National Jewish Health Best Practices for Medication Reconciliation in a Respiratory Academic Medical Center Introduction/Background/History: Please include any relevant information that may be helpful for others to understand this initiative. Medical Reconciliation (MR), a 2012 Joint Commission requirement, is the process of systematically and comprehensively reviewing all the medications a patient is currently taking to ensure that medications being added, changed, or discontinued are carefully evaluated with the goal of maintaining an accurate list and avoiding potential safety concerns. In 2006, The Joint Commission first introduced MR as a required component of the National Patient Safety Goals (NPSG). In 2009, the Society for Hospital Medicine convened multiple stakeholders to produce a consensus statement on MR that was endorsed by many leading organizations, including the American Academy of Pediatrics, Institute for Healthcare, The Joint Commission, Society of General Internal Medicine, and the Society of Hospital Medicine. In addition, the 2010 Patient Protection and Affordable Care Act identified MR components that are critical for optimized patient care. Although properly reconciling medications is proven to reduce medication errors and adverse drug events (ADEs), there are many barriers to implementing MR processes in hospitals and outpatient settings. As a global leader in respiratory health, NJH treats patients from around the world, many of whom have difficult-to-manage respiratory disease and multiple comorbid conditions. This complicates the MR process, as patients may see multiple providers within the system and may have incomplete medication histories. NJH has over 300 health care providers (HCPs), and over 40,000 patient encounters each year, many of which are from patients with asthma, COPD, or other respiratory illnesses. MR is extremely important in this patient population because of the increased risk for polypharmacy. In an effort to improve our process as well as the outcomes for our respiratory patients, NJH has identified an interdepartmental process redesign team to carefully examine its current MR process and data in order to identify gaps and areas for improvement. Objective Electronic Medical Record (EMR) data as well as subjective interviews with NJH providers indicated a strong need for improvement, including improved documentation and a standardization and simplification of the documentation process. Initiative Goal: Please describe the overall goal of this initiative, including the patient population or disease area that this initiative will address. The overall goal for this initiative is to meet The Joint Commission requirements and quality standards of at least 90% of patients receiving an accurate medication list after visiting National Jewish Health. The supporting objectives to achieve the overall goal include: 1. Identify quality indicators for an accurate medication list and meet quantitative goals for these indicators. 2. Improve the interdisciplinary process of MR at NJH. 3. Develop education and tools for providers and patients that are sustainable internally and replicable externally.
4. Improve communication with patients through print and hands-on education as well as use of the patient portal. 5. Improve patients transfer of care by communicating accurate medication lists with physicians outside of NJH. Target Learners: Please describe the intended participants of this educational initiative, as well as the estimated number of learners. The new process will be piloted on the adult respiratory clinics, and lessons learned from our pilot will be applied to the rollout of the MR process to the rest of the institution, which includes 134 MDs, 117 nurses, and 46 MA/CNAs, and 5 pharmacists. Patients will also be a target audience of this initiative. Collaborators: Please include a brief description of the role of each collaborator in the initiative. At NJH, we believe that a collective team approach is better than a team of one in order to achieve the most robust and comprehensive educational programs, including needs assessments, educational design, activity implementation and educational outcomes that ultimately lead to improved patient health. This project is interdepartmental in nature, and includes the following key collaborators at NJH each department has a member on the practice redesign leadership team: Department of Medicine (Allergy & Pulmonology) Department of Pediatrics Department of Pharmacy Department of Administrative and Executive Services Department of Information Services and Technology Department of Nursing Department of Patient Quality and Safety Department of Professional Education Patients Educational Design: Please describe how this initiative will be designed, as well as the approximate time span of this initiative. This program is a 24 month initiative from planning to completion of outcomes, and has been designed using an adaptation of the a toolkit based on the Medications at Transitions and Clinical Handoffs (MATCH) website, which was developed through the support of the Agency for Healthcare Research and Quality (AHRQ), and was based on a collaboration between Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, and The Joint Commission, and helped us to create a systematic methodology and framework for our program design in order to critically review and improve our process. The MATCH Toolkit includes the following step-wise approach, which we ve adapted to meet the needs of our institution, as well as the American Medical Association s (AMA) format for PI CME:
Stage A - Baseline & Planning Stage B - Intervention & Process Change Stage C - Assessment Sustainability Step 1: Build the Project Foundation: Gain Leadership Support, Identify Resources, Project Team & Scope, & Link to Other Institutional Initiatives Step 2: Establish a Measurement Strategy using the EMR & Create a Flowchart of Current Medication Reconciliation Process Step 3: Developing Change: Design the Medication Reconciliation Process Based on Gaps & Integrate Design into Existing Workflow Step 4: Pilot Test the New Design & Develop Implementation Strategy Step 5: Develop the Education & Training Strategy & Curriculum for HCPs & Patients Step 6: Post-Assessment: Report EMR Results Step 7: Process Evaluation for Continuous Step 8: Post-Implementation Strategies to Increase & Sustain Compliance Publication Strategy: Please describe how educational outcomes results from this initiative will be disseminated. Aggregate data will be shared organizationally, locally and nationally. Our goal is that this project is sustainable internally, and also replicable by other organizations. Upon success of this initiative, we plan to use this framework with other PI/QI initiatives here at NJH. Educational outcomes will be submitted for publication to the Journal of Continuing Education in Health Care Professions (JCHEP), and a summary will be published on NJH s website, www.njhealth.org/education. In addition, we will submit an abstract for presentation at the Alliance for Continuing Education in the Health Professions (ACEHP) as well as the Society for Academic Continuing Medication Education (SACME). Educational/Quality/ Professional Practice Gaps Strategies Used to Identify Gaps (eg, peer-reviewed published data, national consensus sources for clinical performance/quality measures, chart audit/ehr data, medical claims data, etc.) Learning Objectives ABMS MOC Process (Part I-IV) and/or Core Competencies Addressed (e.g., IOM, ACGME, ABMS) Educational Outcomes/Measures (Please include Moore Level 1 when appropriate) Strategies Used to Measure Outcomes (e.g., direct and objective performance assessments, chart, medical claims data, EHR data, disease screening, patient surveys, etc.)
Missing data is a gap in quality, and can increase the risk for adverse drug events (ADEs). Our EMR can indicate that a patient is not taking any medications. This designation should be used in lieu of no (i.e. missing) data entry. An EMR audit indicated that 1% of patients were missing a medication list in the EMR altogether. A one month data snapshot showed there were 45 patients in just that one month with a missing list. The health care team (MA, nurses, physicians) will be able to ascertain and document the medication history at each patient visit, including the absence of medications. Our goal is that 100% of patients active in our practice will have documentation of a medication list, or have the documentation that they are not taking any medications. Patients are missing a sig (dose and frequency information) on prescribed medications on their list. Therefore, the medication list is incomplete, and the patient has an increased risk for ADEs. An EMR audit indicated that 17% of patients (or 606 patients in only one month) were missing a sig. MAs will be able to correctly document the medication history sig (dose and frequency), using the pharmacy tools built into the EMR. able to communicate the importance of participating in complete documentation of the sig for prescribed medications in the patients medication history. importance of providing complete and accurate medication histories, containing dose and frequency, to NJH providers. Our goal is to reduce the percent of patients lacking a sig on any prescribed medication to 5% or less. Patients have redundant respiratory medications on their medication list (listed twice, or listed as brand name and generic name), which is a patient safety issue and can increase the risk for ADEs. An EMR audit indicated able to correctly identify duplicate or equivalent respiratory medications in a patient s medication list. able to communicate the Our goal is that no patients will have any duplicate rescue inhalers medications on their medication list. We plan to expand this measure to other respiratory medications in addition to rescue inhalers.
that 5% of unique patients had at least two of the same rescue inhalers on their medication list. This equates to 157 patients in only one month s time with duplicate rescue inhalers. importance of eliminating duplicate or equivalent respiratory medications in the patients medication history. Patients are not consistently getting their printed Medication List. The print form of the list is our standard tool to communicate the medication regiment to the patients, and can increase patient medication adherence. An EMR audit indicated that only 32% of patients are receiving their printed medication list, and The Joint Commission requires that 90% of patients receive an accurate medication list. The health care team will systematically communicate the reconciled medication list in a printed form to the patients. importance of an accurate medication list. ; Provide Patient-Centered Care Our goal is that at least 95% of our clinic patients will receive a printed copy of their reconciled medication list. & Patient Surveys Patients are lacking at least one documented offer or decline of the Medication Safety handout. The Safety handout is an important patient education tool to prevent ADEs and promote medication safety. An EMR audit indicated that only 41% of patients (or 1,655 patients in only one month s time) are receiving (or declining) the Safety handout. The health care team will recognize the importance of patients knowledge of medication safety issues regarding their own medication regimen. importance of Medication Safety and will have improved communication with their health care team. ; Provide Patient-Centered Care Our goal is that at least 95% of patients have a documented receipt and/or decline of the Medication Safety Handout at the time of their visit. & Patient Surveys Please contact the educational provider for additional information regarding the initiative.