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FRHS Kaizen Workshop #1
Medication Reconciliation (MRR)
Admission / Discharge Only
October 3-5, 2007
Kaizen #1: Medication Reconciliation Admit / Discharge
Mission: To improve the process of medication reconciliation to assure patient safety.
Objectives: 1. Achieve a 50% improvement in accuracy of medication
information upon admission.2. Reduce nursing time spent by 12.5%/day.3. Reduce delays in medication administration by 50%.4. Reduce medical errors by 80%5. Support the new hospitalist program.Train-the-Trainer objectives6. Learn Lean tools as process improvement method.7. Diffuse improvement mindset throughout the hospital.8. Reduce waste throughout all major processes.
Medication Reconciliation KaizenTeam
Kaizen Team Work
David, Beth, Steve, John, Rhonda, Beth H, Melissa, Carol, Mark, Missy, Vicky, Gloria, Alison, Patsy
ER
Direct Admit
External Transfer
Obtain list of current meds;Contact physicianContact external pharmacy
How to get?
Review initial orders
Contact admitting physician to identify meds
Reconcile meds
Review external facility list
15 min
Nurse write out med list (if needed);Fax order to internal pharmacy
1-2 hours
30 – 60 min
Nurses temp orders are cancelled and re-entered
Physicians don’t write full admit med’s list;Nurses act on med’s list
15 min
20 sec to 15 min
ADMISSION
Getand/or Give meds
Physicians don’t respond
Process Efficiency: 100% max, 31% min
Admit/PCP don’t agree on med list for patient
Total Admission times:Min: 97.2minMax: 2.5 hr
All pre-op meds discontinued when
going to surgery/transfer;
Pharmacy out of loop;
No auto discharge between units.
Discharge form placed on each chart at each location
Create standing orders
Computer versus manual documentation system for meds (ED gets but another area enters)
Standardized process for FRHS physician offices in relaying med list.
Nursing making decisions outside scope of practice. Collaboration with pharmacy.incomplete orders are not written and relayed to pharmacy – i.e. no dose, route.Education
improvements for new people.
VALUE STREAM MAP – MEDICATION RECONCILIATION
Physician discharge order form and signs
Print Discharge Instructions
DISCHARGE
Are meds complete?
Calls physician to complete list
Physician task to write meds, activity, diet, etc.
Enter full info into CPSI
No
Yes DONE
Incomplete physician meds;Or continue home meds;Physicians don’t respond till later.
Discharge order about not on all charts. Educate nurses and physicians on location.
Process Efficiency for discharge: 56% Best 30% Worse Case
15 min
2 min to 1 hr
Redo
2 min
Physicians not writing complete list of meds for patient to continue to take.
Computer generated list of all home meds and meds taken while hospitalized.
Should list only meds active on day of discharge.
: Value Added
: No value added
Total Time:Min: 41 minMax: 112 min
Complete separate forms as needed for transfers.
Redo work to getting transfer forms completed.
VALUE STREAM MAP – MEDICATION RECONCILIATION
Nurse – obtain list of meds if not already provided and enter in CPSI
Nurse to contact physician and send MRR to physician for review
Fax completed MRR to pharmacy and process and review
ER Admit 1a
External transfer: list of meds sent with patient transfer
Direct Admit: fax list of admission orders and list of home meds
Review list of external facility
How to get info?
Review initial orders
30 min 15 min 20 seconds 2 min to 60 min 30 min
FUTURE STATE - ADMISSION
FUTURE VALUE STREAM DISCHARGE
Physician to complete discharge order form. Separate discharge forms for patients gtransferring to ecf or other facility. Physician to complete
Physician to review MRR to verify any home meds to resume and addi tional meds to continue.
Review written discharge instructions with patients or external facility.
20 min 2 min
0 min
5 -15 min
Fax verify MRR and d/c meds to pharmacy to review
PROCESS IMPROVEMENT WHO WHEN
1 Physician order form Patsy & Beth W.
2 At discharge bring file…. ?
3 Modification of medication reconciliation report to highlight or subtract Rhonda & Vickie
4 Standing order based on diagnosis. Alison and Gloria
5 Go back 90 days in computer system for hospital meds Rhonda and Vickie
6 Computerized physician orders Missy & Beth H
7 Standard time or procedures for salary FRHS to respective physician list. John and Steve
8 ER enter medication list in CPSI Mark and Carol
9 All FRHS docs enter meds into CPSI – EMR, nurses pull OP list upon admission.
10 Chart link for nurses to view past medical history
11 Education Physicians and nurses regarding medication reconciliation Carol and Mark
12 Pharmacy contacts physician directly to clarify “missing dose or frequency” Missy & Beth H
13 Pharm “D” goes to floor / or review electronic chart for clinical monitoring, interactions on home & in-house medications.
