1. 1 Coordinating Institution Wide Implementation of Medication Reconciliation: Tips, Strategies & Lessons Learned Coordinating Institution Wide Implementation of Medication Reconciliation: Tips, Strategies & Lessons Learned March 25, 2009 Safer Health Care Now! National Webinar / Teleconference March 25, 2009 Safer Health Care Now! National Webinar / Teleconference Olavo Fernandes PharmD, FCSHP Pharmacy Clinical Site Leader, University Health Network Assistant Professor, Univ of Toronto and Safety Specialist, ISMP Canada Interdisciplinary Members of UHN Medication Reconciliation Task Force Image: green.gps.caltech.edu/pictures_images/GreenTree.jpg

2. 2 What has your medication reconciliation implementation journey in your ER been like ? OR

3. 3 Objectives 1.Highlight strategies for overcoming challenges to successfully implement medication reconciliation at various interfaces 2.Share coordination tips/ lessons learned to prepare your organization to meet medication reconciliation requirements 3.Outline the key elements of an organizational communication plan and clinician/ leadership resource package for medication reconciliation

4. 4 How do we Navigate the Challenges of Effectively Meeting Accreditation Requirements for Medication Reconciliation ?

5. 5 How do we actually “get started and sustain” implementation? Five Tips & Strategies 1.People – Empowering Clinicians 2.Coordination 3.Communication 4.Leadership 5.Tools / Systems to Support the Clinicians

6. 6 How do we actually “get started and sustain” implementation? Leadership Coordination Communic atio n People Tools/ Systems Five Tips & Strategies

7. 7 Challenges & Questions Who does the BPMH? Who does the BPMH? Who does the reconciliation/ resolving the discrepancies? Who does the reconciliation/ resolving the discrepancies? Proactive vs. Reactive Multidisciplinary practice models ? Proactive vs. Reactive Multidisciplinary practice models ? – Proactive: BPMH → admission orders (AMO) →reconciliation check – Reactive/ Concurrent: primary history → AMO →BPMH →reactive reconciliation – Hybrid Systems Manual vs. Electronic Processes ? Manual vs. Electronic Processes ?

8. 8 Structured Implementation & Rollout Plan Step-wise Milestones for each Inpatient Clinical Area 1.ID stakeholders/ preliminary education 2.Formal education to unit/clinical area champions 3.Baseline admission reconciliation data collection 4.Creation of a team practice model 5.Finalize practice model – input from staff 6.Prescriber/ Nursing/ Pharmacist In-services 7.Start Front line implementation- Admission reconciliation 8.Sustain as part of daily practice with ongoing feedback and improvement

9. 9 Questions to Address As a Team Who?Who? –Who- in your local practice site, who responsible for BPMH? Reconciliation? Shared responsibility? Who does what? (MD/ RN/ Phmt/ Technician/ Students) –BPMH training: designated individuals or “organization-wide” How?How? –How are medication histories currently being conducted? Does med rec implementation involve building upon pre- existing practice or a major shift in practice Where?Where? –Decide where the BPMH is documented (visible to all staff, only useful if everyone knows where it is, can find it, can use it). –Will it be a pre-printed form/ computerized record/ clinical notes? S. Ingram BScPhm, ACPR, ED- TGH

10. UHN Clinician Validation Program Interactive Learning/ Education Session Interactive Learning/ Education Session Key Readings Key Readings Standardized Patient Validation Program Standardized Patient Validation Program – Obtaining BPMH from a standardized patient–actor – Admission reconciliation to identify discrepancies – Coding of discrepancies – Interactive discussion on areas of strength / improvement

11. 11 Getting Started/ Focussed Limited Resources Why is Medication Reconciliation so important in the ED ? “Gateway” to acute care admission and transitions in care “Gateway” to acute care admission and transitions in care “Opportunity” – ideally med rec performed as close to arrival/ decision to admit “Opportunity” – ideally med rec performed as close to arrival/ decision to admit – Family / medication vials & lists optimally available “Efficiency” – upstream reconciliation/ resolution improves safety/ saves times and resources downstream to subsequent transitions “Efficiency” – upstream reconciliation/ resolution improves safety/ saves times and resources downstream to subsequent transitions “Shared Responsibility” – ED/ Admitting services; all health care professionals – physicians, nurses, pharmacists, allied health and patients “Shared Responsibility” – ED/ Admitting services; all health care professionals – physicians, nurses, pharmacists, allied health and patients S. Ingram BScPhm, ACPR, ED- TGH/

