1. MEDICATION RECONCILIATION in a Pre-Admission Clinic
CRITICAL SUCCESS FACTORS
The factors that we are going to talk about today can be incorporated into any team.
Cynthia Turner, B. Pharm, R.Ph.
Medication Reconciliation Pharmacist
Vancouver Island Health Authority (VIHA)

2. What It Takes To Produce Successful Results
At the end of this presentation:
IF you are looking for ideas to improve your results
THEN complete the checklist to guide where your team might need to focus their continuous improvement efforts

3. VIHA
Serving all of Vancouver Island, British Columbia, population 730,000
15 acute care hospitals
1461 acute care beds
4760 long term care beds
Royal Jubilee Hospital

4. Med Rec Process Overview
See Same Day Surgical Admission pts., Royal Jubilee Hospital
In Pre-Admission Clinic (PAC)
Document BPMH
Use multiple sources of medication information
Involves Multidisciplinary Team
Reconcile meds on wards
< 24h post-op

5. The Results tell the Story
Implemented: Aug 06 – 1 ward
Now – 4 surgical wards involved
Our Results are:
Sustainable [month to month]
Reproducible [ward to ward]
Consistently  goal
Consistently  national average
We are proud that our results are: sustainable, reprod, etc.

6. Royal 2; 1st ward – Sustainability Unintentional Discrepancies
Sample size small
Discrepancies occurred
over weekend
Discrepancies occurred over weekend FOR EXAMPLE: at the beginning the Med Rec program was only staffed part time in the PAC. One patient that did not have a BPMH produced for them, did not have their anti-seizure medication ordered for them postop. They subsequently experiences intractible seizures the morning after their surgery. Examples like this prompted the full time staffing of the Med Rec program.

7. West 3; 3rd ward - Reproducibility Unintentional Discrepancies

8. Unintentional Discrepancies Local Teams better than National average
This is a powerful way to present information to snr exec - compare to rest of country

9. Unintentional Discrepancies “Then and Now” – < Target Goal
We were asked for 1 slide to demonstrate the impact med rec has had – 3 wards, 1 slide, another way to present to snr team, used for big dot board of directors presentation.

10. Med Rec Steering Group
Bob Clark - Executive Director, Pharmacy, Diagnostic & Surgical
Services
Dr. Con Rusnak - Executive Medical Director, Pharmacy, Diag. &
Surgical Services
Leslie Moss - Executive Director, Quality & Patient Safety
Michele Babich - Director of Pharmacy
David McCoy – Director, Post-Surgical Care Programs
Dr. Richard Bachand – Manager, Clinical Pharmacy Services
Ev Pearce – Manager, Quality and Safety
Andrea Bentley – Manager, Booking and Pre-Admission

11. Team Members Cynthia Turner - Medication Reconciliation Pharmacist
Lori Brodie - Facilitator
Alyse Capron - Quality Improvement Consultant
Dr. Hans Cunningham - Chief of Surgery; Surgical Services
Sarah Crawford - Clinical Nurse Leader, Royal 2
Robyne Maxwell - Clinical Nurse Educator, Royal 2/Royal 3, BU
Andrea Taylor - Clinical Nurse Leader, Royal 3
Kristie Waterman – Clinical Nurse Leader, West 3
Marian Chalifoux - Clinical Nurse Educator, West 3
Rhonda Porter - Clinical Nurse Leader, Surgical Daycare
Claire Fisher - RN, Pre-Admission Clinic
Dr. Richard Bachand - Manager, Clinical Pharmacy Services

12. CRITICAL SUCCESS FACTORS
Documentation
Communication
Education
Program Sustainability
Spread Mentor
This are 5 critical success factors that we feel have contributed to our program’s success

13. CRITICAL SUCCESS FACTORS
Documentation
Build in process to double check BPMH
BPMH same place in chart every time
Accuracy of medication information
TRUST is KEY
Double check BPMH if lag time between collecting and use of info = SDC RN

14. 1. Documentation Build in process to double check BPMH
 if BPMH not used right away
 keeps info. current
 our process: SDC Nurse notifies both
Physician and Med Rec Pharmacist
of med. changes
The SDC nurse uses a standardized process to document the medication changes

15. Medication Reconciliation
1. Documentation
BPMH in same place in chart every time
 Ensure the physician can find the BPMH
 Process to alert physicians to presence
of BPMH
 Reminder notice where to find
 Form in Physician Order section of chart
PDSA cycles
REMINDER
Please Complete Home
Medication Reconciliation
Physician Order Form

16. 1. Documentation c) Accuracy of BPMH Use multiple sources of info.
 Family Physician History
 Patient Clinic Questionnaire
 B.C. PharmaNet profile (14 mos)
 Pt. Interview
~ 100%

