Quality Improvement Medication Reconciliation Tools, Techniques and Tales

Transcription

1 Quality Improvement Medication Reconciliation Tools, Techniques and Tales Presented by: Marsha Nicholson, Steve Scott, City of Toronto Long-Term Care Homes and Services Division January 10, 2012

2 Outline 1. Integrated Quality Management in City of Toronto LTCHS LEAN DMAIC Cycle PDSA Cycle 2. Castleview Wychwood Towers LEAN At Work 3. MED REC as a system improvement across multiple sites.

3 You can t solve a problem on the same level you created it. A. Einstein

4 Integrated Quality Management in City of Toronto Long-Term Care Homes and Services

5 Our Quality Management Framework Senior management commitment and leadership, integrating and inter-relating work in quality, safety, risk, ethics and resource utilization Led and coordinated by a division-wide Quality Council with representation from all homes and community programs Home-specific Quality Councils Management and frontline staff involvement in teams Monitoring, projects, initiatives, enhancements A continuous journey and constant reflection on opportunities for improvement

6 Our Quality Management Framework Focuses on creating a culture of quality and safety, to achieve our vision, satisfy residents and clients needs/expressed desires, improve processes, produce positive outcomes and meet Accreditation Canada standards Reliance on Accreditation Canada quality dimensions of: population focus, accessibility, safety, worklife, client-centred services, continuity of services, effectiveness, efficiency Partnership with HQO as 1 st LTC home to introduce LEAN Effective quality management needs a variety of methodologies in the toolkit

7 Our Quality Management Framework Involves overall committee/group (e.g. Quality Council) to ensure prioritization and coordination of effort and homespecific committees Involves teams, ensuring that staff who are directly involved in the work are included in the improvement initiatives Involves COMMUNICATION to and from everyone QI Bulletin boards, story boards; divisional, community programs and home-specific newsletters Residents Councils, Residents Councils Summit, Family Committees, Home Advisory Committees, Advisory Committee on Long-Term Care Homes and Services

8 Our Belief Positive, sustainable change that meets residents and clients needs and produces positive outcomes can only happen when those involved in providing and receiving care and services are part of the change process Quality Councils and Quality Teams Residents Councils Residents Councils Summit Family Committee and Community Advisory Committees

9 LEAN Methodology LEAN [process improvement] thinking begins with driving out waste so that all work adds value and serves the customer s needs. Identifying value-added and non-value-added steps in every process is the beginning of the journey toward lean operations

10 How Does Process Improvement Fit In? LEAN is part of the quality improvement toolkit A series of steps taken by process owners to identify, analyze and improve an existing process Process improvement generally follows a specific methodology or strategy to produce successful results Improvement is most effective or sustainable within a system of improvement Need good understanding of IQM to effectively use and fit in LEAN

11 Value-Added vs. Non-Value Added Activities Value-Added Activities must satisfy three criteria: 1) Work that results in anything important to the resident 2) Work that physically transforms resident care 3) Work that is done right the first time (without corrections or rework) Non-Value Added Activities: Consume resources but does not add value to the resident Necessary but Non-Value Added work: Does not add value, but must be done anyway (i.e. regulations)

12 What is Waste? Waste is anything that does not add value from the customer s point of view, whether it is an internal or external customer Process Improvement identifies 8 Wastes 1. Defects 2. Overproduction 3. Waiting 4. Non-utilized talent 5. Transportation 6. Inventory 7. Motion 8. Extra Processing

13 Defects WASTE TYPES OF WASTE DESCRIPTION Rework due to faulty processes Repeating things because correct information wasn't provided in the first place Overproduction Producing more than is needed or earlier than needed by the next process Waiting People unable to complete their work because they are waiting for people, equipment or information Non utilized brainpower Not using people to their fullest potential Transportation Moving materials unnecessarily Inventory Too much stock Information or clients waiting Motion Unnecessary people motions, travel, walking and searching Things not within reach Extra or complex processing Performing unnecessary steps that do not add value

14 Process Improvement Methodology For Process Improvement we use the DMAIC Cycle Control Define Measure Improve Analyze

15 The DMAIC Cycle Define: this stage involves identifying a situation or problem and gaining an understanding of the process involving that problem Define Measure: the measurement phase is about verifying the problem and collecting baseline data so when improvements are made they can be quantified Control Improve Analyze Measure Analyze: data is analyzed to further identify opportunities for improvement to provide a baseline during the improve phase

16 The DMAIC Cycle (continued) Improve: during this phase, improvement ideas are developed and tested by the team through mini trials Control Define Measure Control: putting a solution in place can fix a problem for the moment, but the activities in the control phase are designed to insure that the problem does not slip back to the way it was Improve Analyze

17 Castleview Wychwood Towers City of Toronto Long Term Care Homes & Services

18 History in IQM at CWT Formally embrace and use IQM Well-grounded in use of formal QI tools and techniques Use of indicators Active Quality Council and Quality Teams Had not used LEAN in the past Partnered with OHQC to introduce LEAN and add it to the home s improvement activities

19 Using LEAN in Medication Reconciliation

20 STEP 1: We created a LEAN Team Interdisciplinary Decision makers managers and frontline staff Included the Medical Director Included contracted community pharmacy Supported by external LEAN coaches and subject matter experts