12. 12 Synchronization Challenge of Discharge Tools at Many Institutions Patient Care System Dear Dr Letter EMITT Letter Patient schedule Discharge Prescription Patient Wallet card J. Wong BScPhm ManualElectronicElectronic

13. 13 Multidisciplinary Practice Model Challenges of Medication Discrepancies MD RNRX

14. 14 EMITT2: Schematic of Structured, Multidisciplinary Integrated Medication Reconciliation Strategy Wong J. [Abstract] Pharmacotherapy 2006 ;26: 106 BPMH medical chart note Primary Medication History: MD or RN Admission Reconciliation ER Ward BPMH: Taken by pharmacist 1

15. 15

16. 16 Medications may be altered: new, adjusted, discontinued Ward Decision to discharge patient BPMDP Home Synchronized Outputs Discharge Reconciliation Electronically Generated Prescriptions Medication Information Transfer Letter Patient Medication Grid Patient Medication Wallet Card 2345 Best Possible Medication Discharge Plan Physician Discharge Summary 6 Wong J. Annals of Pharmacotherapy 2008 (in press)

17. 17

18. 18 A. Cesta et al. Ann Pharmacother 2006;40:1074-81. Medication Information Transfer Letter

19. 19 Medication Information Transfer Letter

20. 20 Horizontal : Patient Medication Grid

21. 21 Vertical : Patient Medication Grid

22. 22 Patient Wallet Card

23. 23 Safer Health Care Now! National Measure For Discharge Medication Reconciliation 2007 %eligible patients discharged Team Target 80% TGH GIM * Graph does not include patients discharged without prescriptions * Sample Feb7 – May 17

24. 24 n= 6976 Patient Admissions

25. 25

26. 26 CPOE-BASED MED REC PRACTICE MODEL Baseline Data Evaluation Literature Review Multidisciplinary Feedback

27. 27 UHN Implementation & Rollout Plan 1.Admission Reconciliation Main priority for ALL inpatient areas Main priority for ALL inpatient areas 2.Transfer Reconciliation 3.Discharge Reconciliation 4.Ambulatory Clinics

28. 28

29. 29 Organization Wide : Leadership and Clinician Communication Formal Training of Champions Education/ learning session, required readings, standardized patient validation/ certification training Education/ learning session, required readings, standardized patient validation/ certification training Front-line education in-services: nurses, medical residents, medical staff nurses, medical residents, medical staff Other communication tools: - Paper or electronic chart notification of reconciliation status, promotional video testimonials, hospital intra-net website, posters Leadership presentations: - Accreditation team lead meetings, site operations meetings/ leadership forum, business units, selected medical rounds, multidisciplinary med rec task force - Board, Senior Management MAC, P&T, UHN Ops…..

30. 30

31. 31 UHN Medication Reconciliation Resource Package Includes: 1.UHN Medical Staff Bulletin 2.UHN Organization Wide Roll Out Plan for Inpatient and Ambulatory Areas Admission, Internal Transfer, Discharge, Ambulatory Clinics Admission, Internal Transfer, Discharge, Ambulatory Clinics 3.Step-wise implementation plan for each inpatient ward (admission reconciliation) 4.Medication Reconciliation Fact Sheets (accreditation ROPs and current overall status at UHN) 5.Communication tools : poster, medication reconciliation website on UHN intranet, link to educational video.....Continued Next Slide

33. Hospital Internet Communication

34. Hospital Internet Communication (continued)

35. 35 Includes: 6.Patient Information on Medication Reconciliation 7.Screen Shots: EMITT (electronic medication information transfer tool) 8.Sample documentation/ outputs: EMITT (electronic medication information transfer tool) EPR Medication Reconciliation Status/ BPMH note EPR Medication Reconciliation Status/ BPMH note Electronic reconciled discharge prescription, patient medication schedule, wallet card, medication information transfer letter Electronic reconciled discharge prescription, patient medication schedule, wallet card, medication information transfer letter 9.Clinician Tools: BPMH Tip sheet; Clinician BPMH Interview Guide BPMH Tip sheet; Clinician BPMH Interview Guide 10.Prescriber/ Nursing In-service Presentation Slides UHN Medication Reconciliation Resource Package

36. 36 How do we actually “get started and sustain” implementation? Leadership Coordination Communic atio n People Tools/ Systems Five Tips & Strategies