17. Case Study NEW PROCESS: Pharmacist involved
BPMH
Home
Medication List
Family Physician
Patient Clinic Questionnaire
B.C. Pharma-Net Profile
Patient Interview
Metformin
500 mg tid
Ramipril
2.5 mg daily
5 mg daily
Atorvastatin
10 mg daily
20 mg daily
Pantoprazole
40 mg daily ?
Metoclopramide
10 mg tid
Magic m/wash
20 mL tid
Oxycontin
30 mg q12h
We were surprised when we looked at the inaccuracy of individual sources of information.
This is not about blaming the surgeon for not doing his job correctly, it is about the info. Available to them postop to come up with the BPMH.
I like to say to surgeons, how can you hope to come up with an accurate BPMH when you have IMCOMPLETE information at your disposal
=SYSTEMS IMPROVEMENT
Source Accuracy:
68% % %
100 %
(Based on 49 pt.)

18. 18 Intro. Med Rec Form: BPMH documentation/Rx at present – Draft 21
PDSA Cycle # To identify Form as an Order
PDSA Cycle # To clearly define area of responsibility on Form
PDSA Cycle # To focus Physician to their area (yellow highlighting)
PDSA Cycle # To eliminate SDC Nurses from documenting medications on Form (new process)
After all the talk of the form….. 18

19. Documentation Summary TRUST IS KEY!!!
Physicians, nurses, pharmacists all need to TRUST the documentation is accurate
At our site – becomes a Physician Order
Time saving step for multidisciplinary team
Story: Urologist “I love this form!” and demanding at VGH
Every player has to trust is accurate
At our site, the BPMH becomes an physician order and therefore a prescription
Time saving step for everyone
Wrap it up with a story: Urologist actually wrote “I love this form” on the bottom of one of the forms the first time he used it.

20. CRITICAL SUCCESS FACTORS
Communication
Speak language of audience
Preparation and Follow-up are critical
Show-off your results
BIGGER THAN 1ST THOUGHT
ON SLIDE 18:
THE 2ND critical success factor is communication and the 3 key points are:
Just read…………

21. 2. Communication Speak language of audience Two examples
IMPACT of program on  patient safety
IMPACT of program on patient admissions
We are one year into it, lived with data long enough….”what are we really saying?”
This is powerful data………..speaks to the hospital Executive as we want their continued support of the med rec program

22. OVERVIEW of Unintentional Discrepancies
6 month review patients (3570 meds reconciled)
BASELINE PREDICTION: 615
WHAT REALLY HAPPENED WITH MED REC?
DIFFERENCE = potential avoided discrepancies:
This slide speaks to the difference we have made on the unintentional discrepancy totals by implementing the program
Our baseline information showed on average 1 unintentional discrepancy per patient. With 615 patients we would expect 615 unintentional discrepancies.
In reality, with med rec, we experienced 24. Therefore we can extrapolate that to show that we theoretically avoided 591 unintentional discrepancies over a 6 month period.
….and you can appreciate that if you go back to your snr exec. with these kind of numbers, this is the type of data they like to see…..

23. Impact of Process at RJH
ALL Admissions Jan to Jun 2007
Med Rec Process 8 %
Non Med Rec %

24. Impact of Process at RJH
Non-Emergency admissions Jan to Jun 2007
Med Rec Process 18%
Predict with 4 West added numbers will increase to 19% (non emergency admissions) and 10% (including emergency)
Non Med Rec 82%

25. 2. Communication Preparation and follow-up is critical
Before: Attend physician meetings, nurse staff meetings etc.
After: Ensure everyone is performing their role problems occur with new residents, physicians, nurses etc.
Chief of Surgery on team, important to include him on decision making on certain aspects of the program. We were subsequently invited to present at Surg. Exec. Mtg. Good intro, when arrives on their specialty, aware, have seen me before, “haven’t we met?”
The chiefs of depts were able to advocate on behalf of the program when we came to present at their dept specific meetings prior to med rec being implemented in their area.
As similar cascade was used with the clinical nurse leaders and educators, meeting with them before presenting at staff meetings
AFTER: Communication is ongoing especially as there is new staff coming on board all the time

26. 2. Communication Show-off your results
- Before & after measures on wards
- Poster in Senior Executive area
- Display in cafeteria, newsletter etc.
Don’t be afraid to be a show off with your good results. People want some follow up and reasons to continue doing what they are doing.
We ensure that we are as visible as possible in a multitude of ways – being quiet gets you nowhere! (don’t read out)

