Health Authority
Spread and Sustainability
Transfer MedRec
Team Charter
November 2011-2013
Background
Medication Reconciliation is a ROP as prescribed by Accreditation Canada. Compliance with this ROP is
required in order for the organization to achieve accreditation and retain its status as a teaching
organization. It aligns with Horizon’s Strategic Direction of Making Quality Count which ultimately
enhances patient safety, mitigates risk, streamlines processes and improves communication.
Team Sponsors:
VP Health Services Planning, Quality & Research
Team Leaders:
Regional MedRec Committee
Director Research and Patient Safety
Director Pharmacy Services
Zone MedRec Committees
Zone 1: Janice Irvine-Meek & Beth Kennedy
Zone 2: Rachel Harris & Heidi Mew
Zone 3 : Glenn Whiteway & Dawn Torpe
Zone 7 : Keith Noseworthy & Sandra Black
Core Team Members (Zone Committee’s)
Pharmacy
Nursing Administration
Patient Safety
Physicians
Clinical Network Representatives (Nurses)
Information Systems (possible AdHoc membership)
Resource Requirements:
Budget:

Funding for printing of promotional materials (as part of communication plan)
Human resources:


Membership from all stakeholder areas to devote approximately 2 – 4 hours per week to
Medication Reconciliation Implementation related duties.
Nursing & Physician involvement in pilot trials
Spread and Sustainability 2011-2013
Page 1
Health Authority
Spread and Sustainability
What are you trying to accomplish?
Aim: Implement Medication Reconciliation within all Horizon zones to accurately and
completely reconcile medications at points of Transfer and Discharge.
Through the leadership and direction of the Regional Medication Reconciliation Committee
(R-MEDREC), each zone within Horizon Health Network will form a respective Zone
Medication Reconciliation Committee (Z-MEDREC), These zone based committee’s will
formulate a comprehensive project plan that will guide the implementation of medication
reconciliation at all necessary points of patient transfer and discharge.
Key components:
 Leadership, guidance and support of R-MEDREC
 Development of Medication Reconciliation Committees and Working Groups (if
deemed necessary by Z-MEDREC)
 Development of Project Plan
 Review of existing zone transfer/discharge processes and forms
 Creation of zone transfer/discharge processes and forms for Medication
Reconciliation
 Development and implementation of Communication Plan (as part of project
planning)
 Development and implementation of zone specific MedRec education/training
 Trial runs in designated pilot areas for transfer and discharge(if deemed necessary
by Z-MEDREC)
 Complete education/training, communication and full Implementation of processes
and forms for MedRec at transfer and discharge by June 2013.
Scope and Boundaries:
R-MEDREC
In Scope:
 Implementation planning at the regional level
 Guidance and support on MedRec topics/issues (e.g. Regional decisions for high level
issues)
 Coordination and communication with Zone MedRec Committee’s
 Development of regional level education program
 Future development of indicators for Medication Reconciliation
 Reporting to senior leadership and other necessary stakeholders
Out of Scope:
 Human resources for replacements of R-MEDREC/Z-MEDREC members
 Development of zone specific MedRec forms and processes
 Development of zone specific training and delivery
 Implementation planning at the zone level
Boundaries:
 MedRec implementation will be for Horizon Health Network zones only and will not
Spread and Sustainability 2011-2013
Page 2
Health Authority
Spread and Sustainability
cover other departments, organizations or healthcare facilities outside Horizon.
Z-MEDREC
In Scope:
 Implementation planning for the specific zone
 Coordination with Regional MedRec Committee, as appropriate
 Development and implementation of zone-specific MedRec processes, forms,
education/training, communication, etc.
Out of Scope:
 Human resources for replacements of zone medrec committee members and staff
receiving training
Boundaries:
 Staff workload and competing zone-level projects/initiatives
Improvement Objectives:
1. Increase the awareness of medication reconciliation amongst staff through
promotion.
2. Educate staff on performing medication reconciliation processes on appropriate
patients at the points of transfer and discharge.
3. All services that have the MedRec Required Organizational Practice (ROP) assigned
to them in their Accreditation Canada Standards, demonstrate that they actively
perform medication reconciliation processes on appropriate patients at the points
of transfer and discharge
Spread and Sustainability 2011-2013
Page 3
Health Authority
Spread and Sustainability
Measures
Current Performance
Goal
(Baseline)
(Preferred)
Outcome Measure:

Number of instances where
Medication Discrepancies
discovered (Medication
Incidents Avoided)
NA
How will we know a change is an improvement?
Process Measures:

Number of Services/Zone
performing Medication
Reconciliation at Transfer
Total number of Services
required by Accreditation
Canada ROP to perform
MedRec at Transfer

Number of Services/Zone
performing Medication
Reconciliation at Discharge
Total number of Services
required by Accreditation
Canada ROP to perform
MedRec at Discharge

Number of times Transfer
MedRec is performed
Total number of transfers
requiring Transfer MedRec

Number of times Discharge
MedRec is performed
Total number of discharges
requiring Discharge MedRec

Number of incomplete
Transfer MedRec performed
Total number of Transfer
MedRec attempted
NA
0%

