Rapid Fire Presentations
Fraser Health Region - BC
Capital Health Region – AB
Northern Health Region - BC
Providence Health Care - BC
Vancouver Coastal Health – BC
BC Mental Health and Addiction Services – BC
BREAK
Interior Health Region - BC
Vancouver Island Health Region - BC
Winnipeg Regional Health - MB
Calgary Health Region - AB
Children’s and Woman’s - BC
Medication
Reconciliation
Janice Munroe
Pharmacy Medication Safety Coordinator
November 29, 2005
Where are we in Fraser Health?
¾
Executive level support
¾ Senior level multidisciplinary Steering Committee
¾
Identification of Pilot site
¾ Peace Arch Hospital
¾
Engagement of leaders at pilot site
¾
Identification of Project Team leads and members
¾ Co-leads
¾ Multidisciplinary Team
¾
Draft Project Charter
Pilot Team - Project Plan
¾
Finalize Project Charter
¾
Develop Project Timelines
¾
Process flow mapping
¾
Identify resources required to complete
Items for consideration……
¾
Initial pilot area – admission vs discharge
¾
Site Project Team evolution as spread occurs
¾
Spread to other FH sites – multiple vs single?
¾
Community involvement – phase I or II or??
The Road Ahead…..
¾ Impossible
to envision all of the issues
that will arise
¾ Strong executive support
¾ Goal of the dedicated multidisciplinary
team is to improve patient care
¾ Working together we will succeed!
Rapid Fire Presentations
Fraser Health Region - BC
Capital Health Region – AB
Northern Health Region - BC
Providence Health Care - BC
Vancouver Coastal Health - BC
Interior Health Region - BC
BC Mental Health and Addiction Services - BC
Vancouver Island Health Region - BC
Winnipeg Regional Health - MB
Calgary Health Region - AB
Children’s and Woman’s - BC
Safer Healthcare Now!Medication Reconciliation
Suburban/Rural Capital
Health, AB
Who?
Primary/Secondary care sites
• Westview Health Centre- Stony Plain
• Redwater Health Centre• Fort Saskatchewan Health Centre
• Devon General Hospital
• Leduc Community Hospital
• Sturgeon Community Hospital
September 2005
9
September 2005
10
Our Team
Project Coordinator –
Esther Nelles (0.4 FTE)
Pharmacists Maryann Chmilar (0.5 FTE)
RN - 0.5 FTE
Educator - 0.5 FTE
Nurse ClinicianSturgeon Community Hospital (1.0 FTE)
September 2005
11
Next Steps
„
„
Hire the remaining members of the
team.
December- informing the
stakeholders of the plan and its
implications
September 2005
12
Rapid Fire Presentations
Fraser Health Region - BC
Capital Health Region – AB
Northern Health Region - BC
Providence Health Care - BC
Vancouver Coastal Health - BC
Interior Health Region - BC
BC Mental Health and Addiction Services - BC
Vancouver Island Health Region - BC
Winnipeg Regional Health - MB
Calgary Health Region - AB
Others...
13
Medication Reconciliation
in Northern BC
Presenters:
Cam Egli and Greg Atherton
Northern Health
9
Safer Healthcare Now!
