Achieving Compliance with Medication Reconciliation Utilizing Improvement Methods Tuesday, July 1, 2008 12:00 – 1:00 p.m. EDT © American Academy of Pediatrics.

Achieving Compliance with Medication Reconciliation

Utilizing Improvement Methods

Tuesday, July 1, 200812:00 – 1:00 p.m. EDT

© American Academy of Pediatrics 2008

Moderator: Uma Kotagal, MD, MBBS, MSc, FAAPVice President for Quality and TransformationDirector, Center for Health Policy and Clinical EffectivenessCincinnati Children’s Hospital Medical CenterCincinnati, Ohio

DISCLOSURESFinancial Relationships

One individual involved in this webinar: Melissa A. Singleton, M.Ed., Project Manager-Consultant

has disclosed a financial relationship with an entity producing, marketing, re-selling, or distributing health care goods or

services consumed by, or used on, patients. Her husband is employed by Walgreen Co. as a Workforce Administration

Manager (technology position) for the company’s call centers. The AAP determined that this financial relationship does not

relate to the educational assignment.

None of the other involved individuals (Speakers, Moderators, Project Advisory Committee members, or Staff) has disclosed

a relevant financial relationship.

Refer to full AAP Disclosure Policy & Grid available below for download.

DISCLOSURESOff-Label/Investigational Uses

None of the individuals (Speakers, Moderators, Project Advisory Committee members, or Staff) has disclosed that they intend to discuss or demonstrate pharmaceuticals and/or medical devices

that are not approved.

Refer to full AAP Disclosure Policy & Grid available below for download.

This activity was funded through an educational grant from the Physicians’

Foundation for Health Systems Excellence.

Visit our website:http://www.aap.org/saferhealthcare

Resources: Useful strategies, valuable information links, and expert advice on reducing or eliminating medical errors affecting children.

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download just the Podcast or slide set from an archive.

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CME CREDITLive Webinar Only

The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

 The AAP designates this educational activity for a maximum of 1.0

AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

 This activity is acceptable for up to 1.0 AAP credits. These credits

can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Members of the American Academy of Pediatrics.

OTHER CREDITLive Webinar Only

This program is approved for 1.0 NAPNAP contact hours of which 1.0 contain pharmacology (Rx) content per the National Association of Pediatric Nurse Practitioners Continuing Education Guidelines.

 The American Academy of Physician Assistants accepts AMA PRA

Category 1 Credit(s)TM from organizations accredited by the ACCME.

Important Note:You must have been pre-registered for this webinar in order to

claim CME or other credit for your participation.

Speaker: Maria Etris, RN, BSNProject Manager, Division of Patient SafetyCincinnati Children’s Hospital Medical CenterCincinnati, Ohio

Speaker: Jason Olivea, MS, MPAQuality Improvement ConsultantCincinnati Children’s Hospital Medical CenterCincinnati, Ohio

Speaker: Christine White, MD, MATPediatric Chief ResidentCincinnati Children’s Hospital Medical CenterCincinnati, Ohio

LEARNING OBJECTIVESUpon completion of the webinar, participants will be able to:

• Cite the requirements of medication reconciliation and one hospital’s compliance prior to implementing improvement strategies.

• Describe improvement strategies that were tested and implemented to achieve success with completing medication reconciliation within 24 hours of admission.

• Apply improvement strategies to sustain success with medication reconciliation compliance.

Achieving Compliance with Medication Reconciliation Utilizing Improvement

Methods

Safer Health Care for Kids WebinarJuly 1, 2008

Maria Etris, RN, BSN Project Manager, Patient SafetyJason Olivea, MS, MPA Quality Improvement ConsultantChristine White, MD, MAT, Pediatric Chief Resident

Medication ReconciliationEndorsed as a Safe Practice throughout the nation.

Medication Reconciliation & The Joint Commission…

2005: “New” National Patient Safety Goal with 1 year phase in period to be implemented by January ’ 06

Included: Creating the Medication List Reconciling the list at admission, transitions in care,

