2 Admission MedRec at Lions Gate Hospital Objectives:What is MedRec?Why do MedRec?How was MedRec implemented?Brief overview of Lean MethodologyHow Lean was used for implementationHow are we doing now?Audit ResultsWhat are key “lessons learned?”Impacts of MedRec
3 Admission MedRec at Lions Gate Hospital Ever wondered…Right medication?Right dose?Right time?Ask crowd:How many have been admitted to hospital?How many ever wondered how their medications are ordered?How many wondered whether they are receiving the right medication, with the right dose at the right time?This is the objective of MedRec – to ensure that the right home medications are re-ordered upon admission.
4 Admission MedRec at Lions Gate Hospital What is MedRec?Best Possible Medication HistoryReconciliation or ordering of home medications
5 Admission MedRec at Lions Gate Hospital What is MedRec?“Best Possible” Medication HistoryReconciliation (Orders)Regional MedRec form used by Vancouver Coastal sitesOrdering: Dr. makes his/her intentions clear about what to do with a patient’s home medications (e.g. continue per pharmanet, dc, etc., change dose, etc.)Pharmanet(Prescribed Drugs)
6 Admission MedRec at Lions Gate Hospital Why do MedRec?Did you know…“40-50% of patients on admission” are at risk of unintentional medication discrepancies?Medication errors may harm patientsOf these, 6% are at risk of harm serious enough to increase length of stay from 2-8 days2.MedRec aims to:1) Reduce unintentional discrepancies (discrepancies that can lead to medication error or patient hard, such as omissions, unintentional changes in doses, etc.)2) Reduce intentional undocumented discrepancies (e.g. Dr. intentionally changed dose, but didn’t document anywhere on chart. So, it creates additional workload for staff to clarify orders)This could mean:Patient harmLower quality of careReadmissionsAdverse effects on patient flowAdditional costs due to extended length of stay of 2 to 8 days
7 Admission MedRec at Lions Gate Hospital Why do MedRec?Some Local DataAt Lions Gate:About 38.8 daily admissions12.5 patients at risk of unintentional discrepancies0.75 patients daily at risk of staying 2 to 8 days longerAbout $246K additional costs per year(based on average cost of $450/patient/night)Emphasize MedRec is implemented only on admission…
8 Admission MedRec at Lions Gate Hospital Continuous improvement How was MedRec implemented?Lean is about…Maximizing ValueMinimizing WasteImproving QualityContinuous improvementAs a site, LGH chose to implement MedRec through the use of Lean Methodology.
9 Observe and Collect Data Steps to Achieving Continuous Improvement– sequence to approach the toolsObserve and Collect DataStandard WorkUnit Layout/ Cell Design (Flow)Mistake ProofingVisual ControlsOther tools to improve flow and implement pullContinuous Improvement-”Without Standards, there can be no improvement“ Taiichi OhnoThen:Improve the ProcessAnd Then:Repeat!Understand the Current StateFirst:Rather than thinking specific tools do not apply, consider if their concept can provide benefit.See for yourself & collect objective data that becomes the starting point for discussionsAdapted from Virginia Mason Lean Leader Certification Materials
10 VCH Improvement System Future State Development Current State Analysis Lean TollgateSustainmentAudit/RefineImplementation/Go-LiveUsed this tollgate was used to plan for the projectFuture State DevelopmentCurrent State AnalysisProject DefinitionLTS_VCH Improvement System_V1
11 Admission MedRec at Lions Gate Hospital Observations: Data Collection How was MedRec implemented?Observations: Data CollectionObserve the process and workflow in Admitting and the ED
12 Admission MedRec at Lions Gate Hospital How was MedRec implemented?Future State Value Stream MapTriageEmerg NurseEmerg DoctorAdmissionMRO printed for certain areas in EmergBPMH documented by RN or Pharmacist onMRP reconciles home medicationsMedRec Order (MRO) form processedMRO printed automatically for areas with “likely admits”; upon request for other ED areasStakeholder engagement:Engaged clinical nurse educators, admitting managers, physicians, pharmacists, and ED leadership teamGetting “process workers” to design future stateAdditional info: Lions Gate ED uses clindoc, which does not have the dedicated section for medication history
13 Admission MedRec at Lions Gate Hospital How was MedRec implemented?Standard Operating Procedures:WhoWhatUseful when:Variation in workPoor outcomes when training new staffInconsistent patient/worker satisfactionUnable to maintain previous improvementsIncludes:Sequence of tasks (who will do what),Best practices to complete the activity,The length of time it takesHowWhenWhy
14 Admission MedRec at Lions Gate Hospital How was MedRec implemented?Snapshot of the Standard work instruction disseminated to unit leaders and staffEnsures process is performed the same way – reduces variation and enables us to improve the process
15 Admission MedRec at Lions Gate Hospital Did not meet MedRec criteria How was MedRec implemented?Auditing and Breakthrough Lanes:Did not meet MedRec criteriaImplemented the use of Breakthrough lanes, which is a Lean tool used to track issues and develop action plan at the frontline level.Daily tracking sheet: Used to audit MedRec completion on a daily basis; used mainly by nurse educators or PCCs.Met MedRec criteria
16 Admission MedRec at Lions Gate Hospital How was MedRec implemented?Auditing and Breakthrough Lanes:Why did not meet MedRec criteria?Pareto Chart to track “common themes” or “common reasons” why MedRec is “missed”
17 Admission MedRec at Lions Gate Hospital How was MedRec implemented?Auditing and Breakthrough Lanes:Develop Action Plan to address the issues highlighted by the pareto chartMost units discuss MedRec issues at their safety huddles or staff meetings.Did not meet MedRec?Now what????