– Multi-disciplinary teams established in each of three HSDA’s
z Each team’s membership varies
–
Medication Reconciliation “team” is reporting to NI HSDA working
Group
z Members:
Greg Atherton (Rx) – Quesnel
– Cam Egli (Rx) - Regional Director
– Bruna Schnepf (RN and Admin) – Omineca Director of Nursing
– RN and MD in Quesnel - TBA
–
15
Northern Health
¾
NH Team is just forming
¾ Initial meeting planned in December
¾
Aim statement
¾
Reduce the mean number of unintentional discrepancies at admission on
the pilot unit by 50% within three months
¾
Baseline data - yet to be compiled
¾
Plan for the region
¾ Start with pilot project in Quesnel (GR Baker Hospital)
¾ Roll out to one site within each HSDA (Dawson Creek and
Smithers)
¾ NH-wide roll out coupled to new CIS
16
Northern Health
¾
Complexities we face:
¾
¾
¾
Many software programs in NH Rx
Geography
Human resources
17
Rapid Fire Presentations
Fraser Health Region - BC
Capital Health Region – AB
Northern Health Region - BC
Providence Health Care - BC
Vancouver Coastal Health - BC
BC Mental Health and Addiction Services - BC
Interior Health Region - BC
Vancouver Island Health Region - BC
Winnipeg Regional Health - MB
Calgary Health Region - AB
Children’s and Woman’s - BC
Medication
Reconciliation
Vancouver Coastal Health
Providence Health Care
Providence Healthcare
• St. Paul’s Hospital
– 426 tertiary acute care beds
• Mount St. Joseph Hospital
– 128 community acute care beds
– 100 residential care beds
• Holy Family Hospital
– 142 residential care beds
– 76 rehab beds
• St. Vincent’s Hospitals
– 369 residential care beds
• Youville
– 84 residential care beds
September 2005
20
Medication Reconciliation at PHC
• Team formed ~ 2 ½ years ago
– Pharmacy, nursing, pharmacy IT
– Acute and Residential care
• Focusing on transitions at:
– Admitting
– Transfer
• Acute Æ Acute
• Acute Æ Residential
– Discharge
September 2005
21
Regionalization of Pharmacy Services
VCH/PHC Beds by Site and Type
800
600
Acute - Tertiary
Beds
Acute - Community
Residential
400
Rehab
200
0
0
1
September 2005
2
3
Site
4
5
6
22
Opportunities for Reconciliation
Opportunities for Reconciliation
800
Community
Contracted
Facilities
600
Acute - Tertiary
Beds
Acute - Community
Residential
400
Rehab
200
0
0
1
September 2005
2
3
Site
4
5
6
23
Regional Medication
Reconciliation Initiatives
• Report to Regional Medicine Council
• Teams at
–
–
–
–
–
Richmond
Vancouver Acute
PHC
Lions Gate
Sunshine Coast/Garibaldi
September 2005
24
Pharmacy Startup Meeting
•
•
•
•
•
•
•
•
Availability of data
Extraction of data
User access
Current processes
Pilot
Membership
Resources
Evaluation
September 2005
25
Pharmacy Startup Meeting
• Decisions
– VA, NS and PHC to focus on the discharge process
– RGH under discussion
– Sunshine coast to focus on admission process
• Tasks
–
–
–
–
Define membership at local level
Structure
Start-up meeting
Discharge prescription feasibility and
implementation cost
September 2005
26
Regional Medication
Reconciliation Initiatives
September 2005
27
Rapid Fire Presentations
Fraser Health Region - BC
Capital Health Region – AB
Northern Health Region - BC
Providence Health Care - BC
Vancouver Coastal Health - BC
BC Mental Health and Addiction Services - BC
Interior Health Region - BC
Vancouver Island Health Region - BC
Winnipeg Regional Health - MB
Calgary Health Region - AB
Others...
Lions Gate Hospital
North Shore Coast Garibaldi
VCH
Team:
Romilda Ang: Director Professional Practice
Derek Andrews: Pharmacy Computer Coordinator
Mark Collins: Pharmacy Clinical Coordinator
Baseline Survey
Emergency Department
October 2005
„ ER pharmacist
„ 18 admitted patients over 6 days.
„ N = 121 Rx’s
„ Average = 7 Rx’s per patient (n = 2-17)
„ 35 min. per patient
„
Baseline discrepancy rate
Mean Discrepancy Rate
Number/ Patient
Undocumented Intentional
(Documentation Accuracy)
0.6
Unintentional
(Rate of error)
0.7
Incidence of Intended Therapy:
None AND Intentional = 80%
(MRSI)
Patients with discrepancy
Patients (N=18)
Discrepancy
Number
Percent
Intentional
14
78 %
Unintentional
4
22%
Undocumented
7
39%
Undocum. OR Uninten.
9
50 %
Information Systems:
Testing McKesson Computer Upgrade
Home Medication Reports
„ Medication Reconciliation Report
„ Medication Discharge Reconciliation Report
„ Discharge Planning Report
„
Rapid Fire Presentations
Fraser Health Region - BC
Capital Health Region – AB
Northern Health Region - BC
Providence Health Care - BC
Vancouver Coastal Health - BC
BC Mental Health and Addiction Services - BC
Interior Health Region - BC
Vancouver Island Health Region - BC
Winnipeg Regional Health - MB
Calgary Health Region - AB
Others...