& at discharge Providing list to family

2006: Many FAQ’s and varied interpretations of Goal2007: Additional Expectation

Provide list to next care provider

2008: No Change

CCHMC’s Historical Performance with Medication Reconciliation

Medical ServicesInpatient Medication Reconciliation Compliance Upon Admission

0%

20%

40%

60%

80%

100%

1/7

/2007 n

=270

1/2

1/2

007 n

=214

2/4

/2007 n

=210

2/1

8/2

007 n

=160

3/4

/2007 n

=236

3/1

8/2

007 n

=212

4/1

/2007 n

=168

4/1

5/2

007 n

=213

4/2

9/2

007 n

=209

5/1

3/2

007 n

=210

5/2

7/2

007 n

=175

6/1

0/2

007 n

=172

6/2

4/2

007 n

=164

7/8

/2007 n

=185

7/2

2/2

007 n

=183

8/5

/2007 n

=186

8/1

9/2

007 n

=196

9/2

/2007 n

=179

9/1

6/2

007 n

=178

9/3

0/2

007 n

=204

10/1

4/2

007 n

=186

10/2

8/2

007 n

=186

11/1

1/2

007 n

=224

11/2

5/2

007 n

=160

12/9

/2007 n

=171

12/2

3/2

007 n

=179

1/6

/2008 n

=203

1/2

0/2

008 n

=214

2/3

/2008 n

=272

2/1

7/2

008 n

=213

3/2

/2008 n

=218

3/1

6/2

008 n

=199

3/3

0/2

008 n

=181

4/1

3/2

008 n

=182

4/2

7/2

008 n

=204

5/1

1/2

008 n

=194

Week Ending

% o

f p

atie

nts

% Reconciled Median (% Reconciled)

2006

Baseline

2007 Improvement

Phase

2007-08 Implementation

& Spread Phases

2008 Sustainability

Phase

Chartering our Improvement Team

I. Team Name: Inpatient Medical Services Medication Reconciliation Team (Steering & Improvement Teams)

II. Date we started & Median Performance: 12/06 & 60%III. Date we finished & Median Performance: 1/08 & 94%IV. Keys for Team Successes:

Have the right people at the table Well defined project & start small Pick an area where you have buy-in with support & commitment to

testing Pick an area where you can see & measure the change

V. Project Constraints: Technical availability (Currently, Information Services focus is on

EPIC, questions surround the ability to provide timely enhancements to MRT.)

Resources for data collection at Admission & Discharge. Multiple Medication Reconciliation Tools are being utilized (i.e. paper

& electronic versions)

Medication Reconciliation Steering Team

Purpose of Team: (a) To provide strategic Direction & Feedback (b) To receive

monthly Updates from the Improvement Team (C) Assist in removing organizational

Barriers.

Team Members:

Frequency of Meetings: Monthly

Uma Kotagal: Sr. VP Quality TransformationWilliam Kent: Sr. VP Patient Care

Michael Farrell: Chief of StaffCheryl Hoying: Sr. VP of Patient ServicesPeter Clayton: VP of Surgical ServicesAndy Spooner: Chief Information Officer

Lori Mackey: VP CHRFMaryAnn Morris: Sr. Director of Accredation

Medication Reconciliation Improvement Team

Purpose of the Team: Utilization of Improvement Science Methodologies to achieve

90%> Compliance re: Admission Medication Reconciliation for Inpatient Medical Services

(AIM).

Team Members:

Frequency of Team Meetings: Bi-Weekly

Cherly Braumbaugh: APNDonna Tinker: Clinical Manager

Amanda Carver: RNRafael Mena Resident PhysicianMaria Etris: Project Manager

Jason Olivea: Quality Improvement ConsultantChristine White Chief Resident

January 2007Where we started Heading…….

The Utilization of Improvement Science Methodology

• A different way of thinking- What Are We Trying to Accomplish & How Will We Know?

• Focus on Improving the System and not simply ensuring compliance

• Pt. Safety Focus not simply a Joint Commission requirement

Do

StudyAct

Plan

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?

The Improvement Approach

It all Starts at the Top• Organizational Support and Leadership

– Cabinet Support (Steering Committee)– Cabinet Physician Champion

• Strategic Improvement Priority• Quarterly Scorecard

Strategic Priorities Quarterly Score Card

CSI Inpatient Unit Level Quarterly Quality Dashboard

PROJECT MANAGEMENT PHASES

1.0DefineProject

(D)

2.0MeasureCurrent

State(M)

3.0AnalyzeCurrent

State(A)

4.0Plan, Do,

Study, Act Cycles

(P)

5.0Implement Improve-

ment(I)

7.0Sustain

Improve-ment

(S)

6.0Spread

Improvements(S)

What is the problem?

What are we trying to accomplish (i.e. AIM)?

What were the initial Key Drivers to achieve success?

What does the Process look like?

DEFINE PHASE: To Identify Problem Area, Scope of Project, Charter Team

1.0DefineProject

(D)

Potential Medication Reconciliation Areas Requiring Improvement

• Inpatient Admission– Creating the List– Reconciling the List

• Inpatient Discharge• Outpatient Admission• Outpatient Discharge• Available to Parents• Available to Next Care provider

1.1Define

TheProblemArea to

Focus On

Why Selected?

