Health Authority
Spread and Sustainability
Transfer Medication Reconciliation Team Charter
November 2011-2013
Background
In support of our mission, vision and values to work with individuals, families and partners to promote
and improve the health of our communities and to advance safe and trusted patient c are, we need to
fully implement medication reconciliation at all transfer points.
We will define transfer points and focus on transfer within the three facilities.
Team Sponsors: Cathy Blades, executive Sponsor
Team Leader: The process owners: Joyce d’Entremont, Director of Nursing, Peggy Green Director of
Clinical Services Therapeutics, Measurement Leads: Nancy McLaughlin and Kathy Wilson.
Core Team Members: physicians, nursing staff, pharmacy staff, clerical support, ward clerks, nursing
clinical resource. Organization representatives that understand the practice gap and want to lead the
improvement change should include clinical staff, physicians, and quality support.
Ad hoc Members: Clinical Resource, Risk and Patient Safety, Meditech experts, Meditech super-users,
health records (scanning and archiving).
Resource Requirements:
What is needed for the team to be successful in leading, sustaining and spreading the improvement work
within their organization?
Budget: Travel to smaller sites for training when/if Telehealth not an option, educational materials
Human resources: Time commitments for those involved in planning, education, implementation,
measurement and assessment.
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What are you trying to accomplish?
Aim: Patients will have their medications reconciled 100 % of the time at levels of care
transfers where new orders are required to be written.
State what you are trying to accomplish and by when: As per above by November 201s
Key components:
 What will you do? Patients will have their medications reconciled at levels of care
transfers where new orders are required to be written.
 How much? 100% of patients.
 By when? At time of transfer.
Scope and Boundaries:
What’s in scope? To ALCU, ICU to med/surg, surgery to med surg, floor to peri-operative
and then to floor, into ICU, into and out of mental health, into and out of RCU at DGH.
What’s not in scope? Any area when new orders are not required to be written. Any area
where transfer to that unit are currently considered an admission (vets, RCU, HSL, RCU)
Perioperative, med surg to med/surg, hospital to hospital transfer within and outside our
district.
By when? By November 2013
Improvement Objectives:
List specific, concise and measurable objectives with defined timelines. If achieved they
should result in the improvement you wish to accomplish.
January - April 2012 finalize district transfer med rec policy
January – get core group together for a meeting
January – CMAR project rolls out
April/May –educate staff on transfer med rec
June / July – pilot on ICU to 3 East transfer in YRH
August – PDSA on audit pilot
September /October– second pilot or full roll out
September / October – Education for full implementation
November/December – audit
January 2013 – PDSA
April 2013 – if changes need to happen then implement. If not then completion of roll out.
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Measures
Current Performance
Goal
(Baseline)
(Preferred)
- Fewer medication
related adverse events.
(misinterpreted
medications)
- decrease in number of
medication related
adverse events
- Number of patients
who receive medication
reconciliation at
transfer of levels of care
where new orders are
required to be written.
- 100 % of patients to
receive medication
reconciliation at
transfer of care where
new orders are required
to be written.
- decrease length of
stay post full
implementation
- decrease in length of
stay.
Process Measures: (What key
processes/actions consistently done
are likely required to achieve
customer results?)
Successful
implementation of the
policy and procedures
surrounding this
project.
Support from all
stakeholders
Full implementation.
Balancing Measure: (What aspect of
our system do we need to monitor to
ensure our attention on our aim does
not negatively affect other aspects of
the system?)
Ask for feedback from
stakeholders as it
relates to work flow,
outcomes, etc.
Share positive feedback
with team and address
negative feedback.
Make changes in
process if necessary.
(PDSA)
Focus on 1-3 useful measures.
Measures tell if you are meeting your
objectives and indicate if you are
accomplishing your AIM.
How will we know a change is an improvement?
Outcome Measure: (What result will
the customer experience if the
process is significantly improved?):
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Change Concepts and Ideas to test
What Changes can we make that will lead to an improvement?
