FRHS Kaizen Workshop #1
Medication Reconciliation (MRR)
Admission / Discharge Only
October 3-5, 2007
Kaizen #1: Medication Reconciliation
Admit / Discharge
Mission:
To improve the process of medication reconciliation to
assure patient safety.
Objectives:
1.
Achieve a 50% improvement in accuracy of medication
information upon admission.
2. Reduce nursing time spent by 12.5%/day.
3. Reduce delays in medication administration by 50%.
4. Reduce medical errors by 80%
5. Support the new hospitalist program.
Train-the-Trainer objectives
6. Learn Lean tools as process improvement method.
7. Diffuse improvement mindset throughout the hospital.
8. Reduce waste throughout all major processes.
Medication Reconciliation
KaizenTeam
Kaizen Team Work
David, Beth, Steve, John, Rhonda,
Beth H, Melissa, Carol, Mark, Missy,
Vicky, Gloria, Alison, Patsy
VALUE STREAM MAP – MEDICATION RECONCILIATION
Process Efficiency: 100% max, 31% min
ADMISSION
Discharge form placed
on each chart at each
location
ER
Direct
Admit
External
Transfer
Obtain list
of current
meds;
Contact
physician

Contact
external
pharmacy

Physicians
don’t respond
How to
get?
Review
initial
orders
Education
improvement
s for new
people.
Nursing making decisions
outside scope of practice.
Collaboration with
pharmacy.
incomplete orders are not
written and relayed to
pharmacy – i.e. no dose,
route.
30 – 60 min
Create standing
orders
Standardized
process for
FRHS physician
offices in
relaying med list.
Contact
admitting
physician to
identify meds
15 min
Review
external
facility list
15 min
1-2 hours
Total Admission
times:
Min: 97.2min
Max: 2.5 hr
Reconcile
meds
Computer versus
manual
documentation
system for meds (ED
gets but another
area enters)
Physicians don’t write full admit
med’s list;
Nurses act on med’s list
Admit/PCP don’t agree on med list for
patient
20 sec to 15
min
Nurse
write out
med list
(if
needed);

Fax order
to internal
pharmacy

Get
and/or
Give
meds
All pre-op meds
discontinued when
going to
surgery/transfer;
Pharmacy out of
loop;
No auto discharge
between units.
Nurses temp
orders are
cancelled and
re-entered
VALUE STREAM MAP – MEDICATION RECONCILIATION
DISCHARGE
Process Efficiency for discharge: 56% Best 30% Worse Case
Yes
Physician
discharge
order
form and
signs
Incomplete
physician
meds;
Or continue
home meds;
Physicians
don’t respond
till later.
Discharge order
about not on all
charts. Educate
nurses and
physicians on
location.
15 min
DONE
Print
Discharge
Instructions

Are meds
complete?

