Contra Costa Regional Medical Center
Martinez, California, USA
Team
Stephanie R. Bailey, MPH, Director of Ancillary Services (team leader)
Oliver Graham, MD, Internist (physician champion)
Dana Colomb, RN, Staff Nurse (nursing champion)
Terri Horvath, RN, Nurse Program Manager, Clinical Informatics
Shideh Ataii, PharmD, Director of Pharmacy
Sung Park, RPh, Pharmacist
*This represents a list of core team members who meet on a weekly basis. There were many other nurses and physicians who attend on an as needed basis.
Aim
To reduce the rate of medications unreconciled at admission, transfer and discharge transition points by 50 percent within 3 months of spread to each inpatient unit.
Measures
Changes
The boundaries for this project included admissions to, transfers within, and discharges from our inpatient facility and providing discharge medication information to our large ambulatory care network. Our inpatient units and outpatient clinics utilize paper medical documentation and the MediTech Pharmacy system.
Developed data collection tool and collected baseline and ongoing data to track our progress with process and outcome measures
Developed a paper admission medication reconciliation and order form (MROF) and supporting workflows
Tested the MROF using rapid cycle testing and listening to staff feedback, then implemented and spread the process to all inpatient units within 7 months
Marketed the project to “sell” it to stakeholders
Coached staff to use the form and the process
Conducted staff trainings
Developed a transfer and discharge reconciliation process modeled after the admission process with electronic efficiencies added
Provided new, electronic access to discharge medication information to clinic providers seeing patients post-discharge
Results
Summary of Results / Lessons Learned / Next Steps
We reduced the percent of unreconciled medications upon admission by 94 percent (from 21.4 percent to 1.2 percent) on the medicine, surgery, ICU and IMCU units. The rate of unreconciled medications upon transfer was reduced by 66 percent (from 12 percent to 4 percent). This was made possible by developing and spreading an effective medication reconciliation process. Discharge reconciliation is being tested on a pilot unit and will begin to spread to other units.
Lessons Learned
We have learned that in order to successfully imbed a new process like medication reconciliation into the culture of the organization, it’s important to involve the right people and create the right process that works for stakeholders. With these key ingredients, a new process will spread successfully with staff “pulling” it into their areas rather than leaders “pushing” it into their work flow. Our experience with rapid and effective adoption of the new processes helped us achieve mentor status with IHI in Medication Reconciliation [as part of the 100,000 Lives Campaign].
“Borrow” ideas, forms, etc., from other organizations to take advantage of already established best practices.
Have senior management staff be highly visible with their support and commitment to the project.
Identify a team leader who has facilitation skills and who is not identified as being biased toward any discipline involved with the project (nursing, providers, pharmacy).
Select true “champions” from each nursing, pharmacy and medical staff to be on the project team. These individuals are the eyes and ears of many stakeholders. They need not be the formal leaders in the organization.
Hold weekly team meetings with durations of 45 minutes and be prompt and productive. This demonstrates that their time away from the bedside is valued.
For each discipline, keep in mind “what’s in it for me?” when developing workflows. When staff see a benefit to them or the patient, the process “sells itself” and staff are inspired to comply.
Test thoroughly before implementing/spreading and be responsive to staff feedback. When staff see their suggestions incorporated into the process, you’ve gained a strong supporter.
Collect medication history once and have everyone work from the same list. This reinforces an integrated approach to care.
Confirm that the admission reconciliation process is highly reliable before beginning discharge reconciliation. Otherwise, discharge reconciliation rollout will be a bumpy road and the headlights will be shining on the problems with the admission process.
Design workflows to take advantage of current habits. This makes it easy for staff to do the right thing.
Standardize all steps in the process everywhere.
Have safeguards in place to make it difficult for staff to “fall back” to the old process.
Have steps in place to identify process failures and mitigate them.
Contact Information
Stephanie R. Bailey, MPH, Director of Ancillary Services
Contra Costa Regional Medical Center
sbailey@hsd.co.contra-costa.ca.us
[Storyboard presentation at IHI's 2006 National Forum]