14 Problem solve why all Pre-op meds are not “stopped” at pre-op, transfer
15 Why pharmacy is out of loop on patient transfer and times to stop drugs? Missy & Beth H
16 IMI to associate standards of care for medication reconciliation into physicians pay
17 Require PCP to fax current medications on admission
Week #1 – Medication Reconciliation Process Improvement
Date: 10/3-5/07 Team: Beth and Patsy
PROBLEM SITUATION: COUNTERMEASURE(S)
Standard: Consistent process / placement for discharge orders Containment: edcuation of unit clerks; education of physicians (new); continual surveying of users for improvement
Current Situation: Various processes being used due to phy preferenceaddition of 2nd return section for consultants (possibly)
Long term System Solution: Hospitalist program with full complimentDiscrepancy: Phy preference
Extent: Every Discharge
Why Recommended? Can't teach old dogs new tricksRationale: Continuity of care / patient safety / fed compliance
GOAL IMPLEMENTATIONWhat Who When Where Status
Do What: Find consistent patien discharge orders Continue use of current form all
clinical
areas FRHS doneTo What: Patient records redo form with government updates Care Mgmt qrtly FRHS pending
How Much: all discharges education of unit clerks TL Nov units pendingBy When: at discharge instruction time education of physicians
CAUSE ANALYSIS
Potentia l Causes: How Checked? Result?Phy Preference 1:1, committee partial by-in
location of form
various unit clerks with no set
placement unable to find
FOLLOW-UP
Most Likely Cause(s) Check method:Check frequency:
Problem Statement: Who will check?Why? No consistant process Target
Why? No consistent by-in Actual Why? No consistent placement of order form on chart
Why? Lack of training Why? Lack of accountability for process completion
O N D J F M A M J J A S
Root Cause: Accountability Issues
Recommended Actions: a ll
redesign form, proof, approvals, print, distribuet,
use, collection data
THEME: Review Physician order - discharge form
Problem Solving Report
Discharge OrdersForm
Sample
Date: 10/3-5/07 Team: Steve & John
PROBLEM SITUATION COUNTERMEASURE(S)
Standard: each patient should have accurate list of home meds Containment:Review HFAP standards & match P&P with standard development
develop new physician order sheet with options to cont/stop home meds
Long term System Solution:Implement new med reconciliation P&P and protocol
Extent: vaies house-wide
Why Recommended?develop responsibility for parties involved and avoid nurses ordering outside
scope of practice and direct physicians to specifically state medications
GOAL IMPLEMENTATIONWhat Who When Where Status
Do What: establish med reconciliation protocol/p&p benchmark facilities who have meds John/Steve 4-Oct FRHS pending
To What: provides direction for nursing staff and physicians develop P&P on Med Reconcile
Steve, Beth
Patsy 7-Nov FRHS pending
How Much: every admission train physicians/pharmacy/nursing
Beth,
PatsyGloria Dec FRHS pending
By When: Nov 2007 track efficiency of protocols Beth, Patsy ongoing FRHS pending
CAUSE ANALYSIS
Potentia l Causes: How Checked? Result?
No P&P in place interview none exists
FOLLOW-UPMost Likely Cause(s): have not implemented new standard Check method: interviews and chart audits
Check frequency: monthlyProblem Statement: New standard has not been implemented Who will check? Nursing leadership and QA
Why? Confusion over who is to take the lead in this process Target Why? Lack of knowledge of guideline Actual
Why? Failure to read QA updates Why? Lack of clarity on role of pharmacy and nursing
Why?
Pharmacy leadership
recent change
and
contracted service
J F M A M J J A S O N DRoot Cause: Recommended Actions:
New leadership and lack of clarity on role. Require physician to provide information/decision
THEME: Physician provides home med list
Problem Solving Report
Current Situation: phsician states "continue home meds"
Rationale: Nursing unable to obtain needed information from
Discrepancy: Nursing currentlyl making judgement calls
DRAFT Policy
Physician List
Sample
Date: 10/3-5/07 Team: Rhonda & Vicky
PROBLEM SITUATION: COUNTERMEASURE(S)
Standard: report shows current and dinscontinued meds Containment:change form design - give option to prevent all or only current meds
Current Situation: not utilized - doesn't fit users needs
Long term System Solution:Discrepancy: only want current meds at discharge to home apply global standards to the report. Always print lines for additional
meds, a lways print home meds documented on admission, a lways printExtent: house-wide box for meds documented on admission and for physician.
