1. Manager Toolkit for the Medication Administration Process

2. Optimizing Medication Administration Project August SeptemberOctober December January Overview Progress Since Last Update Key Metrics Issues/Concerns/Roadblocks Linkage to BPE/BP/EFP: Safe and without error Problem: The current medication administration process is inefficient and prone to error. The current process requires many work steps (total process takes over 8 minutes) and multiple interruptions that cause workflow constraints and nurses not consistently verifying the “7 rights.” (right drug, patient, dose, time, route, rationale, documentation) As a result, there is a greater risk for medication errors. Further, our HCAHPS scores for communication regarding medication was at 58% “top box” in FY2008 (baseline). Goal/Benefit: Implement a standardized medication administration process which eliminates inefficient work steps, minimizes interruptions, prompts less log-ins, and improves bedside documentation in an effort to better use real-time information related to the 7 rights of medication administration, reduce errors, improve nurse productivity, and improve patient satisfaction scores to 59%. Phase 2: implement technology to enhance process Scope: Full house roll-out. Deliverables: – A safer and more efficient medication administration process – Decrease in medication errors Next Steps IC 7/31/09 Total medication errors Number of near misses Medication administration time HCAHPS Communication Regarding Medication Scores - Process finalized and approved by practice committee and medication safety committee (see attachment A) - Policy modified (see attachment B) - Education plan developed (see attachment C) - Sustainability (Control) plan developed (see timeline and attachment D) - Communicated policy changes and education plan to chairs of respective committees Executive Sponsors: Janney/Fennessy/Zoph Project Owners: Ashley Currier, Denise Anderson Sponsors: Payson/Dejuras//JacobsenImprovement Leader: Ryan Inlow Education must reach staff by August 31 st Contingency Plan– Check in meetings with managers (A/D/R) Adherence to expectations for non-compliance APhase 2 - Practice to approve policy (August 4 th ) - Education to approve roll-out plan (August 4 th ) - Education plan presented to managers (August 5 th ) - Workplan and expectations, Tools, Resources, Manager accountability plan - Policy roll-out (August 31 st ) - Quality Council to approve reg review additions (Sept 1 st ) (see attachment D) - Podcast out (September- Date TBA) - Unit to complete observations using paper form (September) - Unit to complete observations via regulatory review (October-ongoing) - DMAIC team to conduct staff interviews (September and October) - Staff to complete survey monkey (November- early) (see attachment E) - DMAIC team to f/u re: survey monkey results (November- late)

3. Medication Administration Process Implementation Manager Workplan August 2009 September 2009 October 2009 November 2009 December 2009 2010 Education (All RNs) 6 th -31 st check in with manager from team (Ashley, Denise and Ryan) 25 th Policy in effect 31 st Encourage Staff to view Sept. podcast Observations by units and DMAIC team (*use observation form) Unit check-in sessions with staff (Ashley, Denise and Ryan) Manager & leadership best practice discussion sessions (optional—dates TBA) Survey Monkey to staff (re: interruptions check in) Date TBA F/U with units re: survey results (Ashley, Denise and Ryan) Observations submitted via the regulatory review *ongoing—5 th of every month* F/U with units re: regulatory review data (Ashley, Denise, and Ryan) Unit check-in sessions re: action items from survey follow up (Ashley, Denise and Ryan) Launch Phase 2 (potential technology enhancemen ts/barcoding) Implementation Phase Control Phase

4. Education Roll-Out Plan Attend Manager meeting to discuss – New Policy changes (Main policy and Appendix D) – Expectations of manager to assist with education (using toolkit) – Copy of Policy *changes highlighted – Copy of Appendix D *modified – Talking points for managers – Changes to highlight – Expectations to discuss – Observation and reg review plan – Case Study ELM (in place of September M and M—tentative) – Interruption/distraction action item reminder and follow-up plan (survey) – Job Aid and Badge cards – Incorporation of observations into regulatory review – Observation form distributed – Unit check-in sessions (completed by DMAIC team) – Manager/leadership help sessions (coaching or observation assistance) – Survey Monkey out to staff re: interruptions/distractions check in

5. Staff Survey Control Phase Surveys will be completed by staff to acknowledge interruptions that are still occurring and the impact of these interruptions Survey questions include: In the past month: – My patients have had water at the bedside and available for medication administration. – I have had the dietary supplies that I need to administer medications. – I have had the medications available from the pharmacy. – I have minimal interruptions from the care team while passing medications. – The computer at the bedside was operational and ready to use during medication administration. – I have not been interrupted by the patient to attend to care needs such as turning, cleaning up or assisting to the bathroom during medication administration. – I have the equipment I need to administer medications such as infusion pumps and data scopes. These results will be reviewed with the units and/or DMAIC team and action items will result