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Using change management to install med rec process
Contra Costa uses rapid cycle change for success
Why has The Joint Commission backed away from medication reconciliation for 2009? "Basically because they realized it's very, very, very hard to do. I've been involved in the IHI community, and I don't think anybody had any idea how hard this would be to do, even people in the trenches. I don't think anybody realized how complex this was," says Steven Tremain, MD, ABFP, FACPE, chief medical officer and chief medical information officer at Contra Costa Regional Medical Center (CCRMC) in Martinez, CA, and senior medical director, Contra Costa Health Service.
When work on medication reconciliation began at Contra Costa in 2005, Tremain, trained as a family physician, was director of system redesign and executive sponsor for innovation work at the Institute for Healthcare Improvement.
Tremain begins the med rec story with the three things that set the hospital up for a better chance of success.
One, he says, "We are not a community hospital, we're a closed medical staff. And we're not even a university hospital, we are a residency program; we train family medicine residents, and we have basically family medicine or general internist hospitalists oversee the care of every inpatient and teach the residents along with the subspecialists who are appropriate. But basically every patient in the hospital belongs to a generalist hospitalist team. So there is a generalist who owns every patient. We don't have this thing of five different specialists not wanting to take responsibility that they didn't prescribe."
Two, the physician champion on board recognized from the get-go that physician involvement and ownership was essential to the med rec puzzle.
Three, the team's understanding of human factors and change management systems. We had a very acute knowledge of change. "We learned the [IHI] improvement model; we even sent our team leader back to the IHI, and she participated in their improvement advisor program.
"So we didn't try to do this from the seat of our pants. We begged, borrowed, and stole from others, and then we made this a high priority in the organization because we knew how difficult it would be," he says.
Short team meetings important
Initially, the team met every Friday for 45 minutes, from 11 to 11:45 am. The team included the hospital's director of ancillary services as lead; a physician champion; a resident; a nursing champion; two pharmacists; one pharmacy technician; a clinical informaticist; a forms expert; a nursing rep for every service; and an MD for every service.
"They followed the whole improvement model to the letter. They understood small tests of change; they understand rapid cycle improvement," Tremain says.
"If you would Google high-functioning team, you would find several attributes for that team. This team met every one of them: multidisciplinary, goal-oriented, and a lot of team collaboration."
Within the first meeting, the team reviewed other mentor hospitals' policies and procedures and drafted a procedure for CCRMC that they planned to trial the following Monday. They chose an 8-bed telemetry unit. "It's a controlled environment, there's less staff, and it's only 8 beds," Tremain says. How small was the small test of change scheduled for the following Monday? One patient.
Use small test of change
As part of its small test of change, an element of IHI's model of improvement, the team decided to test the first patient admitted to the tele unit Monday morning. The direction was first to tackle admission, then transfer, and finally discharge and after testing to roll out it out in that order.
Using the med rec form, dummied up in the initial meeting, the resident admitted the patient. It didn't work. "Of course not. Where have we ever gotten this presumption that we can design something in a room and it would work? The Wright brothers' plane didn't get designed in a room," Tremain says.
The team huddled immediately after this trial and changed the process and the form based on what they saw in the test and scheduled another test of change for the very next day.
"They cycled this. And over 14 days, they had somewhere between six and eight iterations of this process. That was August 2005, and we've changed it once since then — the real proof of a well designed small rapid test of change," Tremain says. "To the casual observer it sounds like, 'Oh my God, we've got this mandate from The Joint Commission. We've got to do it in five months. What do we do? Why are you wasting your time on one patient?' Because that's where you learn."
So the team worked out the kinks in the new admission process within two weeks. During that time, the team met with residents who do the majority of admissions at CCRMC. Historically, Tremain says, the residents would write the medications in the patient's history, then write them again on the order form. "And then we were asking them to do this med rec process a third time? So understanding the work flow, we said, 'Hmm, what if we declare this med rec form part of the medical record and when we get to the H&P, the resident can write 'see med rec form'? The resident writes down the meds on that form and then we have a simple discontinue, continue, modify; circle one and now that's the order form, too. So the physicians have to write down the meds once."
Taking away steps, making jobs easier, the work panned out for CCRMC. The change also affected the nursing process of med rec. Previously, the nurses were doing their own medication reconciliation. "Do you think the nurses' lists and the doctors' lists were ever reconciled against each other? No. So we told the nurses, 'Stop writing down your lists. You can write on the med rec form on your intake, too,'" Tremain says. The nurses then could take the med list completed by the physician and verify it verbally by reading it to the patient.
