PARADE: Audit Tool and
Intervention Guidance
Anne Myrka
IPRO
January 20, 2015 2-3pm
Collaborative Disclosures
 Project is designed to encourage collaboration
 Through that effort we will facilitate the sharing of facility
names, team members and email addresses with all
involved in project
 We will not share your individual QI findings or QI data
with any other organization without your consent
 Please contact Anne if you do NOT wish to have your
contact information shared
2
Objectives
 Reiterate project focus, objectives and strategy
 Provide support identifying team members
 Identify target patient population
 Provide audit tool and intervention guidance
 Open Q&A
3
Brief Recap
 Complete PARADE Request for Technical Assistance if
not already done and forward to Anne
(anne.myrka@hcqis.org or fax: 518-426-3418)
 January 6th Webinar, Request for Technical Assistance
and recording is found at:
http://qio.ipro.org/care-transitions/healthcare- professionals/pastevents
4
Preventing and Reducing Adverse Drug Events
(PARADE)
Improve
Medication
Reconciliation
Examine and
improve current
care practices
Improve the quality
of the initial home
medication list
Improve Medication Management of
High Risk Drugs
Adoption and
implementation of
evidence based
guidelines within
and across care
settings
Adopt improvement
coordination
between providers
Anticoagulants
(atrial fibrillation, orthopedic,
perioperative, VTE, stroke)
Cycle 1
Hypoglycemics
(insulin, oral agents)
 Improve care coordination:
 Cross setting communication
 Improve care management:
 Quality improvement
 Reduce readmissions caused by ADEs
Opioids
(effective use of pain control
modalities)
Cycle 2
Antibiotics
(right drug, with start, stop, and
duration clear)
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Goal of Medication Reconciliation and High
Risk Drug Safety Process
Decrease medication errors and patient harm by:
1.
Obtaining, verifying, and documenting patient’s current prescription and
over-the-counter medications; including vitamins, supplements, eye
drops, creams, ointments, and herbals
2.
Comparing patient’s pre-admission/home medication list to ordered
medicines and treatment plans to identify unintended discrepancies
3.
Discussing unintended discrepancies (e.g., those not explained by the
patient’s clinical condition or formulary status) with the physician for
resolution
4.
Providing and communicating an updated medication list to patients
and to the next provider of service at discharge
5.
 Identifying patients on high risk drugs, and;
6.
 Integrating evidence based ADE prevention processes for identified
patients across care settings
Adapted from The Joint Commission National Patient Safety Goal 03.06.01
 Steps 5 & 6 are unique to IPRO’s
process
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PARADE Strategy
 Based on 6 month improvement cycles
 Cross setting work will be achieved within each care transition
coalition Medication Management Committee monthly meetings
 Cycle 1 is January 6, 2015 – June 30, 2015
 All facilities will focus on Medication Reconciliation and Anticoagulation
Discharge Communication
 Educational webinars on management of hypoglycemics and opioids will
be provided prior to the launch of Cycle 2 (which will expand to process
improvements for hypoglycemics and opioids)
7
PARADE Strategy
 Cycle 1 January 6, 2015 – June 30, 2015
 All facilities (including those who participated in the
pilot study) will complete and return a PARADE Request
for Technical Assistance by January 16, 2015
 Eligible facilities are hospitals, skilled nursing facilities
(SNF), rehabilitation facilities, home healthcare
services/agencies (HHA), residential facilities, adult
homes, primary care providers, pharmacies (hospital,
community, SNF vendors, etc.)
 Participating individuals are administrators, physicians,
nurses, pharmacists (including SNF consultant
pharmacists), quality improvement professionals,
discharge planners, HHA hospital liaisons, etc.
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PARADE Strategy
 Cycle 2 is July 1, 2015 – December 31, 2015
 Continue to work on ADE hospital readmission
measure, high risk drug discharge communication and
med rec improvement processes
 Expand to medication management of hypoglycemics,
opioids, other (e.g. antibiotics)
 IPRO is currently convening subject matter experts to
provide guidance on best practices for management across
care settings during transitions
 Subsequent Cycle work will focus on continued
evidence based improvements, sustainability and
applicable cross-setting emerging measures
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Who should sign Request for Technical
Assistance?
Who should be on the team?
10
Request for Technical Assistance
 The “Primary and Secondary Contacts” should be
employees in your facility who can:
 Ensure that the work will be done
 People who are materially invested in wanting to do the
work and achieve improved outcomes
 Remove barriers to improvement
 The Primary and Secondary Contacts will receive
PARADE emails and notices for webinars, meetings,
etc.
 The “Organizational Representative Signature” can
be anyone in the facility who can ensure ongoing
commitment of resources (usually leadership)
11
Identifying Team Members Within Your Facility
 Team Leader – someone who can build consensus and knows
who, how and when to ask for resources
 Administrative leader – to remove barriers, assign resources
 Clinical Champion(s) – physicians, pharmacists, nurses with
expertise/knowledge regarding anticoagulation, med rec, high
risk drugs, care transitions, the discharge process, etc.
 Direct patient care/front line staff – those who know current
workflow and who can envision how to improve
 Pharmacists – can include pharmacy administration, consultant
pharmacists, dispensing pharmacists, pharmacy techs
 Quality Improvement staff (is often a team leader)
 Information technology staff
12
Identifying Target Patient Population
13
Identify Target Patient Population
Retrospective Audits: Patients discharged on an
anticoagulant within the last 30-60 days
Hospitals:
 VTE/Stroke Core Measures
 Pharmacy reports to identify patients on anticoagulants
Skilled Nursing Facility
 MDS 3.0, Section N, NO400 Medications Received
 Intake referral information/PRI
 Pharmacy reports to identify patients on anticoagulants
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Identify Target Patient Population
Home Health
 OASIS C responses to M2000, M2004, M2010, M2015
 Intake referral information
Transition Coach Services
 Use MDT data and CTM-3 to target interventions
15
Identify Target Patient Population
Common Diagnoses/Conditions associated with
anticoagulation use:




Treatment and Prevention of blood clots (VTE)
Atrial fibrillation/flutter
Orthopedics
Stroke
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2
FPage%2FQnetTier4&cid=1228773564870
(see appendix A for a complete list of ICD-9 codes)
16
Measures and Tools
17
Process Measure:
Medication Reconciliation Audits
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Elements of an Improved Med Rec Process
 Process design - should center on the concept of a single
list to document patient’s current medications (“one
source of truth”)
 Defining roles and responsibilities for medication
reconciliation - determine which discipline(s) should be
involved in each step of your medication reconciliation
process, including their respective roles and
responsibilities
 Integrating medication reconciliation into your existing
workflow - prompts to complete required steps for
medication reconciliation are essential
19
“One Source of Truth”
 Single list documents home medications
 Standardized across the facility
 Maintained in a consistent location in the medical record
 All providers are empowered to update the list as new and
more accurate information is available
 Used at admission, transfer, and discharge for medication
reconciliation
20
Page 46 of the MATCH toolkit
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Types of Unintended Medication Discrepancies
 Omission: Patient reports taking a medication before hospitalization. It was not
ordered on admission or it was not listed on the patient’s discharge instructions.
No clinical explanation supports omission.
 Commission: Medication is ordered at admission that the patient did not take
before hospitalization. Medication is listed on the patients discharge instructions
but it was not ordered during the hospital stay and the patient did not take before
hospitalization. No clinical explanation supports commission.
 Different dose, route or frequency of medication than the patient reports taking
before hospitalization. Different dose, route or frequency of medication listed on
the patients discharge instructions than what was ordered during the hospital
stay or that the patient reports taking before hospitalization. No clinical
explanation supports difference.
 Duplication and/or different medication ordered. Medication in the same
therapeutic class is ordered on admission or is listed on the patents' discharge
instructions and differs from, or duplicates, what the patient reports . No clinical
explanation or formulary substitution supports difference.
22
Process Audits of Internal Facility
Procedures
The Medication Reconciliation Audit Tool – Evaluates:
 Collection and accuracy of the home medication list
 Accuracy and timeliness of the medication reconciliation of the home
list to the admission orders
 Documentation of rationale for intended medication discrepancies
 Incidence of unintended medication discrepancies
 You will audit 5-10 medical records of patients discharged from your
facility on any anticoagulant who have been re-hospitalized within the
past 30 days (if there are no re-hospitalizations within 30 days, try 45
days or 60 days, if needed)
 Choosing records of patients discharged on anticoagulants is to assist
with identification and subsequent root cause analysis of anticoagulant
medication discrepancies
23
24
Process Measure:
Anticoagulation Discharge
Communication Audits
25
Baseline Process Audits of Internal Facility
Procedures
The Anticoagulation Discharge Communication Audit Tool
Evaluates:
 Your facilities internal discharge communication
practices for patients who are discharged on an
anticoagulant
 Using the same 5-10 records that were used for the Med
Rec tool, audit medical records of patients discharged
from your facility on any anticoagulant within the past
30 days (can extend to 45 days or 60 days, if needed)
26
Audit Methods:
Anticoagulation Discharge
Communication (AC-DC)
Audit Tool
Excel version

Preferred method of data
collection

Calculates performance
statistics automatically and
includes performance
dashboard

Color coded performance:
 Green = >90% of
completed fields as
"yes“
= 60-90% “yes”
 Red = <60% “yes”

