists
Documentation Collaboration Involve Patients
Include OTCs Herbals
Admission List Available throughout hospitalizatio
n
Understanding Medication Reconciliation
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Initial Work in Corporate Patient Safety
Collaborative

• July, 2001-February, 2002
• Focus across entire hospitalization
• Quantum Leaps Project Replication
• IHI methodology

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Issues

• Lack of understanding of what reconciliation
  means
• Not sure how to measure
• Whether it happens
• How is it related to Adverse Drug Events?
• Broad scope
• Use of the form
• Administrative priorities not clear
• Accountability

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Evolution of 6 Sigma at OSF Saint Francis Medical
Center

• Intensive Study of 6 Sigma
• SFMC-Caterpillar Partnership for 6 Sigma
• First projects identified in February, 2002
• Medication Reconciliation on Admission as first
  patient safety project

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6 Sigma Infrastructure

• Administrative Team
• Determine Critical Success Factors
• Determine Strategic Areas of Improvement
• Steering team determines projects
• Project leadership team
• Assure resources
• Remove obstacles
• Review and reflect
• Assure spread
• All Hold themselves accountable

• DMAIC/ DMEDI methodology
• Communicate
• Pilot (test and learn)
• Recommend Solutions

• Black belts and team members
• Project sponsor
• Process owner
• Financial Representative (FREP)
• Management infrastructure
• Developing 6 Sigma capability
• Department (budget and capital)
• System for spread

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Comparison of Different QI Terms
MEASURING
DEVELOPING AND TESTING SOLUTIONS
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Project Goals

• Collect a complete list of medications that each
  patient was taking before admission Target 75
• Physician will document reconciliation of each
  medication on admission that the patient takes at
  home Target 75
• Reconciliation Process will be complete by 6
  hours after admission Target 50
• Timeline to complete project in conjunction with
  6 sigma training
• Started February, 2002

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Operational Definition

• Medication History
• Complete and accurate record of medications taken
  at home. For each item it includes name of
  drug, dose, frequency, route and last dose taken.
  
• For Pediatric patients concentration for elixir
  medications and mg/kg/dose

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Project Scope

• Includes All inpatient and observation
• admissions, including children and adults
• Excludes Newborns and outpatients
• Process Start Arrival on patient care unit
• Process Stop Completed medication
• history list and each medication is reconciled

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Medication Reconciliation Process

• Medication history is complete
• Includes name, dose, frequency route
• Dose last taken (date and time)
• Physician
• Reviews and acts upon prior medications
• Documents response
• Writes medication orders
• Pharmacy
• Reviews medication history
• Verifies physician orders
• Enters the order in the computer

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Our Team

• David Gorenz MD
• Deployment Champion
• Tim Miller MD
• Business Leader
• Howard Cohen MD
• Project Sponsor
• Jerry Storm R.Ph.
• Sharon Kauzlarich
• Financial Rep

Becky Hart RN, ED Sara Rusch MD, Chair Dept. of
Medicine
Mary Buis RN, 2700
Vickie Anderson RN, Pediatrics LeAnn Hagaman
RN, IMSU
Cassy Horack, Black Belt Suzette Swanson CCM,
Green Belt Nancy Minesinger CCM, Green Belt Ryan
Taylor Pharm D, Green Belt Ara Peterson RN,
Surgery, Green Belt
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Meetings

• Team Meetings
• Bi-weekly
• 2 hours each
• Leadership Meetings
• Weekly
• Deployment Champion
• Business Leader
• Project Sponsor
• Process Owner
• Black Belt
• Project Update Meeting
• Weekly
• Project Sponsor
• Black Belt

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Initial Project Findings

• Process is diffuse
• Patient is asked the same question multiple
  timesthis has a link to patient satisfaction
• Multiple forms are used
• Medication history is found in multiple areas on
  the chart
• Lacks consistency in what is documented related
  to medication history
• Medication reconciliation process really does not
  exist in the hospital

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6 Sigma Medication Reconciliation
ProjectBaseline Data Medication History Complete
1.36 Sigma
0.21 Sigma
Nursing N 550 medications Physician N 592
medications
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6 Sigma Medication Reconciliation Project Nursing
Physician Medication History Information
Match n592 medications
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6 Sigma Medication Reconciliation Project
Medication Cycle Time--Baseline
Audit (Medication History Complete, Orders
Written, and Medication Entered into Pharmacy
System) n317 medications
Median 8.7
Mean 33
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6 Sigma and the Voice of the Customer

• Surveyed MDs, RNs, Pharmacists
• Design a process that is Easy to Do Business
  With
• Wanted process complete within 2 hours
• Wanted formulary substitutions to be visible at
  time of discharge

