Ask crowd: How many have been admitted to hospital?How many ever wondered how their medications are ordered?How many wondered whether they are receiving the right medication, with the right dose at the right time?This is the objective of MedRec – to ensure that the right home medications are re-ordered upon admission.
Best Possible Medication HistoryReconciliation or ordering of home medications
Regional MedRec form used by Vancouver Coastal sitesOrdering: Dr. makes his/her intentions clear about what to do with a patient’s home medications (e.g. continue per pharmanet, dc, etc., change dose, etc.)
MedRec aims to: 1) Reduce unintentional discrepancies (discrepancies that can lead to medication error or patient hard, such as omissions, unintentional changes in doses, etc.)2) Reduce intentional undocumented discrepancies (e.g. Dr. intentionally changed dose, but didn’t document anywhere on chart. So, it creates additional workload for staff to clarify orders)This could mean: Patient harmLower quality of careReadmissionsAdverse effects on patient flowAdditional costs due to extended length of stay of 2 to 8 days
Emphasize MedRec is implemented only on admission…
As a site, LGH chose to implement MedRec through the use of Lean Methodology.
Used this tollgate was used to plan for the project
Observe the process and workflow in Admitting and the ED
MRO printed automatically for areas with “likely admits”; upon request for other ED areas Stakeholder engagement: Engaged clinical nurse educators, admitting managers, physicians, pharmacists, and ED leadership team Getting “process workers” to design future stateAdditional info: Lions Gate ED uses clindoc, which does not have the dedicated section for medication history
Useful when: Variation in work Poor outcomes when training new staff Inconsistent patient/worker satisfaction Unable to maintain previous improvementsIncludes: Sequence of tasks (who will do what), Best practices to complete the activity, The length of time it takes
Snapshot of the Standard work instruction disseminated to unit leaders and staffEnsures process is performed the same way – reduces variation and enables us to improve the process
Implemented the use of Breakthrough lanes, which is a Lean tool used to track issues and develop action plan at the frontline level.Daily tracking sheet: Used to audit MedRec completion on a daily basis; used mainly by nurse educators or PCCs.
Pareto Chart to track “common themes” or “common reasons” why MedRec is “missed”
Develop Action Plan to address the issues highlighted by the pareto chartMost units discussMedRec issues at their safety huddles or staff meetings.
Explain the 2 types of discrepancies
Data from Decision Support
Address process issues first before implementing change(s)Risk management Engagement and partnership Clear process Small, incremental changes Try and try until you succeed!
A systematic approach to taking the best possible medication history and reconciling home medications1A partnership between caregivers and patients/clients in order to obtain accurate medication information during various transitions of care1A conversation around medications taken at home
Address process issues first before implementing change(s) Staff engagement is key in refining the process (ensure future state works for process workers) These are some of the issues around medication management that MedRec highlighted. So, we worked or are actively working on resolving these issues, so that MedRec can be smoothly incorporated into people’s workflow.
A2 Laarnie St-Laurent - Admission Med Reconciliation at Lions Gate Hospital
Admission MedRec at Lions Gate HospitalObjectives:•What is MedRec?• Why do MedRec?•How was MedRec implemented? Brief overview of Lean Methodology How Lean was used for implementation•How are we doing now? Audit Results•What are key “lessons learned?” Impacts of MedRec
Admission MedRec at Lions Gate HospitalEver wondered…• Right medication? • Right dose? • Right time?
Admission MedRec at Lions Gate HospitalWhat is MedRec?
Admission MedRec at Lions Gate Hospital What is MedRec? “Best Possible” Reconciliation Medication (Orders) History Pharmanet(Prescribed Drugs)
Admission MedRec at Lions Gate HospitalWhy do MedRec?Did you know…• “40-50% of patients on admission” are at risk of unintentional medication discrepancies? Medication errors may harm patients Of these, 6% are at risk of harm serious enough to increase length of stay from 2-8 days2.