21 STEP 2: Completed a LEAN Training Day 26 CWT employees received LEAN training Creating a LEAN culture within an organization first starts with a vision and LEAN strategy that comes from the leadership team, and then teaching LEAN throughout the organization

22 STEP 3: Created a Current State Map The team was guided through an extensive current state map for both the administrative processes and the medication reconciliation processes Power of this exercise is that it was the front-line workers identifying what actually occurred--an eyeopener for management

23 STEP 4: Brainstormed Improvement Ideas The team identified significant areas for improvement in the process and brainstormed specific ideas for improvement. They identified over 50 ideas for improving the system Improvement ideas were generated from all levels of the organization and the mix of professions participating in the event

24 STEP 5: Created a Future State Map The team took their ideas for improvement and created an ideal future state map for both administrative processes and for the medication reconciliation process Collaboration on this part of the exercise meant that improvement ideas generated created a future state map that worked for all professions involved in the process MDs, nurses, pharmacists, and the residents

25 STEP 6: Prioritized Improvement Ideas Once a future state map was created, the team prioritized the 50+ ideas for improvement based on high impact / low impact, and high difficulty / low difficulty

26 STEP 7: Created an Action Plan From the prioritized list the team created an action plan Individuals assigned to areas of responsibility work on their improvements weekly. The LEAN team meets monthly for updates and to brainstorm new ideas for improvements. Our team is currently on target for all timelines

27 MEASURES (10 month timeline) Safety (safer healthcare now! Measures) To # resident s reconciled to 100% on pilot unit (% reconciled) To # unintentional documented discrepancies to 0 (mean #) To # intentional discrepancies to 0 (mean #) Quality To reduce the # of incomplete information being received from CCACs and hospital transfers (defect checklist) Efficiency To improve the efficiency of the med-rec process (time cycle) To improve overall efficiencies in the application process through to arrival of the resident

28 STEP 8: Created a Quality Board The LEAN team created a quality board in the pilot unit to track improvements. Two people are responsible for updating the board and reporting back to the team on a regular basis

29 Time (minutes) 1,200 Castleview Wychwood Towers Unit 3 Average time from arrival to 1st dose NEW ADMISSION arrival to completion of BPMH Pharm. Time TOTAL time (arrival to first dose) BPMH to Med Reconciled and AMO Med arrival to admin med Target for total time: 1, G O O D C - 26 Mar D - 26 Mar E - 1 May F - 5 May A - 21 Mar B - 23 Mar G - 5 May H - 8 Jun I - 9 Jun J - 9 Aug K - 21 Aug

30 Next Steps Continue to strengthen communication with hospital dischargers/ccac re medication reconciliation Continue to reduce the time spent in ensuring accurate and complete medication reconciliation prior to admission Implement Medication Reconciliation process across multisites Continue to select and apply LEAN as one QI methodology for process improvement Continue to support staff excitement Continue IQM Celebrate!

31 The LTCH&S DIVISION LTCH&S Division is a multi-site organization a total of 62 Resident Home Areas Medical Directors at each site provide medical leadership to the 34 Attending Physicians Continuity of medical services is achieved by each Attending Physician responsible for medical services on designated Resident Home Area Continuity of Nursing care is achieved by both Registered Nurses and Registered Practical Nurses assigned to a specific Resident Home Area incorporating the application of a consistent resident assignment service delivery model Pharmacy Service is delivered through a contracted community pharmacy. Each Home has a designated Consultant Pharmacist. This organizational structure and design supports strong interdisciplinary collaboration and effective communication

32 HOW WE IMPLEMENTED THE MEDICATION RECONCILIATION PROCESS ACROSS MULTI-SITES

33 Introduced the medication reconciliation process improvement to all Medical Directors Introduced the medication reconciliation process improvement to all Directors of Nursing/Care Incorporated the process improvement "critical components" into the existing admission/re-admission/discharge process Designed and integrated into the existing admission/re-admission process a BEST POSSIBLE MEDICATION HISTORY RECONCILIATION/ADMISSION ORDERS document The BPMH Reconciliation/Admission Orders incorporates the critical components of Med. Rec. Policy and procedures were prepared and clearly detail the core responsibilities of the nurse, physician, pharmacist and resident/family role in medication reconciliation

34 Medication Reconciliation Implementation continued A staged implementation plan supported by education/training of the nurses, physicians and pharmacist was developed and implemented Close monitoring and follow-up was needed to verify that the team understood the new process Specific indictors for tracking successful completion of medication reconciliation for all new admissions and re-admissions was developed and provided valuable data to alert if there were any process gaps Ongoing tracking of admission and re-admission med rec. data confirms the successful implementation of the new process across the 62 resident home areas

35 % of MED RECONCILIATION Long Term Care Homes and Services Jan - Sep 2011 NEW ADMISSION BA (112) CFL (22) CL (54) CWT (197) FH (95) LL (28) TDA (89) ( ) Total # of New Admissions

36 % of MED RECONCILIATION Long Term Care Homes and Services Jan - Sep 2011 RE - ADMISSION BA (105) CFL (28) CL (56) CWT (141) FH (91) LL (37) TDA (39) ( ) Total # of Re - Admissions

37 Celebrate!

38 Questions? Contacts: