Reducing Medication Reconciliation Failure Rates with Six Sigma and Healthcare Intelligence

Reducing Medication Reconciliation Failure Rates with Six Sigma and Healthcare Intelligence

CAMC Presenters Karen Miller, RN, BSN, MBA; Lean Six Sigma Director; Master Black Belt; Charleston Area Medical Center Diane Taylor, RN, MSN; Director of Nursing Practice; Charleston Area Medical Center

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Objectives Review the challenges of the medication reconciliation process and how applying principles of a six sigma methodology helped to provide a refocused approach. Discuss how health care intelligence and analytics supported the process. Share clinical practice process changes that led to a more efficient and accurate process for medication reconciliation. Review metrics that demonstrate success of the program.

Charleston Area Medical Center Non-profit, 908-bed, 4-campus teaching hospital system and tertiary regional referral center Servicing 557,328 mostly rural population 550,000+ outpatient visits 100,000+ ED visits 40,600+ Cancer Center Visits Memorial Hospital 38,000+ inpatient discharges 5,000+ employees 600+ physicians 500+ health professional students daily General Hospital

Charleston Area Medical Center Primary Stroke Center of Excellence Bariatric Surgery Center of Excellence Heart & Vascular Center of Excellence 9,469 cardiac cath procedures 1,289 open heart bypass procedures Level I Trauma Center Only free standing Women & Children s Hospital in state Level III Neonatal Intensive Care Unit Teays Valley 3,000+ births Women & Children s

Six Sigma Methodology DMADV : To redesign a process by reducing the variation and/or design a new process Define Measure Analyze Design Verify Who are the customers and what are their priorities? How is the process performing and how is it measured? What are the most important causes of the defects? How do we verify that the design meets the goal? How do we design or redesign a process with minimal defects?

Initial Project: CHF Discharge Medication Reconciliation Project Start Date: January 2011 Executive Sponsor: CQO Project Process Owner: CMO Physician Champions: Medicine, Hospitalist, and Information Services Clinical Directors Master Black Belt: Karen Miller Team Members: Nursing Design Team, CPOE Design Team, Information Services, Transcription Services D M A D V Define: Discharge medication defects account for 50% of the total Center for Medicare & Medicaid Services (CMS) discharge instructions defects for Congestive Heart Failure (CHF). Measure/Analyze: Discharge medication reconciliation CMS indicators: 72% of provider dictated discharge summary medications did not match discharge meds ordered 28% of med lists given to patient did not match physician discharge meds ordered or no documentation med list given to patient

Define the DMR Current Process Physician uses Med Administration Check to identify inpatient meds? Nurse adds, deletes, and revises discharge med list based on discharge orders from multiple forms Physician dictates discharge summary up to 30 days past discharge Physician Physician uses Physician home only med uses uses and Home physician & clarification blank Current paper order lists Medication form to order and writes Order meds by circling discharge form continue that meds? prints or from Soarian discontinue? to order meds Key Takeaway: Defining the current process identifies the data elements required for the measure phase and is the basis for discussion with Healthcare Intelligence resource staff Physician uses multiple forms to dictate medications in summary D M A D V

11-10 07-11 10-11 01-12 04-12 07-12 10-12 01-13 04-13 07-13 10-13 Proportion D M A D V Discharge Summary Results 92% decrease in defects Provider identified problems with the medication reconciliation process (home med list, admission & discharge reconciliation) Provider Discharge Med Reconciliation Defects by Stage Baseline All Physicians Electronic DC Instructions 0.6 Hospitalists Automation 0.5 0.4 0.3 0.2 0.1 0.0 UCL=0.0893 _ P=0.0268 LCL=0 Tests performed with unequal sample sizes Audit Date

Implementation of Electronic Home Medication Collection, Admission & Discharge Reconciliation

Issues Patient/family poor historians for home medication list results in incomplete or inaccurate list for provider use Multiple versions of the home med list is used for medication reconciliation The entire medication reconciliation process was a nurse driven process instead of provider driven process Inaccurate discharge medication reconciliation leads to increased readmissions, morbidity, and mortality No process to proactively monitor the accuracy or completeness of the medication reconciliation process (home med list, admission & discharge reconciliation)

D M A D V Multidisciplinary Team Charter Executives chartered team consisting of physicians, nurses, pharmacists, IS, and Six Sigma Address physician concerns about home medication collection identified in the initial project Address defects from nursing transcription of discharge med orders to the patient discharge med list Improve the accuracy of the entire medication reconciliation process (home med list, admission & discharge reconciliation)

Electronic Medication Reconciliation Planning Multidisciplinary team collaboration Future state process mapping Risk identification and mitigation strategy 28 process issues identified for mitigation 21 of the 28 were new process issues for mitigation D M A D V

Future State Process Risks: Electronic Discharge Med Reconciliation Risk: Chooses inpatient home med instead of house icon med prints on med list to stop home med and then start same med. Solution: Default by drug sort house "first. Risk: Provider adds new med under Soarian orders instead of Discharge Med Reconciliation Solution: Education, monitoring, & feedback. D M A D V Risk: Med reconciliation not completed. Solution: Alert when discharge order placed. Risk: Duplicate inpatient and home med ordered. Solution: Default by drug sort. Risk: Meds added in complete status how will nurse know when to print? Solution: Nurse alert if DMR changed after placed in a complete status.

