Medication Reconciliation: One Hospital’s Journey to a Physician-Friendly Process
March / April 2009
Medication Reconciliation:
One Hospital’s Journey to
a Physician-Friendly Process
Clinicians and healthcare organizations recognize that the safety and quality of care is improved by recording and updating a complete list of medications and supplements for every patient at admission, during transfers while in the hospital, and at discharge. The Joint Commission underlines the important of this process — medication reconciliation — by designating it National Patient Safety Goal (NPSG) 8 and requiring that hospitals demonstrate compliance in order to maintain accreditation.
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A patient’s medications are reconciled to avoid errors such as omissions, duplications, and adverse interactions. During transitions of care, medication reconciliation is especially important and challenging. It addresses a true patient safety concern because many patients have multiple prescriptions, increasing the opportunity for confusion and serious drugs interactions.
Even when they understand the importance of medication reconciliation, many hospitals find it difficult to achieve. Certainly, that was our experience at Saint Vincent Health Center in Erie, Pennsylvania, but after a false start and lots of hard, rewarding work, we have a process that has brought us to 92% compliance with NPSG 8. Along the way, we also learned important lessons about process improvement strategies.
Getting Started
During a Joint Commission survey in February 2008, Saint Vincent received an RFI (Recommendation for Improvement) for not using a medication reconciliation process consistently throughout the health center. On learning the results of our survey, our CEO quoted the Nike tag line, saying, “Just do it!” To expedite improvement, we decided to quickly implement a manual, paper-based process for reconciling medications and computerize it later. Saint Vincent is in the process of developing a new electronic system including CPOE, which we plan to implement in the next 3 years.
To improve our process for medication reconciliation, we designated clinical and administrative champions and involved members of our senior leadership team who were committed to fixing our problem and fixing it fast! As director of professional practice, infection control, and patient safety, I worked with our chief nursing officer and executive vice president of quality to assemble a team of staff members from nursing, pharmacy, and operations to draft a process for use throughout the hospital. We developed a 3-page form, and all of the physicians hated it. We failed miserably! We missed one of the most important groups in our planning — the physicians who would be using the process.
As we prepared to start over, our executive vice president and chief of quality suggested we consult St. Vincent’s in-house Lean Six Sigma staff. We stopped having large meetings and worked with a very small group of two nurses, a pharmacy director, and two Lean Six Sigma experts. We did a SIPOC of the problem, which stands for a process of looking at the Supplier, Inputs, Process, Outputs, and Customers. We did a FMEA (failure mode and effects analysis) on the old process and started by having a meeting with department heads who could help us develop an order form and champion the project with their colleagues. It was a two-for-one win, as this became our FMEA for the year for the Hospital Patient Safety Committee.
Designing the new process for medication reconciliation was done as a Kaizen for the small team, during which we held daily meetings to plan our next steps moving forward. Kaizen is a Lean term that refers to intensive improvement events. In this case, we worked on the reconciliation project exclusively for a month of daily 2-to-3 hour meetings.
The FMEA showed that medication reconciliation would decrease errors involving wrong or omitted medications. If the patient or family didn’t supply the correct or complete list of medications taken at home on entry to the hospital, or if the physician failed to address the question of home medications, it was identified as “failure mode.” The FMEA also proved that pharmacy needed to take a greater role in the process as the checkpoint for quality and to answer any medication questions.
Pilot Study
Earlier we had researched what methods other hospitals used for reconciling medications and identified the order sheet as best practice. Once we had a draft order sheet we thought would work, we did a controlled 24-hour pilot study, working side-by-side with our two physician champions. Next we took the draft to the nursing units and trained them in real time how to use it. The pilot studies showed us that the form worked and that we had the physician buy-in necessary for success.
From there we went back to the physician team and asked them to review the form again. We made final changes and implemented the process hospital-wide in late May 2008. At the physicians’ suggestion, we printed the form on purple paper so it would stand out. It was placed on the top of the physician orders for admission, so it would be the first form they saw.
Prior to implementation, those of us who participated in the design phase — the six sigma staff members, pharmacy director, nursing informatics expert, and I — spent considerable time educating and training physicians on the new form and process. We went to meetings of the executive medical staff, department of medicine, and department of surgery and met with physicians in their lounges after hours and in early mornings to talk about the new process and answer questions. We put posters in the physician lounges and gave them tip cards of helpful hints and frequently asked questions. We ultimately had four physician champions. They worked with us to make a DVD about the medication reconciliation process for use throughout the hospital, including at meetings of the medical/surgical staff and executive medical staff. It is now available on our hospital extranet site for anyone to use as a resource. Some of our doctors have become overnight celebrities among their peers! For attending the training, physicians receive patient safety credits for continuing education and pocket-sized reference cards that have answers to frequently asked questions printed on the back.
