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Med rec: It may be the monkey on your back but it's not going away
The challenges to tackling medication reconciliation
"This has been the single most difficult process I have ever worked on to try to implement," says John Benson, PharmD, quality manager, department of pharmacy services at Intermountain Medical Center in Murray, UT.
While no one will deny medication reconciliation is a complex task, and even The Joint Commission has said it will not base accreditation decisions on the goal in 2009, the requirement isn't going away. So what can you do to get your processes in order? Hospital Peer Review spoke with several experts who will share strategies they used at their respective hospitals to help you get your med rec game up to speed.
• Med rec is only part of a larger system problem.
"I don't have a silver bullet. I wish I had a silver bullet. The takeaway is that it is very complex; however, some of the problems are not medication reconciliation problems but are symptoms of other system problems," says Frank Federico, RpH, content director at the Institute for Healthcare Improvement, pointing to communication as a weak spot in health care — communication between providers, during hand offs, and with the patient and post-acute care providers.
When there are problems communicating with the patient's next provider of care, that can create problems with the discharge summary, Federico says. Often the hospital is unable to get the patient's primary care physician on the phone. "So that's a real challenge," he says. "I think what hospitals have uncovered with medication reconciliation is that we have this problem and it has nothing to do with medication reconciliation. It's a hospital problem. If they can't get the list out, it probably means there's problems with the discharge summary as well. So when I coach teams and talk about it and they say, 'It's such a challenge,' I'll say, 'Is that really a problem with the improvement you're trying to make or is that a symptom of a larger system problem you have?'"
The internal communication surrounding internal transfers is indicative, Federico says, of the "hand-off problems in hospitals." The intent of med rec was to ensure that as patients moved through different levels of care, providers did not forget to reorder medications that should be reordered or that medications that were discontinued at one level need to be restarted at another or that medication administration needs to change from oral to IV, he says.
• Physician involvement is key.
All the experts HPR spoke with agree that engaging physicians in the med rec process is not only key but necessary.
Steven Tremain, MD, ABFP, FACPE, chief medical officer and chief medical information officer at Contra Costa Regional Medical Center in Martinez, CA, and senior medical director, Contra Costa Health Service, says: "Our champion physician on our task force, at the very first meeting, said this is a physician's job; it's not a nurse's job. This is medication. We're the only people in this place licensed to write prescriptions. Medications can kill people. This is the doctors' job. We know a lot of people who say this is a nurse's job. I think that's wrong and I will take this torch to my colleagues. So this is a physician's job.'"
The key to success for any facility undertaking med rec, and the key to his system's own success, Tremain says, is having physicians on board, and, perhaps more important, to listen to what their days are like, what their work flows are, and what they think the problems are.
Benson learned the hard way that not having physicians on board ultimately can hurt the process. "If I had to do this over again, one of the first things I would do and recommend to others still really early in the process is try to get physician involvement very early on because they really play a much bigger role in this than we ever considered." Initially, the Intermountain team thought the process would be done with the involvement of nursing and pharmacy. But it found that the lack of physician involvement at discharge, which Benson says "is very much a physician process," complicated the med rec process.
"So having physicians involved and speaking to how this affects them and having it be a really successful process requires that they be really involved," he says.
"The key about any of this is physician engagement, physician engagement, physician engagement, physician engagement," Tremain says. "Most of the places where I've seen this done wrong have made some feeble attempt to include the physicians. The docs are resistant, the docs didn't want to play, [saying,] 'Oh my God, it's a Joint Commission thing.' So [the team] designed a process with 99% of the doctors out of the loop and the process frankly does not become a patient safety project, it becomes a compliance project."
• Take it out of the classroom, engage staff.
When staff hear Joint Commission, they may think, "Here we go, another job for me to do," and this is where quality improvement directors often get push-back. When processes are presented as helping employees to do their job and not as a requirement coming from the top down, there is a much better likelihood for compliance.
Speaking to this, Beau Richmond, MA, performance improvement specialist at Barnes-Jewish Hospital in St. Louis, MO, says "when you engage frontline staff and those who do it every single day, you not only get their buy in, but within time they actually come around generally. Some of the biggest proponents are now the ones who praise us and say, 'I don't know what I would do without my med rec form.'"
One of the biggest lessons the team at Barnes-Jewish learned through its med rec implementation process was that "you've got to get out the classroom," he says.
Richmond, who as performance improvement specialist, often leads teams through process changes says, "With just about everything I'm involved in, a key to success is having a multidisciplinary team at the table. People from all venues that are going to by affected by the process... Engaging your frontline staff, I cannot stress enough with the initiatives I'm involved with. Those are the ones where I truly have success."