Why Recommended?Rationale: new report from computer system Encourage use of the report to ensure med reconciliation at discharge and
decrease medication errors
GOAL: improve report to meet patient needs IMPLEMENTATIONWhat Who When Where Status
Do What: Setup form to better fit users needs
To What: Encourage use of the report of med reconciliation at dischargeHow Much: each discharge (non-death)
By When: immediately form changes Vicky now IS doneconsistent usage by staff Nsg 30 days unit pending
CAUSE ANALYSIS
Potentia l Causes: How Checked? Result?
software issues printed report prints all meds
FOLLOW-UPMost Likely Cause(s): not set-up correctly in system Check method: print the report
Check frequency: at least quarterly with SIQ reportsProblem Statement: report does not meet users needs Who will check? Each dept
Why? This report was not previously used Target Why? Didn't know the report was there Actual
Why? Poor communication Why?
Why? 1 10 20 30
Root Cause: Recommended Actions:poor communication Initial use of report, educate as needed, implement, audit with SIQ reports
THEME: medication reconciliation report
Problem Solving Report
ReconcileSample
ReconcileSample
Extra Lines
Date: 10/3-5/07 Team: Rhonda & Vicky
PROBLEM SITUATION COUNTERMEASURE(S)
Standard: Accurate list of home medications needed at admission Containment:check security switches for RN/LPN and CNAs; Make sure all have
Current Situation: Initia l interview includes list of medications; security switch
Available for 98 days Long term System Solution:Discrepancy: RN/LPN not getting prompt or information to include train nursing to use the copy forward options in CPSI
Extent: varies from patient - to - patient
Why Recommended? To fully utilize this option in CPSIRationale: accurate home med list provides best safety process for patient.
GOAL: provide consistent process for bringing stay information forwardIMPLEMENTATIONWhat Who When Where Status
Do What: use the copy forward option check switches Vicky 4-Oct IS done
To What: cut down on time required to enter information change 100 for RN/LPN Kim 4-Oct IS doneHow Much: 30% change 101 for Certified NA Kim 4-Oct IS done
By When: Immediately promote use of copy forward Nsg 4-Oct Nsg units pending
CAUSE ANALYSIS
Potentia l Causes: How Checked? Result?
security switches settings IT review inconsistent
Lack of training Interview don't know how
FOLLOW-UPMost Likely Cause(s) Check method: user security
Unknown that this option was available Check frequency: 30 daysProblem Statement:: copy forward function not set up Who will check? Point of Care contact
Why? Didn't know function available Target Why? Lack of communication Actual
Why? Computer system education inconsistent Why? No computer educatino process
Why? Lack of priority 1 5 10 15 20 25 30
Recommended Actions:Provide consistency of security levels for copy forward option
THEME: Copy pertinent history from previous stay
Problem Solving Report
Root Cause: lack of followup from softare support
DR. LANDRY - DR. JOHNSON LABOR AND DELIVERY STANDING ORDERS
ADMISSION 1. Admit to Labor and Delivery 2. Nothing by mouth except ice chips until otherwise ordered. 3. Pelvic examination by nurse to evaluate cervix and cephalic presentation. 4. Continuous ele ctronic fetal monitoring while in bed. 5. Bed rest after rupture of membranes. 6. Complete blood count, Type & Screen, if none has been done in last 24 -hours at
once. 7. Dipstick urine for glucose and protein 8. Maternal vital signs (Blood pressure, Te mperature, Pulse, Respiration) per
protocol. 9. Notify physician after initial evaluation. MEDICATIONS 1. Contact physician for pain medication and/or epidural request. 2. Intravenous fluid:
Lactated Ringers @ 125 cc/hour while in labor. 3. If Gr oup B strep positive start:
Ampicillin 2gm bolus then 1gram intravenously every 4 -hours until delivery.
Penicillin 5 million units intravenously then 2.5 million units intravenously every 4 -hours until delivery.
If allergic to Penicillin give: Clindamycin (Cleocin) 900mg intravenously every 8 -hours
until delivery. Erythromycin 500mg intravenously every 6 -hours until
delivery. DELIVERY 1. Oxytocin (Pitocin) 20 units in remaining Intravenous fluid at time of delivery of
placenta 2. Cord blood for lab studies. ____________________________________
Physician’s Signature Date/Time Form # 954-646-0005 Page 1 of 1 Approved OB Section – 2-3-04 ORI.01.16.07Revised 4/2006, 1/2007
Standing Orders Example
Standardized Work Chart
WalkStep
No.