MEDICATION
RECONCILIATION
Nov. 29, 2005
B.C. Mental Health and Addiction
Services
Medication Reconciliation Committee
Riverview Hospital
Forensic Psychiatric Institute
Forensic Clinics
Representation from
Nursing, Pharmacy, Medicine
September 2005
36
Admission Reconciliation
Staff education/awareness
Collect baseline data
„
„
Getting started kit
Retrospective analysis of patient charts in 3
different areas: Riverview Hospital (Forensic
Psychiatric Institute, and Forensic Clinics)
Intentional discrepancy
Undocumented intentional/unintentional
„
September 2005
Pharmacy, nursing, medicine
37
Admission Reconciliation
Meet to discuss
„
Results of baseline data
Plan next steps
„
„
„
„
Staffing requirements
Do we need to modify the forms for AR?
Team make-up
Barriers/ Challenges
September 2005
38
NEXT….
September 2005
39
BREAK
September 2005
40
Rapid Fire Presentations
Fraser Health Region - BC
Capital Health Region – AB
Northern Health Region - BC
Providence Health Care - BC
Vancouver Coastal Health - BC
BC Mental Health and Addiction Services - BC
Interior Health Region - BC
Vancouver Island Health Region - BC
Winnipeg Regional Health - MB
Calgary Health Region - AB
Others...
Interior Health
Medication Reconciliation
Norma Malanowich
Regional Director, Pharmacy
43
Very Early Stages of
Planning & Definition
Pharmacy Lead Medication Reconciliation
1. Specific populations of patients admitted from
Emergency
– Pilots at Kelowna General Hospital and Royal
Inland Hospital
2. Medication Reconciliation incorporated into
pharmacy anticoagulation service and
medication consultation process.
– Pilot locations to be determined: Vernon
Jubilee Hospital + ???
3. Admission to Residential Care
44
Nursing Lead Medication Reconciliation
1. Patient Discharge
– Pilot facilities and units tbd
45
Team Composition
•
Sponsored by Quality, Pharmacy, and site
Medication Safety and Advisory Committees
•
Multi-disciplinary teams created for each pilot
46
How to get started and avoid the
pitfalls:
We’re here to learn from you!
Rapid Fire Presentations
Fraser Health Region - BC
Capital Health Region – AB
Northern Health Region - BC
Providence Health Care - BC
Vancouver Coastal Health - BC
BC Mental Health and Addiction Services - BC
Interior Health Region - BC
Vancouver Island Health Region - BC
Winnipeg Regional Health - MB
Calgary Health Region - AB
Children’s and Woman’s - BC
MEDICATION RECONCILIATION
Richard Bachand Pharm D
Department of Pharmacy
November 29th, 2005
September 2005
48
Team
Newly formed
Team Leader
Nurse Manager
Clinical Nurse Leader
Clinical Nurse Educator
Pharmacy Resident
Surgeon
One of our “Big dot” projects with an executive sponsor
September 2005
49
Focus
Medication reconciliation “ on admission”
Where?
1 to 2 Surgical Units
Planning on involving the pre-admission clinics (PAC)
Baseline data
In progress
Developed
• Pharmacist consult – medication reconciliation form (BPMH)
• Home Medication Reconciliation and Order Form
September 2005
50
CHALLENGES
¾
Manpower resources
¾ Culture
¾ Complex systems
September 2005
51
Rapid Fire Presentations
Fraser Health Region - BC
Capital Health Region – AB
Northern Health Region - BC
Providence Health Care - BC
Vancouver Coastal Health - BC
BC Mental Health and Addiction Services - BC
Interior Health Region - BC
Vancouver Island Health Region - BC
Winnipeg Regional Health - MB
Calgary Health Region - AB
Others...
Medication Reconciliation
Current Status within the
Winnipeg Regional Health Authority
Regional Approach
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Proposal & Budget
Leadership buy-in
Role of the Project Management Office
(PMO)
Standardized form and process
Site Selection
Recruitment of unionized staff
September 2005
54
GOAL
To develop & implement a regional
MedRec process throughout the
continuum of care including:
admission to an acute care unit
referral to home care
primary care
September 2005
55
Objectives
È the mean # undocumented intentional
discrepancies by 75% by December 31, 2006.
È the mean # unintentional discrepancies
by 50% by December 31, 2006.
Ç the MedRec Success Index by 50% by
December 31, 2006.
Spread the MedRec Process to 100% of
Medicine/Family medicine acute care units
by December 31, 2006.