27. Communication examples
Patients:
Brochure
Fine tuned questions
Pharmacy:
UBC presentation
RJH/VGH/Aberdeen
3-5 days training
Students rotate in
Senior Team:
Poster
VIHA Board “Big Dot”
Nurses:
Cafeteria Day/Newsletter
Monthly staff meetings
Muffin “thank you” day
Physicians:
Surgical Executive
Presentations
Chief of Surgery
Dept. meetings
Training Video
Many of these things I have already mentioned. Recently we have used this as a tool for recruitment for VIHA.
Currently what we want to focus on is a patient communication brochure to give to patients at the pac
We are always interested to read on the Communities of Practice website what sort of communication tools other teams are using

28. CRITICAL SUCCESS FACTORS
Education
On-going – new staff, new processes
Standardize material e.g. ward package, educational video etc.
Make use of educational moments
ON SLIDE 26, the 3rd critiical success factor is education
Like communication it is ongoing
What helps education is to standardize material – nurse leaders suggested we produce an educational video to show new staff. A lot of our unintentional discrepancies were coming from our residents being tasked with Rx home meds postop and being unaware of how to use the BPMH. Our chief of surgery suggested this video becomes part of the VIHA resident’s educational package
Educational moments = not all has to be formal, always “out there” talking the talk

29. CRITICAL SUCCESS FACTORS
Program Sustainability
Program still functions when key personnel away
People seek you out to be included
Use FACTS to sell program
(Yes Pharmacist doing this = expert in medications but not on communication/measuring……….can be developed)
Physicians, nurses, wards and other hospitals within VIHA seek us out to be included in the Med Rec program because they believe it is going to be of benefit to them and their patients

30. … one person needs time off

31. CRITICAL SUCCESS FACTORS
Spread Mentor
Med Rec = part of VIHA Strategic Plan
VGH Pre-Admission Clinic
Residential Long Term Care
Dialysis/renal pts.
Pediatric ward
Total Joint Clinic
TRUST is KEY
I never realized when I first started in Med Rec that it would develop into an mentoring role as well.
It is very satisfying to offer assistance and guidance to other teams within VIHA who are wanting to implement their own Med Rec program
Something that is important to keep in mind is that each program will be unique due to their own circumstances.
= offers help on getting started; use our Form to draft off of…..easier than starting from scratch

32. Med Rec – Critical Success Factors Checklist Would you like to improve your team’s Med Rec measures? Are your measures: q   Sustainable (month to month) q   Reproducible as you spread to other areas q   Meeting or beating your goal targets q   Showing better results than the National Average? If you do not answer “Yes” in the above four boxes, then this checklist might offer guidance as to where to focus your continuous improvement efforts Any tick in a “NO” box below indicates where improvements in this area may improve your Med Rec measures.
Area
Success Factor
Yes No D O C U M E N T A I
IF there is a delay between recording the BPMH and when the physician orders home medications, is there a process of review of medications on Best Possible Medication History (BPMH)?
If there is a delay, has our team built in processes to double-check information entered on the BPMH?
Is there a consistent location where the BPMH is placed on the patient’s chart?
Is there a method of alerting physicians that a BPMH is used on a patient’s chart?
Does our team use the maximum number of available medication information sources to create the BPMH (family physician, patient questionnaire, PharmaNet profile, patient interview)?
Do stakeholders TRUST that the medications on the BPMH represent an accurate and complete list at the time of documentation? 32

33. Med Rec – Critical Success Factors Checklist Page 2
Area
Success Factor
Yes No C O M U N I A T
Can we present our data in a more user-friendly format for the average layperson?
Does our team “speak the language of the audience” when sharing information? (e.g. senior team, physicians, patients)
Have we demonstrated the impact our process is making to the rest of our organization?
Do we have a process for informing nurses and physicians about the medication reconciliation process BEFORE implementation in their area?
Do we have a process of follow-up AFTER the physician has ordered the home medications?
Do we have a process for informing new residents, physicians and/or nurses of the Med Rec process?
Have we displayed our results in a public way? e.g. poster to senior exec, newsletters, on wards

34. Med Rec – Critical Success Factors Checklist Page 3
Area
Success Factor
Yes No E D U C A T I O N
Have we standardized the material we use to educate people about this process?
Do we have a formal process of providing the education? (Attend physician meetings, staff meetings etc.)
Do we have an informal process of providing education – to either “catch them in the act of good performance” or redirect their efforts to the intended process?
Have we created any training material that can be used by multiple users e.g. web info, video etc. S B L Y
Do our basic processes still function when key personnel are away?
Do we use small tests of change (PDSA cycles) to trial our change processes?
Do physicians ask to be included in your Med Rec processes?
Does Senior Management enthusiastically support our program?
SPREAD MENTOR
Does your team act as a SPREAD MENTOR – sharing processes, tips for successes, documentation with other med rec teams? 34

35. Contact Information
Cynthia Turner, Med Rec Pharmacist
Lori Brodie, Facilitator
Richard Bachand Manager, Clinical Pharmacy Services