He adds that it's valuable to also have a third-party discipline, not affected by the process change, that can review what you're doing and question processes that don't make sense intuitively.
Echoing Richmond's assertion about "getting out of the classroom," Tremain says creating an environment where change is possible involves "including a lot of those frontline workers, and critically important is getting out of the conference room" and seeing the proposed process played out in real time with frontline staff work flow. This is where modifications or changes that needed to be made present themselves.
"For us," he says, "it was sitting down with the attendings and the residents and understanding the work flow. It took time to invest in spending and actually watching them do an admission, watching them do the paperwork, make some suggestions and listen to their push back and listen to their ideas and incorporate those. That is critical."
His team refined the process over 18 months "and we had many, if not all, doctors on board. Then we reached the tipping point where we needed to mandate it. But we didn't mandate it with 5% of people on board. We mandated it when we had refined it. Fifty to seventy percent of the people were doing it. Then we mandated it, took away the paper prescriptions, so they had no choice, and then we helped them learn."
• Make less work, not more.
Everyone acknowledges health care workers are overburdened with work these days. "We understood their work flow when we put the process into the work flow and we did something critical for change management — we gave them less work, not more work," Tremain says.
With regard to change management, "it's really about understanding the work flow, respecting the employees, recognizing the line employee is an LKE [a local knowledge expert]. They know what's happening in their area. It can't come down from the C suite, it can't come down from the nurse manager's office."
• Understanding change management, using iterative processes and rapid cycle change.
Each hospital HPR spoke with uses some sort of change management system — whether it be Six Sigma, Lean techniques, rapid cycle change, iterative process change, or IHI's model of improvement or the plan-do-study-act (PDSA) process. So understanding and using one of these types of processes should help inform your process change.
Benson says, "One thing that we learned and built it into the proposal was to do an iterative process in implementing medication reconciliation. In other words, we would meet as a group with nursing and pharmacy leadership of the unit when we were implementing medication reconciliation and we would talk about what the process needed to be, the forms we needed to develop, and so on. Then we would implement what we'd talked about and run that for a week or two and then we'd get back together and talk about what's working, what's not working, and where we needed to make adjustments. We did that about three times before we called it implemented."
Once you've implemented it, Benson cautions to not think of it as done, checked off. "One tip would be to continue to reevaluate your process periodically. I think that's important, to not just think it's done... you need to keep looking at it."
• Use "stories" to motivate staff. Data lacking on the efficacy of med rec.
With not much data on how medication reconciliation affects medical error rates, a lot of team leaders have found using "stories" of where med rec might have saved a life or mitigated a harmful event useful. In the face of limited data, Tremain says, "This is where you use the power of stories. Data talk to the head, and stories talk to the heart. You'd like to use both, but sometimes you don't have enough data and then you have to use story."
Throughout the rollout, Tremain says he used such stories. For instance, he told the story of a patient discharged from a unit that had not yet adopted the med rec process. That patient was discharged on warfarin. Once at home, the patient also took the Coumadin in his medicine cabinet not knowing, of course, that one of the two should have been discontinued. "There was no big tragedy; they came in, they had some minor gum bleeding and saw the ER doctor, who saw they had real high levels of Coumadin. If that patient had been on 4B [where the med rec process was in place] that would not have happened," Tremain says.
But Benson does have some numbers in his arsenal to prove the importance of med rec. Together with a PhD nurse researcher, Benson was awarded a grant from the American Society of Health-System Pharmacists to study med rec. He chose two hospitals within the Intermountain system similar in size that also had similar nursing units. Med rec was to be implemented at only one of the facilities, and the team would research baseline data on medication errors in the nursing units and then after med rec implementation at one would do another comparison of error rates.
Pharmacy technicians collected the data from a "very careful" medication history from the patient compared to the admission orders written by a physician and transfer/discharge orders. They looked for errors, duplications, omissions, etc. Comparing those, Benson says, "we calculated how many errors occurred at each site in each of those stages — either pre-implementation or post-implementation phases — and then we compared them to the two sites." The end result? "We found a fairly remarkable difference. There was a statistical and quite a significant difference in medication error rates at the site where we implemented medication reconciliation."
Of course, that afforded Benson with pretty good ammunition to prove the case to implementing med rec at Intermountain. "Once you start showing them hard data that say this makes for less errors and less mistakes and it improves patient safety, everybody pretty much was able to respond to that... It's not only a Joint Commission thing, but this is the right thing and it works."