37. 37 Sample Tools in Guide

38. 38

39. 39

40. 40

41. 41

43. 43

44. 44

45. 45 Tools & Strategies on CoP BPMH guides/ trigger sheets BPMH guides/ trigger sheets BPMH Forms BPMH Forms BPMH leading to admission order forms BPMH leading to admission order forms Patient Risk Assessment / Scoring Patient Risk Assessment / Scoring Instructional Videos Instructional Videos Empowering patients as part of the BPMH process Empowering patients as part of the BPMH process

46. 46 Medication Reconciliation in the Ambulatory Clinics ISMP Canada / O. Fernandes UHN

47. 47 Ambulatory Clinic Medication Reconciliation Meetings with Ambulatory Clinic Leaders/ Clinicians Review models/ tools already in place Review models/ tools already in place Most clinics do not have pharmacists- will need to consider mainly nursing/ prescriber based models Most clinics do not have pharmacists- will need to consider mainly nursing/ prescriber based models Nephrology model – recently updated Nephrology model – recently updated Presented to UHN Med Rec Task Force & Ambulatory Working Group for feedback Presented to UHN Med Rec Task Force & Ambulatory Working Group for feedback Recognition: different types of clinics (chronic care, procedural, different health care professional mix) Recognition: different types of clinics (chronic care, procedural, different health care professional mix)

48. 48 Considerations: UHN Ambulatory Medication Reconciliation Practice Model Clinic Chart Med List Client BPMH on visit Updated Clinic Chart Med List Discrepancies identified Review and follow up where indicated Nurse As applicable Other Healthcare Professional Tools: Paper? (e.g. HD clinic model) Electronic? (e.g. OTTR) Other? Phmt

49. 49

50. 50 Practical Tips to Sustain Med Rec Kim Streitenberger RN, The Hospital for Sick Children, Oct 2008 1.Consider sustainability & spread from the moment you start developing the med rec process in your pilot area 2.Consider change fatigue & competing local & corporate initiatives 3.Embed intervention in existing processes e.g. med rec form doubles as order form 4.Identify frontline med rec champions to provide direct implementation support 5.Make it difficult for people to revert to “old ways” of doing things 6.Provide visible leadership support 7.Share results with patients, families & staff

51. 51 Take Home Messages Consider Five Strategies for implementation Consider Five Strategies for implementation – People- empowering clinicians – Coordination – Communication – Leadership – Tools & systems Involve all team members in developing processes designed for everyday practice Involve all team members in developing processes designed for everyday practice Incorporate tools, systems, clinician education programs and strategies Incorporate tools, systems, clinician education programs and strategies Use data and ongoing performance to drive and inspire change Use data and ongoing performance to drive and inspire change

52. 52 More: Tips from Front Line Clinicians: Develop a system/ practice where clinicians “could not imagine going back to old practice” Develop a system/ practice where clinicians “could not imagine going back to old practice” Physician engagement: Physician engagement: – Involve physicians right from the beginning in the planning process – “buy in” vs. “ownership” – Value added / Time saving – medication reconciliation engrained into everyday practice – Efficicincies : BPMH form that leads to MD orders – Show the local patient safety impact in your ED (SHN data collection) – Share your data regularly and visibly Site Visits- Successful Teams and Colleagues Site Visits- Successful Teams and Colleagues – How are medication histories currently being conducted? Does med rec implementation involve building upon pre-existing practice or a major shift in practice S. Ingram/ J. Volling/ O. Fernandes UHN

53. 53 More: Tips from Front Line Clinicians: Involve Patients! Involve Patients! – patient satisfaction/ engagement – enjoy/ empowered when they are participating in care, – instills confidence in their care); patient-friendly brochures, posters and forms to document medications Know the limitations of your medication information sources/ systems? Know the limitations of your medication information sources/ systems? – DPV viewer – insurance database- not actual patients doses and frequencies Upstream ED reconciliation Upstream ED reconciliation – empowers admitting services to optimally perform discharge reconciliation – Synchronize/ coordinate with ward clinicians Make the best of what is already out there/ tested tools & strategies: Make the best of what is already out there/ tested tools & strategies: – BPMH form to MD orders samples, pre-printed orders, BPMH interview guides, education and training programs, in-services, Posters & videos S. Ingram/ J. Volling/ O. Fernandes UHN

54. 54 Questions olavo.fernandes@uhn.on.ca