Develop a S.M.A.R.T AIM for the Project

S = SpecificM= MeasurableA = ActionableR = RelevantT = Timebound

1.2What are we

trying to Accomplish?

To increase from 57% to 90% (which

includes sustained process stability) for Inpatient Medical Services

Medication Reconciliation Upon Admission by 12/31/07.

(% Weekly Performance on Run Chart)

Identify Key Drivers • Sr. Physician & Nurse Leadership

support.• An effective/efficient means to capture

pt. medications for reconciliation.• Make each defined Clinical Area

Performance Highly Visible• High Reliability Med. Rec. Prescriber

Practices• Prioritize & standardize Updater Work

Flow• Up to Date Prescriber & Updater

Knowledge of requirements

1.3Key Drivers:

Identified components of the system or process that are

vital toAchieving the AIM

AIM

To increase from 57% to 90%> & sustain process

stability at 90%> for Inpatient Medical Services Medication Reconciliation

Upon Admissions by 12/31/07.

(% of Weekly Compliance

via Run Chart)

KEY DRIVERS

Sr. Physician & Nurse Leadership’s to support & sustain a Culture of Safety

Make each MicroSystem’s performance Highly visible

Prescriber & Updater knowledge of 1. Med. Rec. expectations2. Med. Rec. Tool enhancements3. Process Re-Design

An effective/efficient means to capture patient medications for

reconciliation

Prioritized & standardize Updater work flow

High Reliability Med. Rec. Presriber practices

CCHMC Inpatient Medical Services Medication Reconciliation KEY DRIVER Diagram

1.4Key DriverDiagram

Page 1

Medical Inpatient Medication Reconciliation ProcessWednesday, December 12, 2007

Pt. Admitted

Nurse Updates Medication List (20minute goal)

Prescriber Writes Orders in ICIS and

sees prompt

Presriber Selects Yes

Presriber Selects No

Presriber Selects Done

Prescriber Completes Medication

Reconciliation

Prompt disappears in ICIS

Prompt Remains in ICIS

Prompt disappears in ICIS

AM RoundsOrders Reviewed

New Orders Written

MD looks for Prompt

Assumed Medication

Reconciliation Complete

Is Prompt Present?

Medication Reconciliation NOT complete. Delegated to be

done by 1pm

Pt Ready for Discharge

Medication List Reconciled via

Discharge Summary

MD signs Discharge Summary

Prompt with Checkbox to

Confirm Medication List is

Complete for Needed Home

Medications

Medication List Given to Patient/

Family

Discharge Summary Faxed to PCP (includes

Medications)

No

Yes

Process Ends

Focus of Improvement Team’s Work

1.5What does

the Process look like?

MEASUREMENT PHASE: To gather data to build a quantified (data driven) understanding of the current state of the process.

• Operationally define measures

• How we used to use and share data

• Determine Baseline Data via Run Chart

• Develop Additional Charts as needed (i.e. Sustain/Process Stability)

2.0MeasureCurrent

State(M)

Medication ReconciliationOperational Definition of Measures

2.1OperationalDefinition

Re: Med. Rec.

Operational Definition MEASUREMENT: Percent compliant with medication reconciliation upon inpatient

admission

I. Description and Rationale This measure answers the question: What percentage of inpatient admissions have completed medication reconciliation within 24 hours of being admitted? It is measured as percent of inpatient admissions with a length of stay greater than 23 hours that have medication reconciliation updated in ICIS by a nurse and verified by a physician within 24 hours of being admitted. II. Population Definition All inpatient admissions with a length of stay greater than 23 hours III. Data Source(s) Numerator: The medication reconciliation reports created by IS from ICIS found on the medication reconciliation tab of Clinical Links Denominator: A daily report compiled from KIDS and saved on Report.Web IV. Sampling and Data Collection Plan Census of all inpatients with a length of stay greater than 23 hours. V. Calculation Numerator: Number of inpatients meeting above population having medication reconciliation documented in ICIS by a nurse and verified by a physician within 24 hours of admission. Denominator: All inpatient with a length of stay greater than 23 hours VI. Analysis Plan and Frequency of Reporting Data is collected and reported weekly. VII. Reporting Venues Weekly charts are available on the Pursuing Perfection intranet website under the

accreditation link Results are reported quarterly on the Inpatient CSI Dashboard.

