EHR Platforms: Touchworks (4 platforms do not interface) Epic (2 platforms do not interface) PowerChart Meditech NextGen McKesson Centricity
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1 Improving the Hospital Transition Process: Optimizing Medication Reconciliation & Hospital Follow-Up PDW / RPS March 8, 7 John F. Kreckman MD CPE Director SIUCFM-S Hospital / CMO SIUCFM-S 4FM Residency: - Springfield - Quincy - Decatur - Carbondale FQHC: Lincoln Jacksonville - 8 Hospitals: - Memorial Spfd - St Johns Spfd - Memorial T-ville - Memorial Lincoln - Blessing Quincy - Passavant J-ville - Memorial Dct EHR Platforms: Touchworks (4 platforms do not interface) Epic ( platforms do not interface) PowerChart Meditech NextGen McKesson Centricity
2 Hospital Service MMC Obstetrics Inpatient, MFM Home Health Nursing Home Heritage Manor, Capitol Care, Lincoln memorial SIU CFM Hospice SJHS Hospital Service Referrals SIU, Prairie Cardiology Surgical Centers Pharmacy Emergency Rooms First Step when your System does not meet Process requirements???? 4
3 A Work Around If it Continues to Fail???? 5 For Most of Us Process Management Consists of: - Workarounds - Finger Pointing Blame the Individual
4 Take Home #: Can t Fix it if you Don t Know about it. In God We Trust. Everyone else bring your data David Nash MD TJU Take Home #: A Bad Process Will Defeat a Good Person Every Time W.E. Deming Pareto Principle 8/ 85/5 rule: 8% of errors lie with the process 85% of the problems lie within the system 5% lie with the % worker. lie with the individual
5 Take Home #3: The Importance of Process In Order to be an Effective Process: Rube Goldberg Machine Defined Ownership Feedback Controlled - measure - 8/ -process Project Phase I June - Dec 5 Define Process - Hospital Handbook - Defined Roles - Problem List Admit & Discharge Process - PCP Notification -D/c Summary Revised -HFU Appt. All patients -Verbal Sign out to PCP Phase II June - Dec Feedback: -Review of All D/c Summary for errors - Feedback to Team - Error tracking Phase III Readmission Tracking Dec Review and Categorize all - Readmissions within 3 days with - RCA to all team members involved Hospital Metrics June Sept March June Sept Team - Staff # - Models Hand-Offs -Sign-Out 3 -> -Handoff Module (SBAR) Staff # Warfarin Discharge Process -Transition only to PCP -Pharm D Tasked to Review -Enhanced Inpatient education - Tracking 7 March HFU Appointments - -Med Rec -Lost elements of d/c plan Social Determinants of Health
6 Project Where to Start? Take Home # Can t Fix it if you Don t Know about it. June Sept March June Sept 7 March Hospital Metrics O/E Outliers - Mortality - LOS - Readmission Standard Deviations Outliers - Severity of Illness
7 What did we do? Take home # & #3 A Bad Process will Defeat a Good Person Every Time Process Focus: Defined Ownership Feedback Controlled Project: Phase II June Nov 5 Define Process - Hospital Handbook - Defined Roles - Problem List Admit & Discharge Process - PCP Notification -D/c Summary Revised -HFU Appt. All patients -Verbal Sign out to PCP Results Nov4-5 Historical Phase I results Hospital Metrics 3 Day Readmission (Mean).% 5.79% 7 June Sept March June Sept Team - Staff # - Models???? Hand-Offs -Sign-Out 3 -> -Handoff Module (SBAR) Staff # Mortality.%.3% Complication.3%.8% March
8 Project Define Process - Hospital Handbook - Defined Roles - Problem List Admit & Discharge Process - PCP Notification -D/c Summary Revised -HFU Appt. All patients -Verbal Sign out to PCP Better but not fixed Less Confusion / Chaos Hospital Metrics June Sept March June Sept Team - Staff # - Models Hand-Offs -Sign-Out 3 -> -Handoff Module (SBAR) Staff # What did we do? - SIU σ Projects - BMJ Report on Medical Errors 7 March 5, deaths per year med rec --> Med error --> # Med injury --> #3 death $. Trillion of QAYL. 7 deaths a day almost % of all deaths in the US Medication Safety was the # Problem J Health Care Finance. Fall;39():39-5.The economics of health care quality and medical errors