No
Calls physician to
complete list
Enter full
info into
CPSI
Physician task to
write meds, activity,
diet, etc.
Complete
separate
forms as
needed for
transfers.
Redo work to
getting transfer
forms
completed.
Physicians not writing complete list of
meds for patient to continue to take.
Redo
2 min
2 min to 1
hr
: Value Added
: No value added
Computer
generated list of all
home meds and
meds taken while
hospitalized.
Total Time:
Min: 41 min
Max: 112 min
Should list only
meds active on day
of discharge.
FUTURE STATE - ADMISSION
ER Admit
1a
Direct
Admit: fax
list of
admission
orders and
list of
home meds
Review
initial
orders
How
to get
info?
Review
list of
external
facility
External
transfer:
list of meds
sent with
patient
transfer
30 min
30 min
Nurse –
obtain list
of meds if
not already
provided
and enter in
CPSI
Nurse to
contact
physician
and send
MRR to
physician
for review
Fax
completed
MRR to
pharmacy
and process
and review
15 min
2 min to 60 min
20 seconds
FUTURE VALUE STREAM DISCHARGE
Physician
to complete
discharge
order form.
Separate
discharge
Physician to
forms for
review MRR to
patients
verify any home
gtransferrin
meds to resume
g to ecf or
and additional
other
meds to
facility.
continue.
Fax verify
MRR and
d/c meds to
pharmacy
to review
Review
written
discharge
instructions
with
patients or
external
facility.
Physician
to complete
20 min
2 min
0 min
5-15 min
Week #1 – Medication Reconciliation Process Improvement
PROCESS IMPROVEMENT
WHO
1
Physician order form
Patsy & Beth W.
2
At discharge bring file….
?
3
Modification of medication reconciliation report to highlight or subtract
Rhonda & Vickie
4
Standing order based on diagnosis.
Alison and Gloria
5
Go back 90 days in computer system for hospital meds
Rhonda and Vickie
6
Computerized physician orders
Missy & Beth H
7
Standard time or procedures for salary FRHS to respective physician list.
John and Steve
8
ER enter medication list in CPSI
Mark and Carol
9
All FRHS docs enter meds into CPSI – EMR, nurses pull OP list upon
admission.
10
Chart link for nurses to view past medical history
11
Education Physicians and nurses regarding medication reconciliation
Carol and Mark
12
Pharmacy contacts physician directly to clarify “missing dose or frequency”
Missy & Beth H
13
Pharm “D” goes to floor / or review electronic chart for clinical monitoring, interactions on home
& in-house medications.
14
Problem solve why all Pre-op meds are not “stopped” at pre-op, transfer
15
Why pharmacy is out of loop on patient transfer and times to stop drugs?
16
IMI to associate standards of care for medication reconciliation into physicians pay
17
Require PCP to fax current medications on admission
Missy & Beth H
WHEN
Problem Solving Report
Date: 10/3-5/07
THEME: Review Physician order - discharge form
Team: Beth and Patsy
PROBLEM SITUATION:
COUNTERMEASURE(S)
Standard: Consistent process / placement for discharge orders
Containment: edcuation of unit clerks; education of physicians (new);
continual surveying of users for improvement
Current Situation: Various processes being used due to phy preference
addition of 2nd return section for consultants (possibly)
Long term System Solution: Hospitalist program with full compliment
Discrepancy: Phy preference
Extent: Every Discharge
Why Recommended? Can't teach old dogs new tricks
Rationale: Continuity of care / patient safety / fed compliance
GOAL
IMPLEMENTATION
What
Do What: Find consistent patien discharge orders
To What: Patient records
How Much: all discharges
By When: at discharge instruction time
Who
Continue use of current form
redo form with government updates
education of unit clerks
education of physicians
When
clinical
all
areas
Care Mgmt qrtly
TL
Nov
Where
Status
FRHS
FRHS
units
done
pending
pending
CAUSE ANALYSIS
Potential Causes:
Phy Preference
location of form
How Checked?
1:1, committee
various unit clerks
with no set
placement
Result?
partial by-in
unable to find
Most Likely Cause(s)
Problem Statement:
Why? No consistant process
Why? No consistent by-in
Why? No consistent placement of order form on chart
Why? Lack of training
Why? Lack of accountability for process completion
Root Cause: Accountability Issues
FOLLOW-UP
Check method:
Check frequency:
Who will check?
Target
Actual
O
N D J F
M
Recommended Actions: all
redesign form, proof,
approvals, print, distribuet,
use, collection data
A
M J
J
A
S
Discharge
Orders
Form
Sample
Problem Solving Report
Date: 10/3-5/07
THEME: Physician provides home med list
Team: Steve & John
PROBLEM SITUATION
COUNTERMEASURE(S)
Standard: each patient should have accurate list of home meds
Containment:
Review HFAP standards & match P&P with standard development
develop new physician order sheet with options to cont/stop home meds
Long term System Solution:
Implement new med reconciliation P&P and protocol
Current Situation: phsician states "continue home meds"
Discrepancy: Nursing currentlyl making judgement calls
Extent: vaies house-wide
Rationale: Nursing unable to obtain needed information from
GOAL
Why Recommended?
develop responsibility for parties involved and avoid nurses ordering outside
scope of practice and direct physicians to specifically state medications
Do What: establish med reconciliation protocol/p&p
IMPLEMENTATION
What
benchmark facilities who have meds
To What: provides direction for nursing staff and physicians
develop P&P on Med Reconcile