2.2Med. Rec.Run Chart

Inpatient Medication Reconciliation Compliance Upon Admission

0%

20%

40%

60%

80%

100%1/7

/2007 n

=324

1/2

1/2

007 n

=277

2/4

/2007 n

=295

2/1

8/2

007 n

=228

3/4

/2007 n

=316

3/1

8/2

007 n

=296

4/1

/2007 n

=245

4/1

5/2

007 n

=282

4/2

9/2

007 n

=279

5/1

3/2

007 n

=287

5/2

7/2

007 n

=246

6/1

0/2

007 n

=238

6/2

4/2

007 n

=256

7/8

/2007 n

=271

7/2

2/2

007 n

=270

8/5

/2007 n

=305

8/1

9/2

007 n

=289

9/2

/2007 n

=265

9/1

6/2

007 n

=252

9/3

0/2

007 n

=267

10/1

4/2

007 n

=244

10/2

8/2

007 n

=253

11/1

1/2

007 n

=305

11/2

5/2

007 n

=208

12/9

/2007 n

=246

12/2

3/2

007 n

=244

1/6

/2008 n

=257

1/2

0/2

008 n

=282

2/3

/2008 n

=348

2/1

7/2

008 n

=292

3/2

/2008 n

=290

3/1

6/2

008 n

=286

3/3

0/2

008 n

=251

4/1

3/2

008 n

=253

4/2

7/2

008 n

=289

5/1

1/2

008 n

=264

Week Ending

% o

f pa

tien

ts

% Updated by Nursing - Includes those Reconciled % Reconciled Median (% Reconciled)

2.3Med. Rec.

Control Chart

Inpatient Medication Reconciliation Compliance Upon AdmissionP-Chart

0%

20%

40%

60%

80%

100%1/7

/2007 n

=324

1/2

1/2

007 n

=277

2/4

/2007 n

=295

2/1

8/2

007 n

=228

3/4

/2007 n

=316

3/1

8/2

007 n

=296

4/1

/2007 n

=245

4/1

5/2

007 n

=282

4/2

9/2

007 n

=279

5/1

3/2

007 n

=287

5/2

7/2

007 n

=246

6/1

0/2

007 n

=238

6/2

4/2

007 n

=256

7/8

/2007 n

=271

7/2

2/2

007 n

=270

8/5

/2007 n

=305

8/1

9/2

007 n

=289

9/2

/2007 n

=265

9/1

6/2

007 n

=252

9/3

0/2

007 n

=267

10/1

4/2

007 n

=244

10/2

8/2

007 n

=253

11/1

1/2

007 n

=305

11/2

5/2

007 n

=208

12/9

/2007 n

=246

12/2

3/2

007 n

=244

1/6

/2008 n

=257

1/2

0/2

008 n

=282

2/3

/2008 n

=348

2/1

7/2

008 n

=292

3/2

/2008 n

=290

3/1

6/2

008 n

=286

3/3

0/2

008 n

=251

4/1

3/2

008 n

=253

4/2

7/2

008 n

=289

5/1

1/2

008 n

=264

Week Ending

% o

f pa

tien

ts

% Reconciled Average UCL LCL

current control limits based on data from 8/26/07 - 1/6/08

Very High Census

ANALYZE PHASE: To assess & identify Contributing & Root Causes associated with Problem Area Team is Focused on Improving

• Review Data & Assess for Process Stability

• Conduct Simplified Failure Mode Effects Analysis

• Intense Reviews of Individual Failure Modes (Ask 5 Why’s)

3.0AnalyzeCurrent

State(A)

3.1Med. Rec.Run Chart

Inpatient Medication Reconciliation Compliance Upon Admission

0%

20%

40%

60%

80%

100%1/7

/2007 n

=324

1/2

1/2

007 n

=277

2/4

/2007 n

=295

2/1

8/2

007 n

=228

3/4

/2007 n

=316

3/1

8/2

007 n

=296

4/1

/2007 n

=245

4/1

5/2

007 n

=282

4/2

9/2

007 n

=279

5/1

3/2

007 n

=287

5/2

7/2

007 n

=246

6/1

0/2

007 n

=238

6/2

4/2

007 n

=256

7/8

/2007 n

=271

7/2

2/2

007 n

=270

8/5

/2007 n

=305

8/1

9/2

007 n

=289

9/2

/2007 n

=265

9/1

6/2

007 n

=252

9/3

0/2

007 n

=267

10/1

4/2

007 n

=244

10/2

8/2

007 n

=253

11/1

1/2

007 n

=305

11/2

5/2

007 n

=208

12/9

/2007 n

=246

12/2

3/2

007 n

=244

1/6

/2008 n

=257

1/2

0/2

008 n

=282

2/3

/2008 n

=348

2/1

7/2

008 n

=292

3/2

/2008 n

=290

3/1

6/2

008 n

=286

3/3

0/2

008 n

=251

4/1

3/2

008 n

=253

4/2

7/2

008 n

=289

5/1

1/2

008 n

=264

Week Ending

% o

f pa

tien

ts

% Updated by Nursing - Includes those Reconciled % Reconciled Median (% Reconciled)