9 % of Medication Lists had at least Error HFU 4% had Multiple Errors --> σ % Error Rate Baseline DPMO:,7 Z score of. What does that Mean? What does that Mean? 8
10 % Error Rate Baseline DPMO:,7 Z score of. DPMO,,,,, SIGMA IRS tax advice (phone in) Acute low back pain Post-heart attack medications Airline baggage handling Mammography Screening Antibiotic overuse Inpatient Medication Accuracy , 98, preventable hospital deaths Source: GE Medical Systems Prescriptions written by doctors Anesthesia during surgery Domestic airline flight fatality rate 9 Cost of a medication error was $88.57 Pharmacotherapy. 4;34(4):35-7. doi:./phar.37. Epub 3 Nov Hospital Service MMC Nursing Home Heritage Manor, Capitol Care, Lincoln memorial $8,83 $8,83 Obstetrics Inpatient, MFM $8,83 SIU CFM $8,83 $8,83 $,8,83 Home Health Hospice SJHS Hospital Service $8,83 $8,83 $8,83 $8,83 $8,8 3 Referrals SIU, Prairie Cardiology Surgical Centers Pharmacy Emergency Rooms
11 % Error Rate Baseline DPMO:,7 Z score of. DEFINE Define MEASURE ANALYZE IMPROVE CONTROL Admission Hospitalization & Discharge Hospital Follow up MMC step Verification - Entered into PC Rx Added/Removed/Changed Discharge Reconciliation in PC Discharge Reconciliation to TW Clinic Nurse - Verifies Rx list with Patient Clinic Nurse - Reconciles TW with - D/c Summary - Patients Rx List Resident Notified Resident Verification - Signs off - Admit Med Rec Complete Discharge Summary is completed Define & Measure Discharge Summary Flows to TW PCP tasked to Review Reconciled TW Rx Verbal sign out to follow up provider Clinic Resident - Verifies Rx List with Patient - Reconciles TW with - D/c Summary - Patients Rx List Most Common Steps Of Definite Problem Process Management? TW Reconciliation complete > % error rate / Medical Doctors 77% at Least one Error 74% at Least one Error 34% of Measure Meds Wrong Measure Surgical error rate / 48% Radiology at Least one Error % of Meds Wrong Measure % of Meds Wrong
12 8/ rule: Workarounds A Bad Process Blame will Defeat the Residents a Good Person???? Every Time 3 Admission Hospitalization & Discharge Hospital Follow up MMC step Verification - Entered into PC Rx Added/Removed/Changed Discharge Reconciliation in PC Discharge Reconciliation to TW Clinic Nurse - Verifies Rx list with Patient Clinic Nurse - Reconciles TW with - D/c Summary - Patients Rx List Resident Notified Resident Verification - Signs off - Admit Med Rec Complete Discharge Summary is completed Clinic Resident - Verifies Rx List with Patient Discharge Summary Flows to TW - Reconciles TW with - D/c Summary PCP tasked to Review Reconciled TW Rx - Patients Rx List What is wrong with Process? Silo Communication - No Ownership - No Feedback - No Control Verbal sign out to follow up provider TW Reconciliation complete 77% at Least one Error 74% at Least one Error 34% of Measure Meds Wrong Measure 48% at Least one Error % of Meds Wrong Measure % of Meds Wrong
