Medication Reconciliation in Long Term Care

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Using the Model for Improvementin Long Term Care

• Medication Reconciliation in Long Term Care
• Providence Care, Toronto
• January 19, 2009
• Doris Doidge, Project Manager Ontario Node Safer
  Healthcare Now

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Model for Improvement An Overview

• Every system is perfectly designed to get the
  results it gets
• So, you need to change the system in order to get
  different results
• Essential elements of break through improvement
  will, ideas execution

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When you combine these 3 questions
You Get the Model for Improvement
With the PDSA Cycle
Associates in Process Improvement
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The AIM
The Measures
The Changes
Cycles for learning and change
Associates in Process Improvement
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The Aim Statement

• What are we trying to accomplish?
• Aim specific, measureable and answers these
  questions
• How good? (measure)
• By when? (time)
• For whom (or for what system)? (population)
• E.g. I will lose 25 pounds by June 30, 2009
• To reduce adverse drug events, all newly admitted
  patients will have their medications reconciled
  within 48 hours of admission by the prescribing
  clinician by May 15, 2009
• Keeps the team focused on their intention

Associates in Process Improvement
Associates in Process Improvement
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AIM - What Are We Trying to Accomplish?

• Suggest Use Accreditation Canadas quality
  framework to help establish your aim
• Population focus, Accessibility, Safety,
  Worklife, Client-centred services, Continuity of
  services, Efficiency, Effectiveness
• Good or bad Aim statements
• We aim to reduce harm and improve patient safety
  for all of our patients
• By June 2009 we will reduce the incidence of
  pressure ulcers on 3East by 60
• We will reduce the of facility acquired MRSA

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The Measures

• We use measurement all the time
• Baking, gas gauge on your car, sports scores,
  weight management, vital signs
• Measurement does matter
• Did the change you put into place result in
  improvement? Did it make a difference? How are
  we doing? Did we hold the gains?
• Provides us with feedback
• E.g. Aim arrive on time for work 100 of the
  time by March 15, 2009
• Put changes into place (get up earlier)
• Measure to see if it helped me arrive on time for
  work

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Measurement for Learning Improvement

• Measurement for improvement simple measures to
  see if they changes being tested are making a
  difference purpose is learning not to discover
  new knowledge (research)
• Use sampling
• Integrate measurement into daily routine

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Types of Measures

• Outcome measures
• Where are we ultimately trying to go?
• Are your changes leading to improvement
• Measures of the customer or patient
• of patients with zero unintentional
  discrepancies / month
• of adverse drug events/1000 doses
• Process measures
• Are we doing the right things to get there?
• Measures of the workings of the system
• Are we doing the right steps
• of patients receiving medication reconciliation
  on admission
• Balancing measures
• Are the changes we are making to one part of the
  system causing problems in other parts of the
  system
• Measures of other parts of the system
• of patients who leave without being seen
• Use a family of measures

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Displaying Data Over Time

• Display the data youve collected, graphically
  over time
• SHN helps by displaying run charts when you input
  the data for the med rec measures
• Helps you determine if the changes you have made
  have lead to improvement

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The Changes

• How are you going to achieve your Aim
• Need to make a change
• Definition of insanity (Einstein)
• Doing the same thing over and over again and
  expecting the results to be different
• What changes can we make that will result in
  improvement?
• Run PDSA cycles to test the changes you predict
  will make a difference help you achieve your Aim

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Ways to Develop Changes

• Critical thinking about your existing system
• Use of technology
• Benchmarking
• Creative thinking
• Using Change concepts
• A general notion or approach to change that has
  been found to be useful in developing specific
  ideas for changes that lead to improvement
• Eliminate waste (Recycle or reuse remove
  unnecessary steps in a process)
• Improve work flow (remove bottlenecks eliminate
  batching)
• Manage time

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What changes can we make that will result in
improvement?

• Medication Reconciliation
• Test new medication history (BPMH) form
  (identify and implement revisions as needed)
• Test having RN complete medication history (BPMH)
  and compare with pharmacist completing medication
  history
• Test the process that has been developed for
  initiating and completing the reconciliation
  process

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Using the PDSA Cycle

• Test the change in the real work setting
• Use PDSA cycle to test a change
• Plan the change
• Try the plan
• Observe the results
• Act on what is learned from the test
• Even if you think a change is obvious test it
  it may not get you the results you want in your
  setting
• Dont put all your efforts into designing a
  change without testing it
• E.g. BPMH forms

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Why test a change?