1. What is the current performance?

2. How much variability in the data exists week to week?

Simplified FMEA: High Level version of traditional FMEA

MRT signed onto & patient

accessedClick YesClick Yes

User ID & User ID & PasswordPassword

Find patient Find patient based upon based upon

MR#MR#

a) Value of MRT tool vs. Perceived burden

b) Not aware of recent enhancements

c) Lack of flexibility of MD to do MRT due toworkload

d) Easy distractibility when utilizing MRT

e) RN Med. List not in MRT

a) Multiple patientidentifiers to accessinformation (ie. ICISPat. ID # & MRTPat. MR #)

a) Slowness ofMRT sign on

b) Need to sign onusing multiple steps(lack of contentsharing)

a) Slowness of MRTSoftware

b) MRT software is down

a) Work with IS toresolve

Medication Reconciliation Admission Process- ‘Is MRT signed onto & patient accessed?’

FA

ILU

RE

MO

DE

SP

LA

NN

ED

IM

PR

OV

EM

EN

TS

CU

RR

EN

T

PR

OC

ES

S

a) Create downtime paper MRTForms

a) Work with ISto resolve contentsharing

a) Sr. Leadership to support and instill value ofMRT

b) Identify best place to write orders & do Med.Rec. w/out distraction

c) MRT completed as part of ED/ORAdmissions process by ED/OR staff

d) Analyze physician workflow to determine ifalternative opportunities exists to completeMRT

Revision 3 - 2/14/05

3.2Simplified

FMEA

Example of One Step Within Med. Rec.

Process

3.3Failure Mode

Reviews

Inpatient Medical Services Medication Reconciliation Bundle Compliance Reporting Tool

Unit/Dept Pt. Admitted: _______________________________________

Date Pt. Admitted: ________________ Service Team: __________________________________ Time Pt. Admitted: ________________ Shift Pt. Admitted: Day Evening Night Medication Reconciliation Updated by Nursing

1. From the time the patient was admitted, how many minutes did it take for the admitting nurse to update the Medication Reconciliation Tool?

# of minutes: __________________

Medication Reconciliation Completed by Prescriber 2. Was the following components of the Med. Rec. BUNDLE completed? a. Did the admitting prescriber reconcile pts. medications? b. Was the Blue Reminder Prompt used as designed? c. Did the Sr. Resident ask if Medication Reconciliation was completed on the pt. during ROUNDS? d. Did the prescriber utilize the Resident Sign Out as a reminder to reconcile pt. medications?

Yes No Yes No Yes No Yes No Yes No Yes No

3. Cause Analysis (if NO to section 2 above, do WHY WHY till underlying issue(s) identified):

General Comments

Individual Failure Mode Identification

IMPROVE PHASE: To identify, test, and select the right improvement solutions.

• What changes can we make that will result in an improvement?

• Document Tests via PDSA Cycles

• Run Charts with Annotations of Changes

4.0Plan, Do,

Study, Act Cycles

(P)

What changes will lead to improvement?

1.) Continue to work with IS to implement Enhancements based upon physician feedback of Electronic Medication Reconciliation Tool 2.) Work with IS to streamline access to Electronic Medication Reconciliation Tool 3.) Work with IS to streamline Electronic Medication Reconciliation Tool & DSS intergration4.) Analyze MD work flow to determine if alternative opportunities exist to complete Electronic Medication Reconciliation Tool

1.) Identify Senior MD & RN leader to champion importance, expectations, resources of Medication Reconciliation

1.) Post physician & nurse performance on respective Units/Div. in Noon Conference Room2.) Develop an E-Mail GROUP LIST to communicate performance of respective staff & units to Div. Leaders

1.) ID & Mitigate during Rounds2.) Built in reminders- Labels on Laptops (COW’s)3.) Resident SignOut Application

1.) CIS Updates2.) ELM Revision3.) New Resident Training4.) Unit Level Education Rolled out w/ CSI 5.) Inpatient, Practice Council, Education Council Support

1.) Rearrange Updater admission process for all admits.