D M A D V Workflow alerts: Risk Mitigation Strategies Alert to nursing (4 hours) and managers (12 hours) if Home Med List (HML) not completed Alert to physician if Admission Med Reconciliation (AMR) not completed within 24 hours of admission Alert to physician to complete Discharge Med Reconciliation (DMR) when discharge ordered Alert to nurse if new med orders placed after the discharge med reconciliation was completed Pilot on large medicine nursing department Feedback and redesign of process Education prioritization based on risks

D M A D V Implementation Strategies Training for nurses, physicians, pharmacists Mandatory computer based training Whole house adoption on a single day Pre loading inpatients home med list on the morning of the conversion Two weeks of live support 24/7 Job Instructional Training (JIT) competency validation within one month of go-live Development of 13 Single Point Lessons (SPL) placed at work stations for visual aids

D M A D V Home Med Collection Free text meds only as last resort

Admission Medication Reconciliation D M A D V

Discharge Medication Reconciliation D M A D V

Single Point Lessons D M A D V 21

D M A DMR Single Point Lesson D V

Continuous Analysis & Improvement Developed home med collection entry tips for high frequency problems associated with expansive Soarian drop down menus (51% OTC meds) Healthcare Intelligence reports for daily and weekly nurse and individual provider defect monitoring for performance management Cycles of analysis and improvements implemented from home med list collection report 50% of patients admitted through EDs D M A D V 58% of ED home med lists had missing required med components Implemented LPN home med collection in EDs resulting in 3-5% missing required med components, representing a 131% improvement

D M A D V Healthcare Intelligence Reports Weekly Daily report for home physician identification meds list of completion nurses missing using required rates and free for completion components text discharge and entry that of medication home need within meds corrections 4 hours reconciliation with of missing before admission between discharge components 8:00 for reconciliation percentages follow a.m. up 5:00 p.m. Key Takeaway: Refinement of reports based on VOC

D M A D V Patient Home Med List % patients meds with with with required a free completed required text med meds status on component HML Home Med missing List (HML) on HML (excludes free text) Key Takeaway: Executive patient data view for patient medications entered on the home medication list

D M A D V Patient Home Med List Key Takeaway: Drill down to department level data to identify patients currently in the department that need home med list corrections

D M A D V Patient Home Med List Key Takeaway: Drill down to patient home med lists that need correction for continuity of care and prep for discharge reconciliation

D M A D V Patient Home Med List Missing required components on Patient location nurse dept and HML location HML collected Key Takeaway: Drill down to patient med components that need corrected.

Home Med Collection D M A D V Key Takeaway: Executive view for home med list collection performance management

D M A D V Home Med Collection Key Takeaway: Drill down to department then to nurse/provider data for home med collection performance management

D M A D V Home List Completion % patients with HML not completed within four hours of admission Key Takeaway: Drill down to department then to nurse data for home med collection timeliness performance management.

D M A D V Provider Discharge % final initial last with DMR Discharge DMR entry entry by Med by by staff physician Privately staff RN RN or or 5:00 Employed midlevel Reconciliation p.m. RN 8:00 (PERN) (DMR) a.m. in complete status and any status Reconciliation Key Takeaway: Executive view of provider discharge medication reconciliation completion rates

D M A D V Provider Discharge Reconciliation Key Takeaway: Medical Affairs and medical department leadership view for provider completion rates

Provider Discharge Reconciliation D M A D V Key Takeaway: Drill down to physician for identification of top performers, performance management and credentialing

Healthcare Intelligence Resources Benefits Access to100% of patient population Eliminate manual data abstraction for key elements Decrease measure phase time Improve analysis for critical variables Sustain gains after improvements D M A D V Key Takeaway: Collaborating with BI team member improves efficiency & effectiveness in all project phases I ask the impossible and Healthcare Intelligence delivers! I simply couldn t do my job without them!

D M A D V Lessons Learned System wide implementation was the right thing to do because of frequent transfers Preloading med lists for all patients morning of go live was the right thing to do Addressing provider compliance real time Needed visual management documents at computers for clinicians before implementation Important to have a knowledgeable and available support team 24/7 Online education module requirement for implementation LPN collection of home med lists in the ED

Impact to Care Delivery Processes Workflow alerts have improved timely collection of home med lists for provider treatment Imported outpatient pharmacies and previous discharge med lists improves home med list collection accuracy Home med list collection process in the ED improves accuracy, timeliness and efficiency Increased provider confidence in the home med list collection accuracy and adoption of using the electronic medication reconciliation process. Decreased provider time in completing discharge summaries Legibility is a non-issue and improves patient safety D M A D V

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