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Make med rec intuitive, not just another step
Identify value- and non-value-added steps
Barnes-Jewish Hospital submitted its medication reconciliation initiative as a poster for the Institute for Healthcare Improvement. Work began in January 2005 and the process was implemented in May 2005 — a quick turnaround — but it "is continuing to evolve and is a reasonably strong practice," says Colleen Becker, RN, MSN, CCRN, perioperative services patient care director of the St. Louis, MO-based hospital.
The hospital is an academic medical center, with residents, private and faculty physicians, as well as nurse practitioners and physician assistants. "So we have a lot of prescribers in our lives," Becker says.
The med rec team included the hospital's manager of clinical pharmacy services, Tony Kessels, PharmD, as Becker's co-lead, as well as surgeons, attending surgeons, residents, attending medical providers both private and faculty, medical residents, and nursing, and Beau Richmond, MA, one of the hospital's performance improvement specialists.
The goal from the beginning, Becker says, "was that we would try to not make more work for everyone. That we would build what we thought was already occurring, just into a documentable fashion. So we thought that people were already doing medication reconciliation in their head; we just needed to provide them documentation tools to make that visible. And so that was our promise."
Medication lists also serve as order lists
The med rec process starts at admission or entry into the organization. When a patient's history is taken, all the drugs that patient is currently on are written down. "Then in that same document, we worked with pharmacy so the prescriber can turn that into an order by checking boxes and signing off on it. And so then the bulk of the work that they already were doing, they would still be doing but it's one and done as reconciliation. Where we had electronic documentation, we built med rec into that as much as possible." Though there were limitations to what that system could do, Becker says the team was able to decrease potential transcription errors and errors due to legibility.
If the list remains a list and is not used as an order form, a report goes into the patient's medical record. If there is an order, it gets scanned to the pharmacy, which reviews it along with the patient's allergy history and dispenses appropriate medication.
"When [prescribers] write for something, they have to sign it and say I'm on Xanax 0.5 mg one per day. So that's the history part. And then what they do, if it's going to turn into an order for reconciliation it says continue this patient on this medication — yes or no. And it's also in the electronic system. If they check yes, we have an internal requirement where we also require a reason as to why the patient is on the drug," Becker says. The reason can be something simple, such as fever or anxiety, but a reason must be documented.
Richmond says, "the physician has made an active decision to either continue or not continue one of those home meds as part of the active med regimen."
A facilitator on the team, well versed in Lean, educated the team on the system's principles. After the education portion, the team was split into two-member groups, which went to every place in the hospital where orders were written. Each team flowcharted every step of the admission medication process, which were put up on the wall for the whole team to see and evaluate. "And so that was so visual and so demonstrative and so powerful a tool. We didn't add any additional steps, no additional pieces of paper. So we had metrics from the very beginning; we started designing our process, and we maintained metrics through our process, and so we did a pilot, a small test of change, with our new process on surgery and medical departments," Becker says.
With its guiding principle of creating less work and making the process as intuitive as possible, the team looked at all the steps, counting them and defining them as either value-added or non-value-added items. Those identified as non-value-added were eliminated.
The initial measures the team looked at were:
To begin with, these measures were valuable, Richmond says. "Some of the questions we started asking ourselves initially were: Where does this exist? Where does this medication list exist? Is it just in the H&P? Is it in other notes? Where can I find the information?"
Now, the "list" is in the order section of the patient's medical record and is electronic.
When patients are transferred between inpatient divisions, the patient already has a med rec form in his or her chart from admission. Those data are entered into the nursing electronic system as well, creating what's referred to in-house as "Eemer," the Emtek medication reconciliation report.
The Eemer has both the patient's home medications and active medication list "so the prescriber can look at all of those and it has the yes/no checkbox on it. They make their clinical medical decision whether to continue the drugs with indications and then [the form] also has blank spots on the bottom so if [prescribers] want to add something, they can. And then they sign off and it becomes an active order, again scanned to pharmacy," Becker says.
The Eemer is helpful because "when it's printed out, you can see at the very top of that form what the home meds are, if there were home meds entered on entry to the organization. Whatever clinician is looking at that paper doesn't have to go back to the paper chart and start flipping through the order sections. It's right there at the top of the sheet," Richmond says.
Use of the form also eliminated several steps from the process as it had been. Physicians can print the form themselves when a patient is going to be transferred. "I don't have to look for a chart, I don't have to look for a piece of paper and then go find the chart. There was such waste in the process. It was amazing. Not just the number of steps but the amount of time that it took those people to be able to do their work," Becker says.
The Eemer is also useful in the next stage — discharge. The nurses have it available when physicians are ready to write their order for discharge. The form, though, Becker says, is written for clinicians, not patients. The nurses are tasked with translating the information into language patients can easily understand and adhere to. "Then it goes into documentation as the form the patient will take home. It goes with them and to each facility transfer," Becker says.