4.1Interventions

Document your learnings thru Plan Do Study Act (PDSA) Cycles

Key Components for Documenting your PDSA:- State Objective of Test- Make Prediction- Outline the Execution of Test = PLAN- Document the Facts/Observations of Test = DO- Assess your Results vs. Prediction & Document

what was learned = STUDY - Determine if you Adopt, Adapt, or Abandon =

ACT

4.2PDSA Cycles

Med. Rec. & Phamracy

Objective To determine if High Alert Medications have been reconciled & the length of time for the pharmacy to validate that as well as contact MD’s with discrepancy.

Prediction That the pharmacy will not be able to conduct Med. Rec. due to lack of staff and the amount of time it will take vs. have the actual prescriber do it on the floor.

Population Inpatient Units w/ High Alert Medications TEST CYCLE 1 Start Date: 3-6-07 End Date: 3-20-07

Plan Brief Description of Test: Every time for 3 high alert medications are ordered Pharmacy will check medication reconciliation tool to see if reconciliation has occurred. If medication dose that is ordered is different from that of admission the pharmacy will contact the prescriber to review the discrepancy. The pharmacist will collect the data regarding how long it takes

Do Record data & observations: To check if reconciliation occurred took on avg. of an additional 15 minutes per episode. If there was an issue that the pharmacist need to contact the presriber to review the discrepancy took an avg. of an additional 35 minutes per episode. Any observations which was not part of the plan? Yes No Was test carried out as planned? Yes No

Study Results vs. prediction: The results matched the prediction. What did we learn? Due to multiple layers and systems that are used (MSTAT, Med. Rec. Electronic Tool, Paper) reviewing took a large amount of time. The averages above demonstrate that pharmacy could not sustain this practice for the hospital let along only specific medications. As a result, the pharmacy could not complete Med Rec due to time and resources.

Act Adapt: Adopt: Abandon:

Example of a PDSA CYCLE

Follow Up on Failure Modes-

Making changes• Access from

Order Writing• Pt context sharing• Clarity of

Expectations• Prompt Visible

Until Reconciliation Complete

Optimize Application Functionality• Clarity on Required

Fields• Improved Error

Identification• Hold, Resume, and

Confidential Medication Changes

• Alphabetical Listings• Improved Discharge

Summary Integration• Developed Reporting

Functionality

Impact of Improvements in One Area (A7)

Inpatient Reconciliation Compliane on Admission 2007

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2/20

/200

7

2/27

/200

7

3/6/

2007

3/13

/200

7

3/20

/200

7

3/27

/200

7

4/3/

2007

4/10

/200

7

4/17

/200

7

4/24

/200

7

5/1/

2007

5/8/

2007

5/15

/200

7

5/22

/200

7

5/29

/200

7

6/5/

2007

Week

Co

mp

lian

t

A7 House

A7 53% 65% 70% 80% 88% 95%

House 54% 57% 69% 75% 82% 80%

20-Feb 28-Feb 3-Apr 14-May 6-Jun 11-Jun

View History/No Home Meds included in Audits A7 PDSA all nurses

Enhancement:Wording in ICIS Changed A7 PDSA with Medical

First Weekly email to PI Leaders

First Improvement Team and Steering Team Meetings

Enhancement: Hold, Error Ease, DSS Prompt A7 PDSA with Neuro Team in Rounds

Enhancement: Confidential MedsA7 First Round PDSAs

4.3AnnotatedRun Charts

ViaPDSA Cycles

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

Week

Co

mp

lia

nc

e p

erc

en

tag

e

Medical Services Neuro Team Green Team Yellow Team RCNIC

1st PI Team & Steering

Team Meetings

Meds A7 PDSAIS Enhancement:

Confidential

Wkly Compliance Reports to LDRS

Salmon Color Prompt PDSA

RN Alpha Page phyisicans PDSA

Med. Director Alpha Page

PDSA

Pharmacy PDSA on High Alert

Meds.

IS Enhancement: Wording in ICIS Admit

Prompt Changed

IS Enhancement: Hold, Error Ease,

DSS Prompt

View Hx/No Home Meds now included as

Compliant in Audits

Official Roll out of Green Team Bundle

Official roll out of Yellow Team Bundle

New Resident Training

Chief Engagement Rounds PDSA

Green Team training bundle

IMPLEMENTATION PHASE: To implement selected solution & design all necessary Support Processes for success.