"Now we're doing a second check. And they're not unlinked. So we basically went from writing it down twice for the doctor and once for the nurse to writing it down once by the doctor and none by the nurse.
"Overall, this was really an exercise in change management, and we didn't do it by beating people over the head," Tremain says. He's often asked to come into a hospital to help implement a med rec process. "This is where I criticize some of the other organizations, particularly about med rec. I've been in and out of quality since 1983, and I don't want to go through all this just to check the box, to have a better look at core measures or a better look at The Joint Commission. If this is not going to benefit patient care, then I don't want to be a part of it. I will not just do it to put a veneer on a bad subfloor," he says.
"I've seen so many hospitals that I've gone to to help them do this; they've scanned the margins of the regulation and a doctor signs and says I've reconciled them and nobody knows if they have. And you walk away thinking, is patient care better here or not? There's a lot of push back about medication reconciliation because of how it's being done; the organizations don't see value added to it because they're just checking the boxes."
Using change management models
"The principle issue of our success was the very fact the whole design and roll out was done with modern change management and human factors and the whole model for improvement, and it was not shoved down their throats. And so they drove it. All the enhancements were staff-driven. They weren't management-driven," Tremain says.
"And so we had initially a sort of captive spread until it had enough momentum and we'd refined the process enough to roll it out and we used all the same change management processes to transfer it to discharge. And we found out when we got to discharge, 'Oh oh, we've got a flaw in our process that you're never going to pick up until you get to the discharge process.' So we had to go back and refine the admission process," he adds.
The team completed six or seven rapid cycle change iterations in their trial run on the tele unit. The key to the success? Thinking small in terms of tests of change. And helpful in this, Tremain says, is speaking to frontline staff. Talking with a surgeon, for example, who regularly uses the pre-op form and asking: Why are using it some days and not others? "You might get an answer that has eluded you in just five minutes. So that's really the key," he says.
"One of the phrases we use is 'make it easy to do the desired thing,' whatever that is. Then as you get good at that 'make it hard to do the undesired.'"
The process today
When a patient is coming in as a direct admit from a physician's office, the admitting physician talks with the patient as the first attempt to complete a home med list and compares that to the information in the medical record modules. The physician makes any necessary changes and the patient is admitted. If the patient enters the system from the emergency department, the bedside nurse there, along with the assigned physician, goes over the list with the patient and reconciles it. If that patient is admitted, the admitting resident does it again as a double check. Then the admitting resident or the attending physician writes down all the meds and circles on the form for each med either continue, discontinue, or modify. The nurse takes it off his or her records and the physician adds any additional medications on the form, which is transmitted to the pharmacy. A pharmacy clerk inputs it there and, after approval from the pharmacist, the medications are ordered and sent to the floor.
"We have a check in the ED, a check on admission, and now the nurse is doing his or her intake and they're checking the meds again. When we have questions, we call the local pharmacy. Now we have a reconciled medication list on admission. And then that gets reconciled any time they're moved up or down, not just up but up or down. We do not do lateral transfers because of bed issues and things like that. We do reconcile on the way to the OR and back. We reconcile on discharge," Tremain says.
The last step — discharge — "is where it gets tricky," he adds. At admission, you have the home med list and the admission hospital med list. At discharge, the doctor looks at all the electronic reports, which are manually entered in the pharmacy every time an order is made; the system does not yet have direct order entry. The discharging doctor prints out this report — the home list and the active inpatient med list, and for each medication marks continue, discontinue, or modify. That serves as the outpatient discharge prescription. The goal, Tremain says, is to combine steps when possible and simplifying a process "as long as you can maintain its accuracy." Simplifying tough processes, he says, besides making them faster, makes them more accurate, as there are fewer steps where mistakes can be made.
When the patient is discharged and goes to the ambulatory center in the CCRMC system, the provider can see the discharge list on his or her PC.
WIFM stands for "What's in it for me?" a principle in not just motivating staff but encouraging their acceptance by proving that it's helpful to them doing their job. At CCRMC, Tremain says, "the doctors are the drivers for admission and discharge, and the nurses are the drivers for transfers."
"The WIFM for the transfers all comes to the nurses because they've been scratching their heads. So the nurses are the main drivers of the transfer process because they have the most to gain from it," says Tremain. Keeping WIFM in mind in designing systems is a critical component.