How Much: every admission
By When: Nov 2007
train physicians/pharmacy/nursing
track efficiency of protocols
Who
When
John/Steve
4-Oct
Steve,
Beth
Patsy
7-Nov
Beth,
Patsy
Gloria
Dec
Beth, Patsyongoing
Where
FRHS
Status
pending
FRHS
pending
FRHS
FRHS
pending
pending
CAUSE ANALYSIS
Potential Causes:
No P&P in place
How Checked?
interview
Result?
none exists
Most Likely Cause(s): have not implemented new standard
Problem Statement: New standard has not been implemented
Why? Confusion over who is to take the lead in this process
Why? Lack of knowledge of guideline
Why? Failure to read QA updates
Why? Lack of clarity on role of pharmacy and nursing
FOLLOW-UP
Check method: interviews and chart audits
Check frequency: monthly
Who will check? Nursing leadership and QA
Target
Actual
Why?
Pharmacy
leadership
recent
change
and
contracted
service
Root Cause:
New leadership and lack of clarity on role.
J
F
M
A
M J J A S O N D
Recommended Actions:
Require physician to provide information/decision
DRAFT
Policy
Physician
List
Sample
Problem Solving Report
Date: 10/3-5/07
THEME: medication reconciliation report
Team: Rhonda & Vicky
PROBLEM SITUATION:
COUNTERMEASURE(S)
Standard: report shows current and dinscontinued meds
Containment:
change form design - give option to prevent all or only current meds
Current Situation: not utilized - doesn't fit users needs
Discrepancy: only want current meds at discharge to home
Extent: house-wide
Rationale: new report from computer system
GOAL: improve report to meet patient needs
Long term System Solution:
apply global standards to the report. Always print lines for additional
meds, always print home meds documented on admission, always print
box for meds documented on admission and for physician.
Why Recommended?
Encourage use of the report to ensure med reconciliation at discharge and
decrease medication errors
IMPLEMENTATION
What
Do What: Setup form to better fit users needs
To What: Encourage use of the report of med reconciliation at discharge
How Much: each discharge (non-death)
By When: immediately
form changes
consistent usage by staff
Who
When
Where
Vicky
Nsg
now
IS
30 days unit
Status
done
pending
CAUSE ANALYSIS
Potential Causes:
software issues
How Checked?
printed report
Result?
prints all meds
Most Likely Cause(s): not set-up correctly in system
Problem Statement: report does not meet users needs
Why? This report was not previously used
Why? Didn't know the report was there
Why? Poor communication
Why?
Why?
Root Cause:
poor communication
FOLLOW-UP
Check method: print the report
Check frequency: at least quarterly with SIQ reports
Who will check? Each dept
Target
Actual
1
10
20
30
Recommended Actions:
Initial use of report, educate as needed, implement, audit with SIQ reports
Reconcile
Sample
Reconcile
Sample
Extra Lines
Problem Solving Report
Date: 10/3-5/07
THEME: Copy pertinent history from previous stay
Team: Rhonda & Vicky
PROBLEM SITUATION
COUNTERMEASURE(S)
Standard: Accurate list of home medications needed at admission
Containment:
check security switches for RN/LPN and CNAs; Make sure all have
security switch
Long term System Solution:
train nursing to use the copy forward options in CPSI
Current Situation: Initial interview includes list of medications;
Available for 98 days
Discrepancy: RN/LPN not getting prompt or information to include
Extent: varies from patient - to - patient
Why Recommended? To fully utilize this option in CPSI
Rationale: accurate home med list provides best safety process for patient.
GOAL: provide consistent process for bringing stay information forward
IMPLEMENTATION
What
Do What: use the copy forward option
check switches
To What: cut down on time required to enter information
change 100 for RN/LPN
How Much: 30%
change 101 for Certified NA
By When: Immediately
promote use of copy forward
Who
Vicky
Kim
Kim
Nsg
When
4-Oct
4-Oct
4-Oct
4-Oct
Where
IS
IS
IS
Nsg units
Status
done
done
done
pending
CAUSE ANALYSIS
Potential Causes:
How Checked?
security switches settings IT review
Lack of training
Interview
Result?
inconsistent
don't know how
Most Likely Cause(s)
Unknown that this option was available
Problem Statement:: copy forward function not set up
Why? Didn't know function available
Why? Lack of communication
Why? Computer system education inconsistent
Why? No computer educatino process
Why? Lack of priority
Root Cause: lack of followup from softare support
FOLLOW-UP
Check method: user security
Check frequency: 30 days
Who will check? Point of Care contact
Target
Actual
1
5 10 15 20 25 30
Recommended Actions:
Provide consistency of security levels for copy forward option
DR. LANDRY - DR. JOHNSON
LABOR AND DELIVERY STANDING ORDERS
ADMISSION
1.
Admit to Labor and Delivery
2.
Nothing by mouth except ice chips until otherwise ordered.
3.
Pelvic examination by nurse to evaluate cervix and cephalic presentation.
4.
Continuous electronic fetal monitoring while in bed.
5.
Bed rest after rupture of membranes.
6.
Complete blood count, Type & Screen, if none has been done in last 24-hours at
once.
7.
Dipstick urine for glucose and protein
8.
Maternal vital signs (Blood pressure, Temperature, Pulse, Respiration) per
protocol.
9.
Notify physician after initial evaluation.
MEDICATIONS
1.
Contact physician for pain medication and/or epidural request.
2.
Intravenous fluid:
Lactated Ringers @ 125 cc/hour while in labor.
3.
If Group B strep positive start:

Ampicillin 2gm bolus then 1gram intravenously every 4-hours until
delivery.

Penicillin 5 million units intravenously then 2.5 million units
intravenously every 4-hours until delivery.

If allergic to Penicillin give:

Clindamycin (Cleocin) 900mg intravenously every 8-hours
until delivery.

Erythromycin 500mg intravenously every 6-hours until
delivery.
DELIVERY
1.
Oxytocin (Pitocin) 20 units in remaining Intravenous fluid at time of delivery of
placenta
2.
Cord blood for lab studies.
____________________________________
Physician’s Signature
Date/Time
Form # 954-646-0005
Page 1 of 1
Approved OB Section – 2-3-04
ORI.01.16.07Revised
4/2006, 1/2007
Standing
Orders
Example
Standardized Work Chart
Site:
Std Work
Sheet No:
Department
Name:
Process
Description:
Step
No.
Date:
Page:
1
Time
Observations
Discharge Form
WORK STEPS
Key Man. Auto Walk
1 Patient admitted
2 Discharged orders placed in front of chart
Physician and nursing education: orientation to
form
4 Unable to write "continue home meds"
3
5 Must review / reconcile MRR from CPSI
6 Check continue/discontinue
7 Add new meds (if needed)
8 Date / Sign
9 Fax to pharmacy for review
10 Nurse to review with patinet at discharge
KEY:
Safety
Quality
Check
Q
Delta
Critical
Takt
Time:
In-Process
Stock
Totals
Standardized Work Chart
Site:
Std Work
Sheet No:
Department
Name:
Process
Description:
Step
No.
Date:
Page:
1
WORK STEPS
Key Man. Auto Walk
2 Nurse interviews patinet and family and verifies
or obtains current home med list
3 RN documents in CPSI
4 RN contact physicina and sends MRR for review
5 Physician signs MRR with specific documentation
on initial home meds
6 Nurse sends Mrr to pharmacy for review
Safety
Quality
Check
Q
Delta
Critical
Work
Time
Observations
Direct Admission
1 PCP/office faxes current home med list to unit
KEY:
Takt
Time:
In-Process
Stock
Totals
Problem Solving Report
Date: 10/3-5/07
THEME: Standing order based on diagnosis
Team: Alison, Gloria, & Melissa
PROBLEM SITUATION
COUNTERMEASURE(S)
Standard: Federal guidelines in place currently not met
Containment: Involve physicians
Develop new orders and obtain physician input
Current Situation: Some standing orders but not for all categories
Discrepancy: Does not meet required guidelines
Extent: 8 DRGs of top 25 DRGs to be focus
Rationale: top 25 DRGs monitored along with federal requirements
GOAL
Do What: increase # of standing orders
To What: standing orders for admission process
How Much: minimum - federal requirements
By When: 6 months - 1 yr
Long term System Solution:
Develop standing orders with physicina input and include an
accountability plan
Communicate, communicate, communicate
Why Recommended?
Physician by-in is essential
IMPLEMENTATION
What
Develop draft order
Present to physicians
Revise form based on suggestions
Send for approvals
Implement form usage
Who
When
Patsy
3 mos
Beth, Patsy3 mos
Patsy
3 mos
Patsy, Beth3 mos
Nsg
3 mos
Where
FRHS
FRHS
FRHS
FRHS
FRHS
Status
pending
pending
pending
pending
pending
CAUSE ANALYSIS
Potential Causes:
Orders not accessible
Lack of education
Disconnect of involved
Most Likely Cause(s)
How Checked?
interview
interview
interview
Result?
clerk turnover
no orientation process
no accountability
Problem Statement: disconnect of involved parties
Why? Lack of physician compliance
Why? No orientation process
Why? Time not provided for orientation
Why? Income wanted ASAP
Why? Financial Independence
Root Cause: Stable working environment
FOLLOW-UP
Check method: quarterly data collection
Check frequency: quarterly
Who will check? Care Mgmt Dept
Target
Actual
Apr
July
Oct
Jan
Recommended Actions:
Develop and implement standing orders for federal compliance
Problem Solving Report
Date: 10/3-5/07
THEME: Staff education on medical records