• Use of Implementation Check List to ID the following……

a. Process Ownersb. Hardwire Support Processesc. Formal Education Roll Outd. Communication Plans

Developed

5.0Implement Improve-

ment(I)

Process Owners

• All Chief Resident are Meso-System Process Owner (They cover all Service Areas)

• Medical & Clinical Directors are Micro-System Process Owners

5.1Process Owners

Support Process

• Developed an Algorithm • Tested & showed the ability of Unit

Medical Directors to mitigate failures• Labeled all COW’s • Provided Weekly Performance

Reports

5.2SupportProcess

Formal Education Roll Out for Units

5.3Education

Communication Plans

• Unit Level Leadership involvement & support

• Unit Level Education Coordinator involvement & support

• Med. Rec. Posters put up throughout the Unit

• Worked through the Hospital’s Improvement Structure & various Councils

5.4Communication

Plan

SPREAD PHASE: To Spread the Changes that have led to an improvement to all other areas that apply to the Scope of Project.

• Use of IHI’s Spread Model

a. Work through each of the 3 Chiefsb. Systematic with Spread Packagec. Intensive monitoring of data d. Spread Education Plan

6.0Spread

Improvements(S)

IHI’s Model for Spread

Spread Key Component Checklist

1. Is this a strategic improvement priority? Yes, NPSG.

2. Is there a cabinet champion (or senior leader) who is responsible for the spread? All THREE Chief Residents

3. Is there a credible leader identified who will create and manage the day-to-day spread activities? Christine White along with 2 other Chiefs with Support from Maria Etris & Jason Olivea

4. Is the improvement ready for spread? e.g. successful test ramp(s) Yes, see performance via testing and chart

5. Are the target sites for spread identified? Yes via Service (see our Improvement Team Chart Schedule)

6. Are the key stakeholders who make the adoption decision in the target site(s) defined and aligned? Are there local, credible spread champions? Chief Residents and Attending/Fellows in ICU’s. Clinical & Medical Directors are ID as spread champions.

7. Have the interventions been assessed for ease of adoption and methods identified to enhance acceptance by the target site(s)? Yes

8. Are the specific change interventions clearly defined for spread? Have you identified what must be standardized across all sites vs. what can be customized? Yes. (Example is in e-mail we send to new Units who we are spreading to. Also we standardized the RN’s Updating in ICU’s.

9. Do you have a strategy and timeline to reach all sites? (change matrix) Yes. See our Improvement Team’ Chart and Schedule).

10. Has a communication plan/strategy been developed to support your spread plan including key messages, messengers, audiences, and methods? Yes. We have worked thru CSI and Councils Structures..

11. Is there a sustainability plan that includes a measurement system to monitor performance and feedback data to key process owners? Yes. Formalizing the final document/version.

12. Have critical infrastructure/system changes (support systems or support processes?) been identified to ensure sustainability? Yes. Formalizing the final document/version.

Med. Rec. Spread Owners:

Chief Resident Services/Teams Med. Rec. Ownership

Dr. Christine White Red, Blue, Purple, Green, Orange, Neuro

Primary Owner for all of Medication Reconciliation

Performance

Dr. Donna Claes A5S, RCNIC, PICU, Heme/Onc

Secondary Owner

Dr. Brad Sobolewski Cardiology, GI, Yellow Secondary Owner

6.1Spread Owners

6.2Systematic

&Monitoring

Of Spread

Monitor/ Follow Up

Page 1

Medication Reconciliation Improvement Team Medical Inpatient Admission Bundle

Thursday, September 06, 2007

Preparation/Awareness

Nursing Awareness CSI NPC Nursing Education Council Unit Directors

Prescriber Awareness Chiefs Resident Team Meetings Rounding Service Leaders

Workflow/ Process

RN complete Medication List within 20 minutes of patient arrival/ admission

Prescriber completes Medication Reconciliation as part of admission process

Reminders ICIS Prompt Rounds Resident Sign Out Tool

Weekly Compliance Reports Daily Failure Identification Microsystem Process Owners Mesosystem Process Owners

AIM: To SPREAD Med. Rec. Bundle for all Medical Services to all Inpatient Units by Jan. 2008

(% of Inpatient Unit spread to performing at 90%&<)14 Units Total

6.3Education

Formal Education Roll Out for Units

SUSTAIN PHASE: To sustain improvement & ensure stability.