Demonstration video
27
Audit Methods – Anticoagulation Discharge
Communication (AC-DC) Paper Tool
28
29
Additional Ad Hoc Anticoagulation Baseline
Measure
 Designed for skilled nursing
facilities, outpatient clinics
and others that serve
population over long term
 IPRO study done in 12 SNFs
showed aggregate TTR of
45.5%. Quality goal is 70%.
 For more information:
http://qio.ipro.org/drug-safety/collaborativepartners/analytic-services
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Outcome Measure
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Outcome Measure: Hospital
Re-admissions due to High Risk Drug ADEs
All patients possessing the following elements at time of hospital
discharge:
• ≥ 3 medications ordered in total, and;
• Anticoagulant
• Opioid
• Hypoglycemic
•How? EHR query
• Patient identifier - SSN and MRN
• Drugs - can be identified using drug name text string files provided by
IPRO
• Raw data files transferred to IPRO via secure data transfer protocol
•
Denominator
Raw
Numerator
All patients identified in Denominator with Emergency
Department Visit or Hospital Re-admission within 30 days
•How? IPRO analysis of Medicare Part A data
•
Final
Verified
Numerator
• Determination of presence of ADE by Root
Cause Analysis
• How? CDC abstraction tool verified for
anticoagulants, opioids, and hypoglycemic ADEs.
Preventable ADEs targeted for coalition-wide
evidence based intervention(s).
IPRO will work with each hospital individually to obtain baseline.
32
Outcome Measure: Hospital
Re-admissions due to High Risk Drug ADEs
 IPRO will contact key hospital leads in next few
weeks regarding ADE data retrieval and transfer
procedures
 Hospitals should identify an IT lead to participate in
discussions with IPRO for the electronic data retrieval
process
 IPRO will schedule subsequent meetings
33
Intervention Resources
34
Medication Reconciliation
Intervention Resources
http://www.hospitalmedicine.org/marquis/
35
Medication Reconciliation Improvement Tools
36
Anticoagulation Management Interventions
Anticoagulation Management Interventions:
AHRQ educational DVD and partner teaching booklet
 http://www.ahrq.gov/patients-consumers/diagnosistreatment/treatments/btpills/index.html
IPRO’s Management of Anticoagulation in the PeriProcedural Period http://qio.ipro.org/drug-safety/drugsafety-resources
Identification of and referral to Anticoagulation Clinics
that may exist in your community
Anticoagulation Centers of Excellence
37
Goals for Cycle 1 January – June 2015
 Medication Reconciliation
 All facilities will have processes (including policy and
procedure) in place for successful admission
medication reconciliation by the end of Cycle 1
 Anticoagulation Discharge Communication
 All facilities will communicate greater than 90% of the
requisite anticoagulation management elements to the
subsequent provider upon transfer or discharge by the
end of Cycle 1
38
PARADE Cycle 1 Timeline and Due Dates
Date/Time
January 20, 2015, 2-3pm
January 22, 2015, 2-3pm
January and monthly
thereafter
February 6, 2015
February and March
March 17, 2015, 2-3pm
March 30, 2015
April
May 30, 2015
June
Topic/Activity
Webinar: PARADE Measures and Audit tool guidance and
Q&A
Webinar: Reducing Hypoglycemic Events in the Elderly – Dr.
Medha Munshi
Each Coalition has monthly Med Management Committee
Meetings to advance work
Baseline audits due; IPRO analysis of baseline audit sent to
facilities within 2 weeks
Coalition Med Management Committee Meetings –
interventions/prioritization
Coaching Call; teleconference only: 1-877-287-8135
*8949321*
Remeasure due; IPRO analysis of remeasure sent to
facilities within 2 weeks
Coalition Med Management Committee Meetings
Remeasure due; IPRO analysis of remeasure sent to
facilities within 2 weeks
Coalition Med Management Committee Meetings Review initial 6 month cycle outcomes; create plan for
continuing improvements and sustainability; expand to
hypoglycemic, opioids
39
Summary & Next Steps
 Baseline Med Rec and ACDC process audits to be
completed by Feb. 6, 2015
 Email or fax or completed audits to Anne at:
anne.myrka@hcqis.org or fax: 518-426-3418
 Outcome baseline completion date will be individualized
per hospital
 Coaching Teleconference Call March 17th, 3-4pm –
agenda forthcoming
 Anne can provide individualized support to all facilities
and will be contacting the team leads to schedule
support calls and/or facility visits to assist with baseline
audits
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Discussion & Questions
41
For more information
Anne Myrka
Pharmacist – Drug Safety
(518) 320-3591
Anne.Myrka@hcqis.org
Sara Butterfield
Senior Director – Care Coordination
(518) 320-3504
Sara.Butterfield@hcqis.org
Darren Triller
Senior Director – Drug Safety
(518) 320-3525
Darren.Triller@hcqis.org
IPRO Care Transitions Web Site:
http://qio.ipro.org/care-transitions/overview
IPRO CORPORATE HEADQUARTERS
IPRO Drug Safety Web Site:
http://qio.ipro.org/drug-safety/overview
1979 Marcus Avenue
Lake Success, NY 11042-1002
IPRO REGIONAL OFFICE
20 Corporate Woods Boulevard
Albany, NY 12211-2370
www.atlanticquality.org
This material was prepared by the Atlantic Quality Innovation Network/IPRO, the Medicare Quality Innovation Network Quality Improvement Organization
for New York State, South Carolina, and the District of Columbia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of
the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 11SOW-AQIN-NY-TskC.3-15-04