13 Hypothesis: Improving the Admission Reconciliation will Improve: The Discharge Reconciliation DEFINE MEASURE ANALYZE IMPROVE CONTROL ANALYZE Improving the Discharge Reconciliation will Improve: The Hospital Follow Up Reconciliation How Can We Redefine our Process? - Ownership - Feedback - Control 5 Admission Hospitalization & Discharge Hospital Follow up MMC step Verification - Entered into PC Resident Notified Rx Added/Removed/Changed Discharge Reconciliation in PC Discharge Reconciliation to TW Resident Verification Discharge Summary is completed - Signs off Team - Admit Med Rec Complete Discharge Summary Flows to TW Verification - Reconciled to TW - Corrected List to MMC & FMHS PCP tasked to Review Reconciled TW Rx Verbal sign out to follow up provider Review of Discharge Rec - Resident Correction Visit Protocol Visit # Nurse Attending & Resident - Med Rec - Hospital Plan - hour Visit # - Pcp (Awareness of entire Hospitalization and Follow up) Process: Defined Ownership Feedback Control Follow Up Phone Call - 48 hours / Weekly for 3 days - Reconciling TW Measure Measure Measure
14 7 End of Pilot Accuracy: 85% of Medication Lists 98% of Medications 8
15 % Error Rate Baseline DPMO:,7 Z score of. 5% Error Rate Baseline DPMO: 53,4 Z score of.5 9 Project: Phase II June Nov Results Define Process - Hospital Handbook - Defined Roles - Problem List Admit & Discharge Process - PCP Notification -D/c Summary Revised -HFU Appt. All patients -Verbal Sign out to PCP June Sept March June Sept Team - Staff # - Models 3 Day Readmission (Mean) Staff # Nov4-5 Historical complication 53 patients Nov5 - May Phase I results Phase II results.% 5.79% 3.74% March 7 Mortality.%.3%.93% Hand-Offs -Sign-Out 3 -> -Handoff Module (SBAR) Complication.3%.8%.8% Hospital Metrics
16 Phase I June 5 Phase II June 7 3 3
17 Project Phase III Dec 7 - Define Process - Hospital Handbook - Defined Roles - Problem List Admit & Discharge Process - PCP Notification -D/c Summary Revised -HFU Appt. All patients -Verbal Sign out to PCP Hospital Metrics June Sept March June Sept Team - Staff # - Models Hand-Offs -Sign-Out 3 -> -Handoff Module (SBAR) Staff # Warfarin Discharge Process -Transition only to PCP -Pharm D Tasked to Review -Enhanced Inpatient education - Tracking 7 March HFU Appointments - -Med Rec -Lost elements of d/c plan Social Determinants of Health Project Define Process - Hospital Handbook - Defined Roles - Problem List Admit & Discharge Process - PCP Notification -D/c Summary Revised -HFU Appt. All patients -Verbal Sign out to PCP Feedback: -Review of All D/c Summary for errors - Feedback to Team - Error tracking Readmission Tracking - Review and Categorize all - Readmissions within 3 days with - RCA to all team members involved Hospital Metrics June Sept March June Sept Team - Staff # - Models Hand-Offs -Sign-Out 3 -> -Handoff Module (SBAR) Staff # Warfarin Discharge Process -Transition only to PCP -Pharm D Tasked to Review -Enhanced Inpatient education - Tracking 7 March HFU Appointments - -Med Rec -Lost elements of d/c plan Social Determinants of Health
18 Focus on Process: Defined Ownership Feedback Controlled 8% Process % Individual A Bad Process will Defeat a Good Person Every Time You have to Measure it to Fix it. In God We Trust Everyone Else Bring Your Data Project Phase I June - Dec 5 Define Process - Hospital Handbook - Defined Roles - Problem List Admit & Discharge Process - PCP Notification -D/c Summary Revised -HFU Appt. All patients -Verbal Sign out to PCP Phase II June - Dec Feedback: -Review of All D/c Summary for errors - Feedback to Team - Error tracking Phase III Readmission Tracking Dec Review and Categorize all - Readmissions within 3 days with - RCA to all team members involved Hospital Metrics June Sept March June Sept Team - Staff # - Models Hand-Offs -Sign-Out 3 -> -Handoff Module (SBAR) Staff # Warfarin Discharge Process -Transition only to PCP -Pharm D Tasked to Review -Enhanced Inpatient education - Tracking 7 March HFU Appointments - -Med Rec -Lost elements of d/c plan Social Determinants of Health
19 Please Complete the session evaluation. Thank you. 37
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