Admission MedRec at Lions Gate HospitalWhy do MedRec?Some Local Data• At Lions Gate: About 38.8 daily admissions 12.5 patients at risk of unintentional discrepancies 0.75 patients daily at risk of staying 2 to 8 days longer About $246K additional costs per year (based on average cost of $450/patient/night)
Steps to Achieving Continuous Improvement– sequence to approach the tools Other tools to And Then: improve flow and implement pull Repeat! Mistake Proofing Visual Controls Unit Layout/ Cell Design (Flow) Rather than thinking specific tools do not apply, consider Standard Work if their concept can provide benefit.Observe andCollect Data See for yourself & collect objective data that becomes the starting point for discussions Adapted from Virginia Mason Lean Leader Certification Materials
VCH Improvement System Lean Tollgate Sustainment Audit/Refine Implementation/ Go-Live Future State Development Current State Analysis ProjectDefinition LTS_VCH Improvement System_V1
Admission MedRec at Lions Gate HospitalHow was MedRec implemented?Observations: Data Collection
Admission MedRec at Lions Gate HospitalHow was MedRec implemented?Future State Value Stream Map Triage Emerg Nurse Emerg Admission Doctor MRO •BPMH printed documented by for RN or certain Pharmacist on areas in •MRP Emerg reconciles home medications •MedRec Order (MRO) form processed
Admission MedRec at Lions Gate HospitalHow was MedRec implemented?Standard Operating Procedures: Who What How When Why
Admission MedRec at Lions Gate HospitalHow was MedRec implemented?
Admission MedRec at Lions Gate HospitalHow was MedRec implemented? Auditing and Breakthrough Lanes: Did not meet MedRec criteriaMet MedRec criteria
Admission MedRec at Lions Gate HospitalHow was MedRec implemented?Auditing and Breakthrough Lanes:Why did not meet MedRec criteria?
Admission MedRec at Lions Gate HospitalHow was MedRec implemented?Auditing and Breakthrough Lanes: Did not meet MedRec? Now what????
Admission MedRec at Lions Gate HospitalHow are we doing now? Organizational TargetsCompletion Rate 75%BPMH Completion 75%Reduction in unintentional discrepancies 75%Reduction in undocumented intentional discrepancies 75%
Admission MedRec at Lions Gate HospitalHow are we doing now? Area Quantitative ResultsElective Surgery: •100% have complete, accurate• Implemented on November 2011 medication histories •100% receive post-op medication orders • 75% reduction in unintentional discrepancies • 85% reduction in undocumented intentional discrepancies
Admission MedRec at Lions Gate HospitalHow are we doing now? Area Quantitative ResultsEmergent/Direct Admissions •77.5% to 80% reconciliation rate• Implemented on May 23, 2012 (exceeded target of 75%) •47.5% “best possible medication history” completion rate •50% reduction in unintentional medication discrepancies •55% reduction in undocumented intentional medication discrepancies
Comparison: Vancouver Coastal Site Average Completion Rate • Since ImplementationRichmond Hospital 60%Vancouver General 78%Coastal Squamish General 60% St. Mary’s Hospital 65% Powell River General TBA Lions Gate Hospital 78%
Admission MedRec at Lions Gate HospitalHow are we doing now?Examples of “good saves” and QualitativeResults…
MedRec Success Stories Unit Good saves…Emergency MD ordered only one of patient’s home meds at half the dose the patient was taking. When med history was taken by RN, MD ordered the rest of home meds (5 pages were missed).Pediatrics Patient’s Pharmanet only showed one medication. When BPMH was taken, patient was taking medication at a different dose than on Pharmanet and was also taking a number of other medications NOT on the Pharmanet.Daycare Surgical patient was seen in PSSU 2 weeks prior to surgery, but had filled other prescriptions since then. Daycare RN picked up on new meds when BPMH was done prior to surgery.
Admission MedRec at Lions Gate HospitalReference List:1 Canada. Accreditation Canada. Required Organization Practice. Ottawa: Accrediation Canada, 2012. Print.2 Canada. Optimizing Medication Safety at Care Transitions – Creating a National Challenge. Toronto: 2011. Print.
Admission MedRec at Lions Gate Hospital Thank you for listening! Questions???
Admission MedRec at Lions Gate HospitalWhat is MedRec? Systematic Partnership Conversation February 27, 2013
Admission MedRec at Lions Gate HospitalHow was MedRec implemented? 25 Steps to Lean Map theThinking 1 Value Stream Specify Value 3 5 Establish Work to Flow Perfection 4 Implement Pull Source: James P. Womack. Lean Thinking. February 27, 2013
Admission MedRec at Lions Gate Hospital Medication Management Paper flow Audit & Refine Implement February 27, 2013