• Weekly Posting of Performance Reviews• Algorithm to guide Process Owners• Making System Visible- Performance

Poster in Resident Noon Conference Room

• On-Going Education Plan

7.0Sustain

Improve-ment

(S)

Weekly Updates

7.1WeeklyUpdates

Medical ServicesInpatient Medication Reconciliation Compliance Upon Admission

0%

20%

40%

60%

80%

100%

1/7/

2007

n=

270

1/21

/200

7 n=

214

2/4/

2007

n=

210

2/18

/200

7 n=

160

3/4/

2007

n=

236

3/18

/200

7 n=

212

4/1/

2007

n=

168

4/15

/200

7 n=

213

4/29

/200

7 n=

209

5/13

/200

7 n=

210

5/27

/200

7 n=

175

6/10

/200

7 n=

172

6/24

/200

7 n=

164

7/8/

2007

n=

185

7/22

/200

7 n=

183

8/5/

2007

n=

186

8/19

/200

7 n=

196

9/2/

2007

n=

179

9/16

/200

7 n=

178

9/30

/200

7 n=

204

10/1

4/20

07 n

=18

6

10/2

8/20

07 n

=18

6

11/1

1/20

07 n

=22

4

11/2

5/20

07 n

=16

0

12/9

/200

7 n=

171

12/2

3/20

07 n

=17

9

1/6/

2008

n=

203

1/20

/200

8 n=

214

2/3/

2008

n=

272

2/17

/200

8 n=

213

3/2/

2008

n=

218

3/16

/200

8 n=

199

3/30

/200

8 n=

181

4/13

/200

8 n=

182

4/27

/200

8 n=

204

5/11

/200

8 n=

194

Week Ending

% o

f pa

tien

ts

% Reconciled Median (% Reconciled)

7.2Algorithm

ForProcessOwners

Ex: of Ownership & use of Algorithm for Sustain

7.3Poster forResident

Noon Conf. Rm

Resident Noon Conference Room

On-Going Education Plan

Annual Training of New Resident Physicians- New Resident Training will be done by a Project Manager for Patient Safety or CIS Ed team in the Spring of each year. It will include: (1) review of the application (2) the expectations

Annual Training of New Fellows- Fellow Training will be done by a Project Manager for Patient Safety or CIS Ed team in the Spring of each year. It will include: (1) review of the application (2) the expectations

Training for new RN’s- Incorporated into Patient ServicesOrientation

7.4On-GoingEducation

Plan

Have We Sustained Success Our?

Medical ServicesInpatient Medication Reconciliation Compliance Upon Admission

0%

20%

40%

60%

80%

100%

1/7/

2007

n=2

70

1/21

/200

7 n=

214

2/4/

2007

n=2

10

2/18

/200

7 n=

160

3/4/

2007

n=2

36

3/18

/200

7 n=

212

4/1/

2007

n=1

68

4/15

/200

7 n=

213

4/29

/200

7 n=

209

5/13

/200

7 n=

210

5/27

/200

7 n=

175

6/10

/200

7 n=

172

6/24

/200

7 n=

164

7/8/

2007

n=1

85

7/22

/200

7 n=

183

8/5/

2007

n=1

86

8/19

/200

7 n=

196

9/2/

2007

n=1

79

9/16

/200

7 n=

178

9/30

/200

7 n=

204

10/1

4/20

07 n

=186

10/2

8/20

07 n

=186

11/1

1/20

07 n

=224

11/2

5/20

07 n

=160

12/9

/200

7 n=

171

12/2

3/20

07 n

=179

1/6/

2008

n=2

03

1/20

/200

8 n=

214

2/3/

2008

n=2

72

2/17

/200

8 n=

213

3/2/

2008

n=2

18

3/16

/200

8 n=

199

3/30

/200

8 n=

181

4/13

/200

8 n=

182

4/27

/200

8 n=

204

5/11

/200

8 n=

194

Week Ending

% o

f pat

ient

s

% Reconciled Median (% Reconciled)

YES!

New Med. Rec. Team launched: “Inpatient Surgical Services”

• We have carried over many lessons learned from the previous Project which include:

Strong phyisican leadership up front Understanding of process variability & performance prior to

launch of new team Daily PDSA cycle testing More aggressive with ensuring the right people are at the

table

As a result of the above, this new team has been chartered to complete its work in 90 Days.

“Summary”

• Front line nurses & physicians aligned/involved

• Make the system visible• Effective utilization of Improvement

Science Methodology• Committed Process Owners w/ support

processes

Register TodayFor the Next Safer Health Care for Kids Webinar

Understanding Radiation Riskfrom Diagnostic ImagingWednesday, July 23, 2008

12:00 – 1:00 p.m. EDT

Register at: http://www.aap.org/saferhealthcareunder “Educational Offerings”