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Process Design

• Partnership with OSFMG Sisters Community
  Clinic
• Wallet cards
• Medication Bags to bring pill bottles to hospital
• Know Your Medications Posters
• Developed Medication Reconciliation and Amendment
  Forms
• Developed Scripting Tips sheet
• One Form in One Location
• Emergency Department
• Know Your Medications Poster
• Send patients pill bottles to the nursing units
• Wallet Cards

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Process Design other aspects

• Survey of other institutions
• FMEA

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Pilots

• TIHU
• Emergency Department

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6 Sigma Medication Reconciliation ProjectPilot
Data Medication History Complete
0.33 Sigma
2.11 Sigma
3.52 Sigma
Pre-Pilot N 50 medications Pilot N 507
medications ED Pilot N 232 medications
For TIHU data, P 0 (Chi Square)
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6 Sigma Medication Reconciliation ProjectPilot
DataDose Last Taken Documented
0.43 Sigma
2.33 Sigma
2.49 Sigma
Baseline N 550 medications Pre-Pilot N 20
medications Pilot N 444 medications ED Pilot
N 231 medications
For TIHU data, P 0 (Chi Square)
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6 Sigma Medication Reconciliation
ProjectBaseline and Pilot Data Physician
Documented Reconciliation
1.77 Sigma
0.14 Sigma
Baseline N 592 medications Pilot N
51medications
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6 Sigma Medication Reconciliation Project
Medication Cycle Time--TIHU pilot (Medication
History Complete, Orders Written, Reconciliation
Documented and Medication Entered into Pharmacy
System) n192 medications
Mean 5.6
Median 2. 5
P 0 (by ANOVA and T test) Difference 27.46
(95 CI 18.31 and 36.62)
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Implementation (and Control)

• Identified Process Owner and Sub-Process Owners
• House-wide implementation
• Control Plan
• Project Turnover
• Measurement
• Contingency Plan
• IDX Implementation
• Incorporation of Medication Reconciliation
• Next reconciliation Projects

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Implementation On Hospital Units

• Nursing Unit Staff
• Unit posters
• Education provided to managers and educators of
  each patient care unit
• Detailed education packet
• Educational poster display
• Educational flyers in staff restrooms

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Implementation Medical Staff and Pharmacy

• Physician
• Presentations at Medical Staff Committee Meetings
• Educational flyers
• Dictation cubicles Restrooms
• Mailbox
• Offices
• Pharmacy
• Staff meetings
• Educational poster display
• Educational information
• mailbox and email

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6 Sigma Medication Reconciliation
Project-TIHUMedication History CompleteControl
Phase Measurement
0.33 Sigma
2.11 Sigma
2.95 Sigma
2.93 Sigma
Pre-Pilot N 50 medications Pilot N 507
medications Post-Pilot 1 N 96 medications Post
Pilot 2N 288 medications April N 33
medications
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6 Sigma Medication Reconciliation ProjectPilot
DataDose Last Taken Documented
0.43 Sigma
2.33 Sigma
3.11 Sigma
2.59 Sigma
Pre-Pilot N 20 medications Pilot N 444
medications Post-Pilot 1 N 94 medications
Post Pilot 2 N 276 medications
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6 Sigma Medication Reconciliation
Project Physician Documented Reconciliation in
TIHU Control Measurement
1.77 Sigma
2.88 Sigma
0.14 Sigma
Baseline N 592 medications Pilot N
51medications Post Pilot N 82 medications April
2003 N 33
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Cycle Time Measurement
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Conclusions

• Six Sigma Process allowed us to successfully
  implement new process of medication
  reconciliation on admission
• More complete medication history
• Viewed favorably by all
• Allows pharmacy new view of patients home meds
• Labor and resource intensive

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Barriers

• Resources
• Pharmacy Resources in the ED
• Culture
• Bureaucracy
• Complexity of Communication
• Issues of accountability
• Lack of teamwork

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Lessons Learned

• 1. Would have used small workgroups to work on
  pieces
• of the projectthen have the workgroup report
  back to
• the team during team meetings. We lost a lot
  of time in
• team meetings debating and discussing issues
  that we
• could have handled this way.
• 2. Keep VOC survey small (dont ask too many
  questions, overwhelming to the customer)
• 3. Set longer team meeting times
• 4. Could have been ready with discharge piece
  sooner so team could continue with work
• 5. Should have included Nursing Leadership more
  intimately

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Unanswered Questions

• How accurate is the information?
• Will reconciliation improve the accuracy of the
  information?
• Are there better models?
• Will reconciliation help prevent medication
  errors and ADEs?