About us USING MEDICATION RECONCILIATION TO RECONCILE THE TEAM. St Luke Community Healthcare 3/6/2015

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1 USING MEDICATION RECONCILIATION TO RECONCILE THE TEAM St Luke Community Healthcare About us Community owned & operated; heart of healthcare in the Mission Valley Nestled between Flathead Lake, Mission Mountains, Flathead River and Bison Range/Ravalli Hill in the heart of the Mission Valley 25 bed CAH 22 Acute care 3 LRDP s New Beginnings Birth Center ER 24/7 MD coverage Surgi-Center Orthopedics & General 4 Clinics Polson, Ronan, St. Ignatius 2 FP Clinics 1 RHC in St. Ignatius 1 urgent care/walk in 1

2 Something of interest about silo s-..it s not always the silo Definition of a Silo A trench, pit or especially a tall cylinder (as of wood or concrete) usually sealed to exclude air and used for making and storing silage A deep bin for storing material A tower that is used to store food (such as grain or grass) for farm animals An underground structure that is used for storing and firing a missile 2

3 Types of Silo s Tower Bunker Bag Tower Silo s Tower Cylindrical shape 10 to 90 feet in diameter 30 to 275 feet in height Made from wood, concrete, cast concrete and steele Usually unloaded from the side or bottom, however they can be unloaded from the top, varies based on what they store Material packs inside it, making bottom dense 3

4 Bunker Silo s Usually trench like Concrete walls Filled with tractors, loaders Made airtight by covering it with a tarp Cheap, and well suited for a large operation More temporary, generally go up when more storage is needed. Bag Silo s Heavy plastic tube 8 to 12 feet in diameter Varied length, depending on what storing Packed by machines Unloaded by heavy equipment (tractors, loaders, skidders) Bag torn off as unloaded and discarded 4

5 Some thoughts.. Size 10 to 90 feet in diameter 30 to 275 feet in height 8 to 12 feet wide Construction Concrete, wood, deep, thick walls, tall, large diameters Takes effort to remove the contents and/or exterior of a silo, or to move the walls, A little about silo definitions Business definition Healthcare definition 5

6 The Business Definition.. Barriers develop among organizations many parts (Business Week, 2010) A mind-set present in some companies when certain departments or sections do not wish to share information with others in the same company. This type of mentality will Reduce efficiency Reduce morale May contribute to the demise of the company (Business Dictionary, nd) The Healthcare Definition That s not my problem; someone else will take care of it (Gawande, 2010) A stack of data in a specific discipline without crosstalk with other disciplines, such that one discipline may not understand others when using their terminology (FreeMedicalDictionary) 6

7 But what does this have to do with our Reconciling the Team with Medication Reconciliation????? Baseline Measurement 100% 80% % cases 60% 40% 20% 0% Admit Med List At Transitions At Discharge Agg % 78.4% 83.9% PG % 50.0% 81.0% SLCH % 57.1% 89.3% 7

8 Opportunities Obtain a complete, accurate medication list for all inpatients at admission Complete medication reconciliation at each transition of the inpatient Include OTC and PRN meds the patient may take after discharge on the discharge med list and reconciliation Medication Reconciliation Determined action steps Began working on Med Reconciliation each within our own boundaries (Clinic, ACF) Provided baseline education Told the importance of med reconciliation and steps to complete it Had THAT moment. What??!!! That isn t how you do it??? Or you? Or You? OR YOU???!!!!! Ahhh!!!!!That is what caused this????? 8

9 Aha moment discoveries Communication Training & inconsistent use of the system, across the continuum Unclear expectations (Meditech Med Rec screens) Process issues Reporting issues check box vs med reviewed Pillars & Monuments Meditech, Meditech, Meditech, Meditech It is not about the silo s but the Pillars & Monuments The stages of a team 1. Forming Excitement, questions, eagerness, high positive expectations, maybe some anxiety Principle task is to create clear structure, develop goals, determine direction and roles. Form trust. 2. Storming Team learns they can t reach expectations, behaviors start to change, frustration builds, enthusiasm decreases Principle task is to refocus on the goal, perhaps redefine the goals and tasks 9

10 Stages of a team continued 3. Norming Discrepancies resolved, team begins to function well, increased sense of comfort, members feel like they are part of the team. Principle task is focused on increased productivity 4. Performing Satisfaction with progress, share insights, feel the sum is greater than its parts, solve problems, function well Principle task is to make progress to meet goal, progress measured and celebrated. (Stein, nd) Committee/Team re-forming Issues were clear we needed a broader team Identified champions Dr. Hikmat Maaliki Dr. Heather Jones Representatives from across the continuum to include: DON, ADON, IT, HIT, Pharmacy, Clinic Manager, Clinic Nurse Supervisor, Each clinic super user, Better Health Improvement Specialist, Acute Care super users, ER super users 10

