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Medication Reconciliation: whose job is it anyway?

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Presentation on theme: "Medication Reconciliation: whose job is it anyway?"— Presentation transcript:

1 Medication Reconciliation: whose job is it anyway?

2 Why a Multidisciplinary approach?
Limitations identified in ‘pharmacists only’ approach Baseline data from June 2010 showed pharmacists could reconcile medications for 35% of patients within 48 hours (gold standard is within 24 hours) Insufficient pharmacists to complete and sustain medRec If pharmacist’s sole focus could compromise other medication safety activities. Gaps in medRec process would occur after hours and weekends Address by targeted intervention of complex patients only? We realised that at POW, this needed to be a multidisciplinary initiative. Baseline data from June 2010 showed pharmacists could reconcile medications for only 35% of patients within 48 hours (gold standard to ensure patient safety is within 24 hours) This data was only collected on aged care wards; rough data showed these units have among the highest levels of med rec performed in the hospital and hospital-wide data was suspected to be even lower. Also, there are not enough pharmacist resources to complete and sustain medication reconciliation at all interfaces. If this was pharmacist’s sole focus other medication safety activities could be compromised And may leave gap after hours and weekends An option to address this, could be targeted intervention of complex patients only, but our patient demographic is predominantly elderly, sick and often from a CALD background i.e. all complex and therefore would not make much difference. And so a multidisciplinary team approach was implemented on admission.

3 Initial Training: January 2011
Pharmacy High 5 team developed a presentation Presented to pharmacists and High 5 core group: “Train the trainer” Best Possible Medication history taking Med Rec process Compulsory attendance Resources provided to train/teach ward staff. Training Road shows – ward based training Identified unit-specific processes Grand/ ICU rounds Pharmacy High 5 team developed a presentation based on resources from High 5 website, Canada, Commission We trained pharmacists and core group members on medication history taking and Med Rec process (compulsory attendance). Showed them the resources that they would use to teach their ward staff. We took ‘Training Road shows’- to the wards. Pharmacy team set up a timetable for High 5 members to attend ward training with each of the ward pharmacists. Included all Nurses and Clinicians based on the wards. During the roadshows on the wards we asked the ward pharmacists to include data relevant to their areas, e.g. incident reports from their departments etc. We had to be confident that the pharmacists were well trained enough to “sell” the concept to their ward teams. Often difficult to get a good turn out to the ward trainings – we enlisted the help of Nurse Educators, NUMs etc. Did numerous sessions on most wards.

4 Ongoing Training JMO, Registrar and Resident training
Occasional ward based training Secured additional training slots in orientation program Medical Intern Pre-registration workshop Pharmacist orientation New grad nursing awareness training Training started at the same time as new JMO, Registrar and Resident intakes; we secured increased training slots in their orientation programs to introduce the process. Nursing & pharmacy orientation

5 Patient Safety Culture in our hospital
2010 Patient safety culture survey: ED & Geriatrics 2011: Multidisciplinary approach of High 5 Initiative (60%) eMR commenced in ED (~25%) 2014: Patient safety culture changed for the better? A survey in 2010 that looked at the patient safety culture in our hospital showed that the biggest single problem identified within JMOs was that ‘things fall between the cracks when transferring patients from one unit to another.’ In 2011, we implemented the Hi 5’s project, with the hope that our multidisclipinary approach would improve our hospital patient safety culture. We had a good outcome measured in the initial stages, however certain challenges came in along the way, such as implementating electronic medical records in ED, so now, after 4 years of implementation, we wanted to know whether our approach to Medication reconciliation involved the multidisclipinary team and was everybody aware of this process? Was it helping or hindering or was there a lack of awareness or other barriers we weren’t aware of? Was it just pharmacists still conducting MedRec and utilising the Medication management plan form?

6 2014 Survey: Objectives: Question Design Primary:
Do clinicians understand the importance of Medication Reconciliation: who, how and why? Secondary: Were there any barriers to implementing this change Can these barriers be overcome or resolved? What is your current staff position/specialty? Demographic Questions If there is no documented medication history or MMP in the patient notes, what would be your next course of action? Multiple choice & ‘Free text’ Questions What impact does the MMP have on your clinical decision making? Extremely/Very/Moderately/Slightly/No significant impact Rating scale In your experience, have there been any barriers to completing or recording information on the MMP? Removed bias This is where it led to our recent survey, our primacy objective to assess whether our clinicians understand the importance of Medication Reconciliation, who is responsible for it, how to do it and why it is important? Our secondary objectives were to identify any barriers to implementing this change, and whether or not these could be overcome or resolved?

7 Method 2 Study sites: POWH, Redlands
Study group: Doctors, pharmacists and nurses Collected data for 7 days via Paper forms ‘Survey monkey’ link Supported by Directors of Clinical Services/Nursing/Pharmacy Survey respondents remained Anonymous

8 Results: Demographics
Staff position Approx. Staff Population Population that responded (%) n = 138 Doctors (JMOs & SMOs) 400 49 (12%) Nursing 1200 65 (5%) Pharmacists 32 24 (75%) This slide summarises the demographics of our study group at POWH. 12% of the doctor population (included JMOs & SMOs), 5% of the nursing population and 75% of the pharmacist population responded to this survey. Out of the total 138 responses, almost half were nursing, 36% were doctors and only 17% were pharmacists. We tried to get a broad spectrum of clinicians from all specialties at our hospital (where the MMP had been implemented), and as you can see, the wards with high medication use (eg. Cardiology, Geriatrics, ICU, Medical oncology, Neurology/Stroke & Spinal) had a good response rate.