The MedRec Process is completed within 24
hours in 90% of patients upon admission.
September 2005
56
Framework
Pilot units
Acute care - General/Family Medicine - 6
Home care - 2
Primary Care - 2
Initial focus admission process
standardized form and process
include allergies
September 2005
57
Framework
Spread to other units
Pilot units start testing/development of
the transfer/discharge process
Project Team Staffing
frontline staff
12 - 0.4 EFT nurses
2 pharmacists (1.6 EFT total)
September 2005
58
Pre-Planning
Education for project team
Oct 4 workshop
Overview of med reconciliation, model for
improvement
Oct 24, 25
focus on process improvement
“hands on” PDSA cycles
Ongoing as needed
Site visits
September 2005
59
Pre-Planning
Regional Project Team Meetings
Pre-PDSA work
networking with other teams
baseline audit
develop draft med reconciliation form
flow charting
template for how to perform med history
criteria for pharmacist involvement
develop local teams
communication plan
September 2005
60
Challenges
Multi-site pilot units
Baseline audit
Communication
Spread
Unions
Forms Committee(s)
Scheduling of project team
September 2005
61
Baseline Audit
Diltiazem CD 120 mg OD 240 mg MD changed
Ramipril 10 mg OD
Amiodarone 100 mg OD
Clopidogrel (HOLD)
Ranitidine 150 mg OD
Prednisone 5 mg OD
Acetazolamide 250 mg OD 10 mg MD changed
Atorvastatin 10 mg OD
Glyburide 5 mg BID
Salbutamol 2 puffs BID QID
Pilocarpine 2% 1 drop to BOTH eyes QID
RIGHT eye
September 2005
62
Challenges
Multi-site pilot units
Baseline audit
Communication
Spread
Unions
Forms Committee(s)
Scheduling of project team
September 2005
63
Questions?
Rapid Fire Presentations
Fraser Health Region - BC
Capital Health Region – AB
Northern Health Region - BC
Providence Health Care - BC
Vancouver Coastal Health - BC
BC Mental Health and Addiction Services - BC
Interior Health Region - BC
Vancouver Island Health Region - BC
Winnipeg Regional Health - MB
Calgary Health Region - AB
Children’s and Woman’s - BC
Medication Reconciliation
Calgary Health Region, Alberta
Presented by:
Jamie Stroud, QI Consultant, Internal Medicine, Unit 74 RGH
and
Debbie Friesen, Clinical Pharmacist, Unit 32 FMC
Who’s on What? – Vancouver, BC.
November 29, 2005
Team Make-up
• Unit 74 RGH
•1
•2
•2
•1
•1
•1
•0
physician
clinical pharmacists
clinical nurse educators
unit manager
QI consultant
transition coordinator
RNs
Who’s on What? – Vancouver, BC.
November 29, 2005
Initial Flow Map
Who’s on What? – Vancouver, BC.
November 29, 2005
Unit 74 Baseline Measures
(n=20)
Success Index – 68.9%
Mean # of Undocumented
Intentional Discrepancies –
3.05
Mean # of Unintentional
Who’s on What? – Vancouver,
BC.
Discrepancies
– 0.50
November 29, 2005
Unit 74 – Next Steps
• Refine team
• Understand variability
• Brainstorm ideas for change
• Set goals
• Complete Improvement
charter
• Select area for improvement
• Prepare for PDSA cycle #1
Who’s on What? – Vancouver, BC.
November 29, 2005
Team Make-up
• Unit 32 FMC
• 1 QI physician
• 2 Hospitalist physicians
• 2 clinical pharmacists
• 1 APC nurse manager
• 1 QI consultant
• 1 staff nurse
• 1 hospitalist nurse liaison
• 1 program manager family
Who’s on What? – medicine
Vancouver, BC.
November 29, 2005
Improving the Process (Unit 32)
CALGARY HEALTH REGION
FAMILY PHYSICIAN: ____________________________________
COMMUNITY PHARMACY: _______________________________
Medication Allergies/Intolerances (include specific patient reaction if known):
PRE-ADMISSION MEDICATION LIST
PRESCRIPTION MEDICATIONS
ON ADMISSION
Dosing
Interval
Hold
or D/C
Route
Change
Medication Name & Dose
Continue
(pills, eye drops, patches, inhalers, etc.)