18 Admission MedRec at Lions Gate Hospital Organizational Targets How are we doing now?Organizational TargetsCompletion Rate75%BPMH CompletionReduction in unintentional discrepanciesReduction in undocumented intentional discrepanciesExplain the 2 types of discrepancies
19 Admission MedRec at Lions Gate Hospital How are we doing now?AreaQuantitative ResultsElective Surgery:Implemented on November 2011100% have complete, accurate medication histories100% receive post-op medication orders75% reduction in unintentional discrepancies85% reduction in undocumented intentional discrepancies
20 Admission MedRec at Lions Gate Hospital How are we doing now?AreaQuantitative ResultsEmergent/Direct AdmissionsImplemented on May 23, 201277.5% to 80% reconciliation rate (exceeded target of 75%)47.5% “best possible medication history” completion rate50% reduction in unintentional medication discrepancies55% reduction in undocumented intentional medication discrepancies
21 Average Completion Rate Comparison: Vancouver CoastalSiteAverage Completion RateSince ImplementationRichmond Hospital60%Vancouver General78%CoastalSquamish GeneralSt. Mary’s Hospital65%Powell River GeneralTBALions Gate HospitalData from Decision Support
22 Admission MedRec at Lions Gate Hospital How are we doing now?Examples of “good saves” and Qualitative Results…
23 MedRec Success Stories UnitGood saves…EmergencyMD ordered only one of patient’s home meds at half the dose the patient was taking. When med history was taken by RN, MD ordered the rest of home meds (5 pages were missed).PediatricsPatient’s Pharmanet only showed one medication. When BPMH was taken, patient was taking medication at a different dose than on Pharmanet and was also taking a number of other medications NOT on the Pharmanet.DaycareSurgical patient was seen in PSSU 2 weeks prior to surgery, but had filled other prescriptions since then. Daycare RN picked up on new meds when BPMH was done prior to surgery.
24 Admission MedRec at Lions Gate Hospital Address process issues first before implementing change(s)Risk managementEngagement and partnershipClear processSmall, incremental changesTry and try until you succeed!
25 Admission MedRec at Lions Gate Hospital Reference List:1 Canada. Accreditation Canada. Required Organization Practice. Ottawa: Accrediation Canada, Print.2 Canada. Optimizing Medication Safety at Care Transitions – Creating a National Challenge. Toronto: Print.
26 Admission MedRec at Lions Gate Hospital Thank you for listening! Questions???
27 Admission MedRec at Lions Gate Hospital What is MedRec?SystematicA systematic approach to taking the best possible medication history and reconciling home medications1A partnership between caregivers and patients/clients in order to obtain accurate medication information during various transitions of care1A conversation around medications taken at homePartnershipConversationFebruary 27, 2013
28 Admission MedRec at Lions Gate Hospital How was MedRec implemented?5 Steps to LeanThinkingSource: James P. Womack. Lean Thinking.February 27, 2013
29 Admission MedRec at Lions Gate Hospital Medication Management Address process issues first before implementing change(s)Staff engagement is key in refining the process (ensure future state works for process workers)These are some of the issues around medication management that MedRec highlighted. So, we worked or are actively working on resolving these issues, so that MedRec can be smoothly incorporated into people’s workflow.Paper flowAudit & RefineImplementFebruary 27, 2013