Admission Medication Reconciliation at Lions Gate Hospital Introduce team Lean Transformation Services Laarnie St-Laurent, Lean Coordinator Lorelei Grosser, Lean Coordinator Carissa Looman, Lean Educator

Admission MedRec at Lions Gate Hospital Objectives: What is MedRec? Why do MedRec? How was MedRec implemented? Brief overview of Lean Methodology How Lean was used for implementation How are we doing now? Audit Results What are key “lessons learned?” Impacts of MedRec

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.

Admission MedRec at Lions Gate Hospital What is MedRec? Best Possible Medication History Reconciliation or ordering of home medications

Admission MedRec at Lions Gate Hospital What is MedRec? “Best Possible” Medication History Reconciliation (Orders) Regional MedRec form used by Vancouver Coastal sites Ordering: 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)

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 patients Of 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 harm Lower quality of care Readmissions Adverse effects on patient flow Additional costs due to extended length of stay of 2 to 8 days

Admission MedRec at Lions Gate Hospital Why do MedRec? Some Local Data At Lions Gate: About 38.8 daily admissions 12.5 patients at risk of unintentional discrepancies 0.75 patients daily at risk of staying 2 to 8 days longer About $246K additional costs per year (based on average cost of $450/patient/night) Emphasize MedRec is implemented only on admission…

Admission MedRec at Lions Gate Hospital Continuous improvement How was MedRec implemented? Lean is about… Maximizing Value Minimizing Waste Improving Quality Continuous improvement As a site, LGH chose to implement MedRec through the use of Lean Methodology.

Observe and Collect Data Steps to Achieving Continuous Improvement– sequence to approach the tools Observe and Collect Data Standard Work Unit Layout/ Cell Design (Flow) Mistake Proofing Visual Controls Other tools to improve flow and implement pull Continuous Improvement -”Without Standards, there can be no improvement“ Taiichi Ohno Then: Improve the Process And Then: Repeat! Understand the Current State First: 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 discussions Adapted from Virginia Mason Lean Leader Certification Materials

VCH Improvement System Future State Development Current State Analysis Lean Tollgate Sustainment Audit/Refine Implementation/ Go-Live Used this tollgate was used to plan for the project Future State Development Current State Analysis Project Definition LTS_VCH Improvement System_V1

Admission MedRec at Lions Gate Hospital Observations: Data Collection How was MedRec implemented? Observations: Data Collection Observe the process and workflow in Admitting and the ED

Admission MedRec at Lions Gate Hospital How was MedRec implemented? Future State Value Stream Map Triage Emerg Nurse Emerg Doctor Admission MRO printed for certain areas in Emerg BPMH documented by RN or Pharmacist on MRP reconciles home medications MedRec Order (MRO) form processed MRO printed automatically for areas with “likely admits”; upon request for other ED areas Stakeholder engagement: Engaged clinical nurse educators, admitting managers, physicians, pharmacists, and ED leadership team Getting “process workers” to design future state Additional info: Lions Gate ED uses clindoc, which does not have the dedicated section for medication history

Admission MedRec at Lions Gate Hospital How was MedRec implemented? Standard Operating Procedures: Who What Useful when: Variation in work Poor outcomes when training new staff Inconsistent patient/worker satisfaction Unable to maintain previous improvements Includes: Sequence of tasks (who will do what), Best practices to complete the activity, The length of time it takes How When Why

Admission MedRec at Lions Gate Hospital How was MedRec implemented? Snapshot of the Standard work instruction disseminated to unit leaders and staff Ensures process is performed the same way – reduces variation and enables us to improve the process

Admission MedRec at Lions Gate Hospital Did not meet MedRec criteria How was MedRec implemented? Auditing and Breakthrough Lanes: Did not meet MedRec criteria Implemented 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

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”

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 chart Most units discuss MedRec issues at their safety huddles or staff meetings. Did not meet MedRec? Now what????

Admission MedRec at Lions Gate Hospital Organizational Targets How are we doing now? Organizational Targets Completion Rate 75% BPMH Completion Reduction in unintentional discrepancies Reduction in undocumented intentional discrepancies Explain the 2 types of discrepancies

Admission MedRec at Lions Gate Hospital How are we doing now? Area Quantitative Results Elective Surgery: Implemented on November 2011 100% have complete, accurate medication histories 100% receive post-op medication orders 75% reduction in unintentional discrepancies 85% reduction in undocumented intentional discrepancies

Admission MedRec at Lions Gate Hospital How are we doing now? Area Quantitative Results Emergent/Direct Admissions Implemented on May 23, 2012 77.5% to 80% reconciliation rate (exceeded target of 75%) 47.5% “best possible medication history” completion rate 50% reduction in unintentional medication discrepancies 55% reduction in undocumented intentional medication discrepancies

Average Completion Rate Comparison: Vancouver Coastal Site Average Completion Rate Since Implementation Richmond Hospital 60% Vancouver General 78% Coastal Squamish General St. Mary’s Hospital 65% Powell River General TBA Lions Gate Hospital Data from Decision Support

Admission MedRec at Lions Gate Hospital How are we doing now? Examples of “good saves” and Qualitative Results…

MedRec Success Stories Unit Good saves… Emergency MD 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). Pediatrics Patient’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. Daycare Surgical 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.

Admission MedRec at Lions Gate Hospital Address process issues first before implementing change(s) Risk management Engagement and partnership Clear process Small, incremental changes Try and try until you succeed!

Admission MedRec at Lions Gate Hospital Reference List: 1 Canada. Accreditation Canada. Required Organization Practice. Ottawa: Accrediation Canada, 2012. Print. 2 Canada. Optimizing Medication Safety at Care Transitions – Creating a National Challenge. Toronto: 2011. Print.

Admission MedRec at Lions Gate Hospital Thank you for listening! Questions???

Admission MedRec at Lions Gate Hospital What is MedRec? Systematic A systematic approach to taking the best possible medication history and reconciling home medications1 A partnership between caregivers and patients/clients in order to obtain accurate medication information during various transitions of care1 A conversation around medications taken at home Partnership Conversation February 27, 2013

Admission MedRec at Lions Gate Hospital How was MedRec implemented? 5 Steps to Lean Thinking Source: James P. Womack. Lean Thinking. February 27, 2013

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 flow Audit & Refine Implement February 27, 2013