Number of incomplete
Discharge MedRec performed
Total number of Discharge
MedRec attempted
NA
0%
Spread and Sustainability 2011-2013
NA
100%
NA
100%
NA
100%
100%
NA
Page 4
Health Authority
Spread and Sustainability
Other Measures Under Consideration:
o
o
o
o
o
o
o
o
Number of unreconciled
medications.
Number or percentage of
unreconciled medications
within specific timeframe.
Number or percentage of
medication orders changed.
Number of potential
medication errors intercepted.
Number of discrepancies per
patient.
Percentage of patients with
completed Transfer form in
chart.
Percentage of patients with
completed Transfer form in
chart.
Number of pharmacy consults.
Spread and Sustainability 2011-2013
Page 5
Health Authority
Spread and Sustainability
Change Concepts and Ideas to test
Eliminate Waste


Use of electronic tools that can incorporate active medications into the
Transfer and Discharge MedRec process can greatly reduce the amount of
time required to perform medication reconciliation compared to hand-written
formats.
Incorporate discharge instructions into Discharge MedRec forms to eliminate
need to fill out multiple forms (i.e. Discharge instructions, follow-up
appointment forms, etc)
Improve Work Flow
What Changes can we make that will lead to an improvement?

Give physicians electronic access to electronic forms for transfer and
discharge
Change the Work Environment

With the size and complexity of MedRec, Z-MEDREC are encouraged to form
working groups to split workload into manageable tasks:
o Transfer Working Group
o Discharge Working Group
o Education Working Group
o Special Assignment Working Group
Manage Variation

Use of electronic tools that can incorporate active medications into the
Transfer and Discharge MedRec process. The elimination of hand written
information has been shown to:
o Decrease transcription errors
o Decrease information interpretation errors
o Decrease omission errors
Enhance Customer relationship

Incorporate discharge instructions into Discharge MedRec forms to effectively
communicate important medication information, changes to medication,
special instructions for discharge care and reminders of future follow-up
appointments. This will enhance communication for several customers:
o
o
o
o
Family physicians
Community Pharmacists
Institutions receiving discharged patients
Patient
Spread and Sustainability 2011-2013
Page 6
Health Authority
Spread and Sustainability
Principles for Working Together:
Through the leadership and direction of the Regional Medication Reconciliation Committee
(R-MEDREC), each zone within Horizon Health Network will form a respective Zone
Medication Reconciliation Committee (Z-MEDREC), who will be responsible to design and
implement medication reconciliation processes, procedures, tools and education specific to
their zone. All levels of committee’s should have a multidisciplinary composition and when
possible, consider outside agencies and institutions as they are a part of the discharge
process that is being created for MedRec.
How will we manage the improvement work?
Areas that have existing MedRec processes in place, should consider a balanced distribution
of MedRec duties that involves, Nurses, Physicians, LPN’s, Pharmacy Techs, Pharmacists and
other professions.
Communication is essential to this project and must be both and vertical and horizontal
between:
o Executive Sponsor(s)
o R-MEDREC
o Z-MEDREC
o Working Groups
o Staff
Other general principles for working together include:
 Demonstration of respect, for other members and their perspectives
 Regular attendance and participation
 Timely follow up on assigned tasks
 Only positive attitudes are allowed!
Roles and Responsibilities
Executive Team Sponsor:
 Provide support & guidance
 Provide adequate resources
 Establish an accountability or reporting mechanism to monitor progress
 Help to resolve issues as needed within the team
Team Leader (Process Owner):
 Schedule and facilitate meetings
 Prepare meeting agendas
 Circulate meeting agendas and minutes prior to monthly meetings
 Upload meeting minutes and agendas to Horizon Q Drive
 Upload team information to SHN QIM
Spread and Sustainability 2011-2013
Page 7
Health Authority
Spread and Sustainability



Monitor Plan, Do, Study, Act (PDSA) cycles and measurement data
Facilitate communication with team and other stakeholders
Communication of key messages and regular updates.
Measurement Lead:
 Assist with collection and measurement of indicator data
 Prepare reports for key stakeholders
Team Members:
 Participate in Safer Healthcare Now! SS-FLS virtual learning sessions
 Formulate and utilize a project plan for regionalization of medication reconciliation
at admission, transfer, and discharge
 Utilize PDSA cycles to implement change
 Support education and training requirements for sustainability and spread
 Direct the process to collect measurement data
 Analyze data, audit process and evaluate results to make system changes based on
evidence and trending
 Where appropriate, direct the development and/or participate in sub-committees
and/or working groups
 Share learning within the organization
 Lead and support coworkers to adapt the new process
 Complete tasks or assignments within and between meetings
 Ongoing communication and sharing of information back to individual
site/discipline MedRec teams
Constraints

Time constraints / Competing Priorities of team members

Human Resources

Wide variations in process and practices across region

Travel Restrictions
Deliverables and Key Milestones
Full implementation of MedRec processes at the points of transfer and discharge by June
2013.
Communication Plan
Spread and Sustainability 2011-2013
Page 8
Health Authority
Spread and Sustainability
At discretion of R-MEDREC and Z-MEDREC
Meeting Schedule:
R-MEDREC will meet on a monthly basis and R-MEDREC Members be available to respond
to Z-MEDREC inquiries and requests.
Z-MEDREC will meet monthly (minimum)
Working Groups will meet with enough frequency to complete their assigned tasks
This charter was prepared by: _________________________ Date: _________________________
Senior Management Approval: _______________________ Date: _________________________
(Executive Sponsor)
Spread and Sustainability 2011-2013
Page 9