11 Team re-forming/storming Agreed upon purpose statement To ensure as much as possible the list of home medications appearing in the patient s electronic chart is accurate and complete. This process must occur at every point of contact with the patient throughout the continuum of care. This process is intended to facilitate medication prescribing and promote patient safety. Team re-forming Set our goal Medication reconciliation will occur 80% of the time with transitions from ER to ACF to Clinic/ECF Determined data source(s) PIN Clinical Improvement Study retrospective study used as baseline Audited the process, concurrently MU Medication Reconciliation considered for ongoing monitoring, once available 11

12 Team performing Key steps in the process specified by the medical staff outlined in policy/procedural format Identified key transition points Intake in clinic, ER admission, transition into ACF (admit), transition out of ACF (DC), Transition into ECF (admit) or other facility Standardization the medication reconciliation process across the continuum, using our EMR Team norming Evaluated the process flow, and the 6 C s of medication reconciliation 1. Compiling & Collecting (pt brings in home meds and/or list 2. Clarifying & Correcting (review with pt, update home med list in EMR) 3. Comparing (simultaneously occurs with clarifying and correcting meds brought in and/or from list with patient) 4. Communicating and Reconciling (documenting in the EMR) 5. Maintaining a Clean list (keeping the home med list accurate in the EMR) 6. Consistency (everyone doing it the same) 12

13 Team performing Education & tool development Policy formalization Medication Reconciliation Cheat Sheets User Guides for inpatient setting and clinic setting Drilled into performance of the focus steps Allergies reconciled Unrecognized medications reconciled Duplicates reconciled All medications, OTC, herbals, etc. dose last taken entered and reviewed Heroism in healthcare (medicine) ought to mean having the humility to recognize that we are more likely to fail on our own (Gawande, 2010)...It is really about the team!!!! 13

14 Better is better % 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 71.40% Policy drafted Education Clinic training manual 89.3% 79.8% Med Staff presentation That moment unintended consequences Med Reconciliation Audits ER to ACF % Refocus 88.9% Monitoring phase 78.2% 75% Monitoring phase cont, building electronic report vs audits 71% 76.4% Meaningful Use Reports as data source 75.60% 74.50% 74.70% 76.10% Start next change cycle: Transition to ECF, look at upcoming EMR updates 69.60% Med Rec Rate Goal Clinic Medication Reconciliation 100.0% 90.0% 94.0% Clinic Med Rec Audits 94.0% 94.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 80% 80% 80% 80% 80% 80% 65.5% 61.1% 52.8% 50.0% 34.0% Med Rec Audit tool revised, new auditors onboard 20.0% 10.0% 0.0% March April May June July Aug Med Rec Completion rate Meds Reviewed Goal 14

15 Focus area: Education is the key to reconciling allergies Med Reconciliation Audits ER to ACF % 70.1% 70% 78.70% 60% 34.4% 41.0% 0 Feb Mar Apr May Jun Jul Aug Sep Allergies Reconciled 100.0% 80.0% Clinic Med Rec Audits % 78.0% 60.0% 40.0% 34.0% 30.6% 38.9% 30.6% 20.0% 0.0% March April May June July Aug Allergies updated Focus area: Education is the key to unrecognized med % 9.7% Med Reconciliation Audits ER to ACF % 8.5% 10.4% 11.1% Feb Mar Apr May Jun Jul Aug Sep 0% Unrecognized Meds 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Clinic Med Rec Audits % 11.1% 8.0% 5.6% 1.2% 0.0% March April May June July Aug Unrecognized Med rate 15

16 Focus area: Duplicates (domino effect) % 9.5% Med Reconciliation Audits ER to ACF % 8.5% 5.2% 4.9% Feb Mar Apr May Jun Jul Aug Sep Duplicates on list 0% 12.0% 10.0% Clinic Med Rec Audits % 8.0% 6.0% 4.0% 2.0% 0.0% 5.6% 2.0% 2.4% 1.0% March 0.0% April May June July Aug Duplicate med rate Our Success Is not measured on a graph Communication Teamwork Deeper understanding of the process & the domino effect of our actions across the continuum Standardize responses to medication reconciliation Patient centered team engagement/focus from front line to the top, from the top to the bottom Improvement is continuous, we will always continue to work on medication reconciliation 16

17 Lessons Learned Unintended consequences Role of the EMR/EHR Operability & information flow across modules Medication Reconciliation screens Consistency of use Source of medication list, not always populated Documentation if the patient does NOT take OTC, herbals, supplements, etc. Domino effect In summary, Teamwork divides the task,..and.. It multiplies the success!!! Thank you! 17

18 References Business Dictionary Online (nd) Retrieved February 23, 2015 from Business Dictionary.com Merriam Webster Dictionary Online (nd). Retrieved February 23, 2015, from Merriam Webster Dictionary: Free Dictionary Online (nd). Retrieved February 23, 2015, from The FreeMedicalDictionary by Farlexhttp://medicaldictionary.thefreedictionary.com/Silo+mentality Morse, Gardiner (2010). Harvard Business Review. Health Care Needs a New Kind of Hero. Stein, Judith (nd). Learning & Development. Using the Stages of Team Development. Retrieved March 5, 2014 from 18