Reason for Change/ Hold/
Discontinuation
NON-PRESCRIPTION MEDICATIONS
(OTC’s, herbals, etc.)
Source of Medication List (check all used):
Review of medication vials
Who’s on What? – Vancouver, BC.
Family Physician list
Review of patient medication list
EMS record
Patient recall
Wellnet list
Family Recall
Medication Administration Record from another facility
Pharmacy list
Other (specify):
November 29, 2005
Measures for Unit 32 (FMC)
Success Index: Baseline - 56.9%
(Improvement over time)
Goal: 85% (increase by 50%); Stretch Goal: 100% (increase by 75%)
Mean # of undocumented intentional
discrepancies: Baseline - 1.2
(Documentation accuracy)
Goal: 0.3 (decrease by 75%); Stretch Goal: 0.2 (decrease by 80%)
Mean # of unintentional discrepancies:
Baseline - 1.7
(Rate of error)
Goal: 1.275 (decrease by 25%); Stretch Goal: 0.42 (decrease by 75%)
Who’s on What? – Vancouver, BC.
November 29, 2005
Success Index
100
P e rc e nt
80
60
40
Baseline
(n=24)
PDSA 1: Form
Version 1
(n=7)
PDSA 2: Form
Version 2
(n=5)
PDSA 3: Form
Version 3
(n=11)
20
0
Aug.-Sep., 2005
Who’s on What? – Vancouver, BC.
Oct. 12, 2005
Oct. 25, 2005
Nov. 16/17, 2005
November 29, 2005
M e a n # o f D is c r e p a n c ie s
Mean # of Undocumented Discrepancies
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Baseline
(n=24)
Aug.-Sep., 2005
Who’s on What? – Vancouver, BC.
PDSA 1: Form
Version 1
(n=7)
Oct. 12, 2005
PDSA 2: Form
Version 2
(n=5)
Oct. 25, 2005
PDSA 3: Form
Version 3
(n=11)
Nov. 16/17, 2005
November 29, 2005
M e a n # o f D is c r e p a n c ie s
Mean # of Unintentional Discrepancies
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Baseline
(n=24)
PDSA 1: Form
Version 1
(n=7)
PDSA 2: Form
Version 2
(n=5)
PDSA 3: Form
Version 3
(n=11)
Aug.-Sep., 2005
Who’s on What? – Vancouver, BC.
Oct. 12, 2005
Oct. 25, 2005
Nov. 16/17, 2005
November 29, 2005
Next Steps
• Additional PDSA Cycles
• Further explore Nursing role
• Explore use of form by multiple
health care professionals
• Pilot screening tool
• Monitor progress
Who’s on What? – Vancouver, BC.
November 29, 2005
Rapid Fire Presentations
Fraser Health Region - BC
Capital Health Region – AB
Northern Health Region - BC
Providence Health Care - BC
Vancouver Coastal Health - BC
Interior Health Region - BC
Vancouver Island Health Region - BC
Winnipeg Regional Health - MB
Saskatoon Health Region - SK
Calgary Health Region - AB
Children’s and Woman’s - BC
Medication
Reconciliation
BCCH Emergency Department
The Team
† Dr. Jeffrey Hung – Medicine, ED
† Denise Hudson – Quality Initiatives, ED
† Norma Donovan – CNC, ED
† Faye Kingdon – Programme Manager, ED
† Judy Komori – Leader, Quality Safety &
Risk Management
† Kim Shearer – Sr. Practice Leader, Nursing
Projects
† Ian Sheppard – Director, Pharmacy
September 2005
80
Current & Future Plans
† Start in the Children’s Emergency
Department
† Collect baseline data
† Refine data collection and analysis tools;
implement fully in Emergency
† Develop a “roll out” plan for the rest of
C&W – paediatrics and maternity
September 2005
81
Baseline Data
† To be collected in December 2005
† Chart Audit (retrospective)
„
„
„
September 2005
seen in the Emergency department, and
admitted to an inpatient unit, and
taking 5 for more medications
82
Challenges
† Resource challenges
„
„
Time for staff who have been assigned to do the work, and
Staff with IT skills needed to search and/or
write custom reports to find the required
information in electronic databases
† Finding the patients who meet the
criteria
September 2005
83
Charter
September 2005
84
AIM Statements
September 2005
85
Lunch Time!
Thank you very much…