Eliminate Waste will not dispense meds that are not needed leading to decreased drug
cost, pharmacy time and nursing time.
Improve Work Flow waiting for CMARs in place for this to occur. CMAR will enable the use
of an accurate Meditech generated transfer med rec form to be printed that serves as an
order for docs to use. This will improve work flow due to the design of the form (tick boxes,
less order transcription)
Change the Work Environment
CMARS will be a big change.
Nursing is doing a type of transfer med rec at this pint but it is not documented. This
meditech report will save time in transcribing while doing a formal transfer med rec.
Manage Variation
Consider rolling out transfer med rec at same time as CMARs as a package as it is viewed as
one other change.
Or… mention during CMAR education that transfer med rec will result from CMARs and
show report.
Do small tests of change during rollout.
Need to get pharmacy and nursing ready to deal with faxed copies of the new transfer
orders.
Figure out who will generate the report (transferring or receiving nurse)
Enhance Customer relationship
Decrease errors
Buy-in from staff
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Principles for Working Together:
How will we manage the improvement work?
Open, respectful communication. Timely follow-up on assigned tasks.
Full commitment to see the project through to its completion.
Meet on a monthly basis (or more often if necessary) at face to face meeting or by
conference call to other sites.
We will all have access to the charter.
Decisions made my consensus following input from members.
Progress will be documented on the ROP reporting tool.
Agendas and minutes will be prepared and circulated by Nancy and Kathy with clerical
support’s assistance. We will document action items at the end of each meeting so that
everyone is clear of their expectations and can follow through on them in a timely fashion.
Roles and Responsibilities
Executive Team Sponsor:
Support for our project in the interest of providing safe patient care while complying with
Accreditation Canada standards and ROPs.
Team will communicate via email and reporting tools every 2 months or more often if
requested.
Executive Team Sponsor will communicate to Senior Management Team at the Senior
Management Meetings.
Team Leader (Process Owner):
Support the project and decisions of the team to ensure that the project is completed
successfully and in a timely fashion where the patients and team see the benefit of the
project.
Measurement Lead:
Audits of charts targeting transfer patients.
Report summary to be created and shared with Risk manager, Directors and VP.
Tests for compliance to include: form present, signed and dated, discrepancies identified
and addressed. Was admission med rec completed.
For pilots we will audit 20% o transferred patients during our pilot time frame and then
again 2 months after full implementation.
Then yearly do a random 50 chart audits of transfer patients.
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Team Members:
Shared responsibility to add input and implement
Represent their respective stakeholder’s interest.
Develop learning /education materials
Education of staff
Champions of transfer medication reconciliation
Share information with co-workers and relay feedback to our working group
Be change agents
Have an ongoing commitment to the process through planning, assessing, implementation
and evaluation.
If they can no longer serve as a member they must find a replacement.
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Constraints
Time constraints of members involved.
Commitment levels of people involved.
Travel to other sites to train ($)
Money for education and training.
Must follow Accreditation Canada Standards.
If transfer med rec is done on a patient who has not received admission med rec, we may be
perpetuating an error.
Deliverables and Key Milestones
Policy and Procedure completed
Project Charter complete and approved
Education plan completed.
Pilot started and we get a signed med rec on transfer completed.
Audits completed and results analyzed
Decreased lengths of stay.
Improved medical management of patients.
Decreased med errors.
Communication Plan
Use ROP reporting tool to transfer information to senior management.
Communicate pertinent information to nursing, pharmacy, docs, patients.
Information can be sent through the Safe Medication Working Group via memos,
newsletters, etc.
Meeting Schedule:
Face to face meetings monthly or more often if necessary. Afternooons between 1-2 pm.
Quorum of 50% required.
This charter was prepared by: _________________________ Date: _________________________
Senior Management Approval: _______________________ Date: _________________________
(Executive Sponsor)
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