Team: Mark and Carol
PROBLEM SITUATION
COUNTERMEASURE(S)
Standard: All records will have medication reconciliation
Containment:
training for team members
Current Situation: Standard not being followed
Discrepancy: tools not accepted for compliance
Long term System Solution:
new computer software options
Extent: individual physician preferences preventing standardization
Rationale: Need resolution to provide safest patient
GOAL
Why Recommended?
Software system needed to improve communications between departments
IMPLEMENTATION
What
CPSI trianing
Do What: train
To What: team members and doctors
How Much: one class
By When: next quarter
Who
education
and
IT
When
ASAP
Where
FRHS
Status
pending
CAUSE ANALYSIS
Potential Causes:
ER No list
Physiicans don't provide
How Checked?
interview
interview
Result?
Not important
Too busy
Most Likely Cause(s)
lack of time; CPSI unfriendly
Problem Statement: Lack of by-in
Why? Lack of training
Why? Low priority list
Why? Non-revenue generating
Why? Support service only
Why? Disconnect between support
and customer service revenue
Root Cause:
Limited vision for connecting non-support services to benefits
FOLLOW-UP
Check method: chart audit
Check frequency: monthly at first then quarterly
Who will check? TL in each unit
Target
Actual
J
F M A M J J A S
Recommended Actions:
Train, retrain, and software upgrade
O
D
J
M
J
O
Problem Solving Report
Date: 10/3-5/07
THEME: Pharmacy Involvement
Team: M issy & Beth H
PROBLEM SITUATION:
COUNTERMEASURE(S)
Standard: Internal transfers require medication reconciliation
Containment: Cross the departmental barriers (with armour)
Current Situation: Policy exists for medication
discontinuation for surgical patients; Need policy for transfer
between units.
Long term System Solution:
Discrepancy: Inconsistency in transfer processes.
Orders not always discontinued.
Develop policies and procedures for interdepartmental transfers
Extent:
Why Recommended?
Currently we do not have and need this process to meet guidelines.
Rationale
GOAL
IMPLEMENTATION
What
Policy / Procedures
Do What: Standardize the prcoess
To What: Medication reconciliation
How Much: With all transfers
By When:????
Education to all clinical providers
Who
When
MRec group????
? P&P
all effected done
Where
TBD
dept
levels
Status
pending
pending
CAUSE ANALYSIS
Potential Causes:
Computer limitations
How Checked?
Interview/visual
Limited communication
Interview
Most Likely Cause(s)
Result?
Ineffective process
Breakdown in
communication
system
FOLLOW-UP
Check method: chart audits
Check frequency: goal: monthly, at least 30
Who will check? TL or designee of each dept
Problem Statement:
Why? Orders not faxed to pharmacy
Why? No process in place
Why? Lack of awareness
Why? Disconnect between physician guides and others
Why? We don't know.
Root Cause:
Lack of communication between processes
J
F
M A
M
J J
A S O N D
Recommended Actions:
Develop new process/policies and monitor monthly for compliance.
Target
Actual
RESULTS
BEFORE
AFTER
IMPACT
Physician Order Form (#1)
No consistent process for use and chart placement;
physicians ask nurses to complete.
Continue to use current form; education unit
clerk/physician; qtrly review
Increased usage and compliance - 18 of 18
Med Reconcile report: (#3)
Form contained all home meds and all medications
administered during the hospital stay
Form can be modified so all home meds and only
current medications ordered at time of discharge will
show; continue or discharge boxes available for orders;
nursing option for all meds or current only meds; hardcode med name/type/route
Less medication errors, improved patient safety, less
risk with compliance to applicable regulations.
Standing Orders (#4)