• Increases the belief that a change will result in
  improvement
• Predicts how much improvement can be expected
  from the change
• Whack a mole Look for unintended consequences
  (balancing measures)
• Learn how to adapt the change to the local
  environment
• Evaluate costs and side-effects of the change
  before you implement across a program/organization
  /system
• Opportunity for failures
• Test to know if it is going to fail
• First test with expert
• Then test with someone who is actually going to
  do a job
• Fail fast

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Testing A Change Using PDSA

• Act
• Adopt, adapt or abandon?
• What changes are to be made?
• Whats the next cycle

• Plan
• State objectives
• Make predictions (why)
• Develop plan to carry out the cycle (who, what,
  where, when)

• Do
• Carry out the plan/test
• Document problems, observations.
• Begin analysis of the data

• Study
• Complete analysis
• Compare data to prediction
• Summarize what you learned

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PDSA Worksheet
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Linking Tests of Change

• Once you complete one PDSA cycle, you begin
  another linking the cycles together
• Each tests generates information adds to your
  knowledge, tells you what to change
• Gets the kinks worked out until youre ready to
  implement
• Also helps overcome resistance and facilitate
  buy-in
• You can run several changes concurrently

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Planning Test Cycles
PDSA 1 PDSA 2 PDSA 3
Institute Best Possible Medication History
Eliminate Undocumented Intentional Discrepancies
Develop form to communicate accurate orders
PDSA 1 PDSA 2 PDSA 3
Train people to do BPMH
BPMH completed before admit orders are written
Reduce Adverse Drug Events
Eliminate Unintentional Discrepancies
Make BPMH the med order sheet
Develop a BPMH form
Establish a Reconciliation Process
Developed by B. Harries, Canadian ICU
Collaborative
Flow chart the ideal process
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Real Test Cycles of Change

• Ask a Nurse, a Physician and a Pharmacist to look
  at your draft BPMH form and make suggestions
• Try the form with one clinician and one patient
• Revise it and try it with the next 2 patients
• Find the average time it takes to do BPMH for a
  small sample (3 or4) of medical admissions
• Have a pharmacy tech try the process
• Use feedback from testers to develop training
  materials
• Use data from different time periods to decide
  when it is most crucial to have coverage for
  BPMH

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Two Levels of Measurement

• Project Level Measures

• PDSA Level Measures

• Helps you to answer the questions in each PDSA
  cycle Do and Study

• Answers the question How will we know that a
  change is an improvement

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Measurement Examples

• SHN Measures Submission
• Mean number of undocumented intentional
  discrepancies
• Mean number of unintentional discrepancies
• Percentage of residents reconciled upon admission

• PDSA Cycles
• Tests of Change
• What feedback did we get on the form from the
  unit physician?
• How long did it take to complete a BPMH?
• What of patients had BPMH completed before
  admission orders written?

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• You win the Tour de France not by planning for
  years for the perfect first bicycle ride but by
  constantly making small improvements
• Don Berwick, March 1996

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References

• Associates in Process Improvement (2008).
  http//www.apiweb.org/API_home_page.htm (January
  13, 2009)
• Ballantine, C. (2007). Using The Model for
  Improvement in mental health care Incorporating
  measurement planning small tests of change.
  Safer Mental Healthcare Now! Whitby Mental Health
  Centre.in Mental Health Care HI Impact Program
  (2007). Improvement Team Sponsor Handbook.
• Langley, G. J., Nolan, K.M., Nolan, T.W., Norman,
  C.L. Provost, L.P. (1996). The Improvement
  Guide. San Francisco Jossey-Bass
• Murray, S., Provost, L. Lloyd, R. QI 102 The
  Model for Improvement Your engine for change.
  IHI Open School. http//www.ihi.org/IHI/Programs/I
  HIOpenSchool/IHIOpenSchoolforHealthProfessions.htm
  ?TabId4 (January 13, 2009)