We also trained the nursing staff by making posters for nursing educators to use for training on the units, and we did some train-the-trainer work on the nursing units, which allowed for buy-in at all levels.
The process for use of the form begins at admission, whether the patient is admitted from the emergency department or directly to the nursing unit. Each nurse has been trained to use the form and obtain the medication history from the patient at any point of entry. We have supplied forms to the office managers of groups of employed physicians and specialists so they can initiate the process in the office and send the complete form to the hospital with the patient. Physicians check the appropriate box to continue the home med or not while in the hospital and then again re-evaluate for discharge. This becomes the order for the patient, with new orders written on a new order sheet. The form is faxed to the pharmacy, where pharmacists double-check the information and call the physician if they have questions. Then the pharmacy techs take a clarified order label to the unit on the order/ progress sheet and place it on the chart. The physician must sign the order within 24 hours, per our state regulations for verbal orders. It will also be entered into our MIS as an ancillary note for reference.
Results
Our team is working with the new process and doing random audits on charts to make sure that the form is on the chart and completed by the physician. We will measure this for a period of time to comply with Joint Commission standards, as well as to make sure the process is hardwired. Our medical records staff is assisting with the goal by marking charts as “deficient” if the medication form lacks the physician’s signature. In those cases, physicians must go to medical records to complete the forms.
We are reviewing charts on the unit, interacting with physicians in real time, and asking them how they think it’s going. Our efforts have not gone unnoticed. Physicians have given us good feedback and suggestions for improvement. We also sent letters early on to physicians who were not compliant. The letters were signed by the president of the medical staff and included copies of forms that had errors or were not complete and highlighted that for them to review. We have had the support of our senior leadership team to make this process work, and we are beginning to tackle the next challenges with the process.
Next Steps
Now we are working with our short-stay areas, which include patients having “in-and-out procedures” with little or no change to their medication regimen. These physicians are less happy about filling out the forms. We have developed a form for the procedural areas that will satisfy the needs of physicians, nurses, The Joint Commission, the patient safety officer, and patients, with the emphasis on patient safety. We are trying to look at the process through different eyes and not say that one size must fit all. Our hospital also has an inpatient rehab unit and a skilled care unit within the hospital, which have their own regulations, based on long-term care standards.
The team has been challenged to meet the needs of different areas and ensure medication reconciliation is done at all points of care and transfer in care. The process has been defined for rehab, the skilled care unit, and behavioral health with little change.
Lessons Learned
We are still trying to perfect this process. We will measure and improve it for a period of time well into the future, but there have been positive changes with the new purple form and much better compliance than when we started in March. (Anything is better then not using the form or tearing it off of the chart!) We started with a 3-page form that wasn’t user friendly and now have a 1-page form that incorporates admission, discharge medications, and any new medication started while in the hospital. It has been a journey, but we have come far in the last 2 months and will continue to improve the process, as that is what we do best at Saint Vincent!
We have rewritten our policies to match the process. All medication reconciliation should be done within 24 hours of admission for our inpatients. Finally, we have put a process in place to provide the medication reconciliation form to the next provider of care or consulting physician who will follow up with the patient as well as provide them with the medication home schedule list the nurse reviews prior to discharge with the patient and/or family. We still need to educate our patients to make sure they update the list and bring it with them to subsequent appointments. I believe we have made a great effort to improve patient safety with medication reconciliation at Saint Vincent Health Center. Our latest measure of success shows that we are 92% compliant with this safety goal, which is a significant increase over our initial 70 % compliance measurement.
Jan Ward has worked in healthcare for 24 years. She has been a staff nurse in telemetry, a nurse educator, nurse manager, and the nursing director for medical-surgical units. Presently she is the director of professional practice, infection control, and patient safety for Saint Vincent Health Center. Ward may be contacted at jward@svhs.org.
References
Carpi, V. (2008, February). When consistency counts. Health Management Technology, 60-61.
George, M. (2003). Lean Six Sigma for service. New York:McGraw-Hill, 265-266.
Joint Commission Accreditation of Health Care Organizations, 2006 Patient Safety Goals
Joint Commission Accreditation of Health Care Organizations, 2008 Patient Safety Goals
McCollum, V. (2008, March). OR Manager, 24(3), 21, 23.
Santell, J. P. (2006, April). Reconciliation failures lead to medication errors. Joint Commission Journal of Quality and Patient Safety, 32, 225-229.