Some in place - 17 top 25 DRGs; patient safety and
compliance not optimal
Meeting 100% standards for care involving the top 25
DRGs. Improves education/awareness for new team
members, thus overall by-in for use of product.
Improved patient care/safety. Increases standardization
which maximizes productivity and improves customer
satisfaction by decreased waiting times.
90 Days (#5)
System can restore after 98 days (copy-forward); current
usage unknown
Nursing will be educated on process for bringing
information forward without having to re-type. Speeding
up processes. (Unless an outpatient event)
Smoother process for medication list of home
medications with minimal computer data entry by
nursing. Saving time and more reliable listing.
Scope of Practice for Nursing (#7)
Lack of physician compliance with providing med list
results in nursing making medical decisions in addition
to 'hunting for information' via family, pharmacy, or other
resources.
Develop Policy and Procedure for physician call-back
from unit pages; complete listing of medications will be
provided to all upon referral or transfer; external
pharmacy to be used as a last resort in the event other
resources unable to provide needed info.
Returns nursing scope of practice to acceptable legal
parameters. Decreases time for nursing, pharmacy, and
physician to resolve home medication issues upon
arrival.
ER med list entering into CPSI (#8)
Currently home meds are not being entered into the
computer system by ER team. Current questions about
medications are free texted rather than in electronic flow
sheet.
All ER patients will get home medication list started in
ER.
Decreases time for medication reconciliation
RESULTS
BEFORE
AFTER
IMPACT
Computer usage #11 – system not being utilized to its
maximum potential
All incoming patients would have their home medication
lists started at the earliest entry point – with focus on
ER.
Computer system usage maximized and patient care
improved via speedy medication reconciliation.
Pharmacy missing does; floor review; stopped orders
(#12) – medications are not being discontinued prior to
transfers
All pts will have their orders discontinued upon
transferred and new orders received as the physician
feels appropriate on med rec form for that patient’s
continued care.
Meets hospital policy and improves patient safety.
Pharmacy has only one terminal with trigger for transfers
between floors – but no surgical trigger. Typically not
looked at by the pharmacy team. Pharmacy using
personal decisions on what medications to continue due
to lack of new orders written by physician upon transfer.
Orders for transfer will be complete and include
medication reconciliation between units as per the
HFAP standards. Surgery to fax all post-op orders to
pharmacy.
Medication lists will be printed between transfers and
used as a guide for which meds to continue. Ideally the
physician will provide this information. Nursing and
pharmacy will work in conjunction to review and assess
for potential patient safety issues.
Medication errors reduced.
Conforms to federal guidelines.
Results Summary
CATEGORY
RESULTS
BASELINE
ACHIEVED
Steps:
Lead Time /
Process Efficiency
16
10
Standard works:
written
0
+1
Quality
Standard orders improve care;
Pharmacy review/process MRR;
Physicians use revised MRR to confirm meds
Enter ECF meds into CPS
Decrease medication errors
Time / Productivity
Fewer pharmacy calls;
Fewer nurse calls to physician;
Nurses have less confusion on whose orders to
follow
Med orders more clearly understood;
Fewer calls to physicians for discharge
instructions;
Discharge nurses do not have to enter into
CPSI.
Other
Increase nursing morale with better work flow.
Improve communication between nsg / docs
COMMENTS