9 Results: Education/Training
Answer Yes No Did you receive any education/training? N = 133 (%) 62 (46.6) 71 (53.4) Was the education given at orientation sufficient? N= 106 (%) 58 (54.7) 48 (45.3) Sample Comments/suggestions: “I thought this was the role of the pharmacist? Any training would be useful” (Intern) “Wasn’t able to attend” (Registrar) “Online training, inservice, verbal discussion?” (RN) What this slide shows: Although 54% didn’t receive education at orientation, those that did receive education said it was sufficient. Quality of education was sufficient, but not always accessible

10 Who is responsible for completing the Medication Management Plan (MMP) form?
Team climate? Multidisciplinary?

11 What do you understand to be the main reason/s for Medication Reconciliation?

12 Safety Culture *Medication Management Plan Form = a tool used at POWH to conduct Medication Reconciliation

13 Overall Comments Clinician Comments Doctor
MMPs are very useful for JMOs! A good tool when available in patient notes It’s a great initiative, please keep it going Electronic would be great MMP has no significant impact on admission because it is not usually done on admission Nurse I have found the MMP helpful if I have difficulty reading the doctor’s handwriting and also for checking that doses are correct when the charts change over to the next one Some education would be good so we can use it more effectively on ward rounds It’s not the nurse’s role to fill out the MMP form-should be medical or pharmacist Pharmacist MMPs are very useful but time consuming Only Pharmacists are doing MMPs Increases workload for pharmacists Spectrum of good and bad

14 Discussion Identified barriers: Identified improvements: Limitations
Education reaching all stakeholders (frontline up) Time Documentation (electronic vs paper) Identified improvements: Patient safety culture awareness Multidisciplinary approach identified Limitations Identified barriers: Not reaching all stakeholders when we conducted education/training Time (both completing it, not a priority etc) Documentation processes Improvements/what we’re doing well: Safety culture awareness was evident amongst all clinicians (in that MedRec improves patient safety), and multidisciplinary approach identified but there still seems to be ambiguity surrounding who’s responsibility MedRec is Limitations: Unfortunate limited time to collect data, ‘snapshot’ Would have liked to have more Medical input & feedback (only 12% of doctors responded) and they’re the ones at the frontline Qualitative measure-only representing clinicians’ attitudes towards medication safety, not able to show that medication safety actually equates into a reduction of medication error rate. Need further studies to evaluate this.

15 Factors identified required for future success
Dedicated resources Strong multidisciplinary leadership Physician champion engagement Software that supports the High 5 SOP and Ongoing comprehensive staff education plan Change readiness of organisation Develop a comprehensive strategy to engage and involve senior clinical staff to understand their role and responsibility in advancing medRec in their department and across the organisation Development of electronic documentation tool that supports our medRec SOP Change readiness - organisation not as ready as we would have liked

16 A Doctor’s perspective

17 Doctors’ attitudes ‘We’re very busy’ ‘Can’t the pharmacists do it?’
‘It means writing everything out multiple times’ ‘What’s the point of it?’ ‘Why don’t we just wait until electronic prescribing comes in?’

18 Issues Capturing the correct audience to educate them that its everyones responsibility We are missing the middle level (staff specialists, VMOs etc) IT systems don’t speak to each other (or a mixture of paper and electronic notes) It requires a change in attitude- but support for change Senior staff don’t realise the importance of the process

19 Problem: Professional boundaries and established hierarchies may result in disagreements about where the responsibility for medicines reconciliation lies Solution: Focus on reducing the risk for patients and increasing the availability of timely, accurate information Any potential professional or hierarchical differences should be put aside to enable appropriately trained and competent healthcare professionals to take the lead

20 Problem: Competing demands and the common response that ‘the problem is too big — ‘we don’t know where to start’’ can be overwhelming for staff This can lead to delays in getting medicines reconciliation off the ground Solution: People need to be supported by managers to enable them to prioritise their workload simple structures should be put in place so that medicines reconciliation becomes part of the organisation’’s everyday work

21 There are no quick fixes, but this is a far from insurmountable problem A possible five-level hierarchy approach:

22 There are no shortcuts to breaking down silos.
You can’t fix the environment if the organization doesn’t understand the problem. You can’t improve the development process if the right environment doesn’t exist to enable healthy guidelines. Climb the pyramid brick by brick to the ultimate goal: better clinical outcomes through true collaboration.

23 Practicalities How do we ensure senior physicians care?
IIMS categorised into ‘med rec’ errors? Statistics on IIMS, Med rec compliance to individual departments/teams? League tables?? Grand rounds? Presentations of RCAs concerning medication errors? Using Accreditation- Standard 4 as a bargaining chip?

24 Involving Patients The value of involving patients and/or their carers in the medicines reconciliation process should not be underestimated Patients are a valuable source of information about the medicines they take and, with support, they can be encouraged and enabled to take a fuller and more active part in the process

25 Organisational approach
The profile of medicines reconciliation needs to be raised in all healthcare organisations The Chief Executive, senior management lead and board members of an organisation can help by promoting the uptake of medicines reconciliation Collaborative approach with other Australian hospitals involved Get process right before instituting eMM- detrimental to put bad stuff into a good system

26 Guess what? Its YOUR job!

27 Acknowledgements Survey question design & data collection: Ketty Rivas (Safety and Health Outcomes Officer) , Selina Boughton (Pharmacist) Survey promotion: POWH Pharmacists


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