1
Man. AutoKey
Fax to pharmacy for review
Nurse to review with patinet at discharge
Department Name:
Date / Sign
Totals
Work Sequence LayoutStd Work Sheet No:
WORK STEPS
Process Description: Discharge Form
Time Observations
Site: Takt Time:
Date: Page:
1
7
8
2
3
4
5
9
10
Patient admitted
Discharged orders placed in front of chart
Physician and nursing education: orientation to formUnable to write "continue home meds"
Must review / reconcile MRR from CPSI
Check continue/discontinue
Add new meds (if needed)
6
SafetyKEY:Quality
CheckQ Delta
Critical
In-Process
Stock
Standardized Work Chart
Department Name:
WORK STEPS
Process Description: Direct Admission
PCP/office faxes current home med list to unit
Nurse interviews patinet and family and verifies
or obtains current home med list
RN documents in CPSI
RN contact physicina and sends MRR for review
Physician signs MRR with specific documentation
on initial home meds
5
6
2
3
4
Work Sequence LayoutStd Work Sheet No:
Site: Takt Time:
Date: Page:
1
Time Observations
Totals
Nurse sends Mrr to pharmacy for review
Man. AutoKey WalkStep
No.
1
SafetyKEY:Quality
CheckQ Delta
Critical
In-Process
Stock
Date: 10/3-5/07 Team: Alison, Gloria, & M elissa
PROBLEM SITUATION COUNTERMEASURE(S)
Standard: Federal guidelines in place currently not met Containment: Involve physicians Develop new orders and obtain physician input
Current Situation: Some standing orders but not for a ll categories
Long term System Solution:Discrepancy: Does not meet required guidelines Develop standing orders with physicina input and include an
accountability planExtent: 8 DRGs of top 25 DRGs to be focus Communicate, communicate, communicate
Why Recommended?Rationale: top 25 DRGs monitored along with federal requirements Physician by-in is essential
GOAL IMPLEMENTATIONWhat Who When Where Status
Do What: increase # of standing orders Develop draft order Patsy 3 mos FRHS pending
To What: standing orders for admission process Present to physicians Beth, Patsy 3 mos FRHS pendingHow Much: minimum - federal requirements Revise form based on suggestions Patsy 3 mos FRHS pending
By When: 6 months - 1 yr Send for approvals Patsy, Beth 3 mos FRHS pendingImplement form usage Nsg 3 mos FRHS pending
CAUSE ANALYSIS
Potentia l Causes: How Checked? Result?
Orders not accessible interview clerk turnover
Lack of education interview no orientation process
Disconnect of involved interview no accountability FOLLOW-UPMost Likely Cause(s) Check method: quarterly data collection
Check frequency: quarterlyProblem Statement: disconnect of involved parties Who will check? Care Mgmt Dept
Why? Lack of physician compliance Target Why? No orientation process Actual
Why? Time not provided for orientation Why? Income wanted ASAP
Why? Financial Independence Apr July Oct Jan
Root Cause: Stable working environment Recommended Actions:Develop and implement standing orders for federal compliance
THEME: Standing order based on diagnosis
Problem Solving Report
Date: 10/3-5/07 Team: M ark and Carol
PROBLEM SITUATION COUNTERMEASURE(S)
Standard: All records will have medication reconciliation Containment:training for team members
Current Situation: Standard not being followed
Long term System Solution:Discrepancy: tools not accepted for compliance new computer software options
Extent: individual physician preferences preventing standardization
Why Recommended?Software system needed to improve communications between departments
GOAL IMPLEMENTATIONWhat Who When Where Status
Do What: tra in CPSI trianing education ASAP FRHS pending
To What: team members and doctors andHow Much: one class IT
By When: next quarter
CAUSE ANALYSIS
Potentia l Causes: How Checked? Result?
ER No list interview Not important
Physiicans don't provide interview Too busy
FOLLOW-UPMost Likely Cause(s) Check method: chart audit
lack of time; CPSI unfriendly Check frequency: monthly at first then quarterlyProblem Statement: Lack of by-in Who will check? TL in each unit
Why? Lack of training Target Why? Low priority list Actual
Why? Non-revenue generating Why? Support service only
J F M A M J J A S O D J M J ORoot Cause: Recommended Actions:
Limited vision for connecting non-support services to benefits Train, retrain, and software upgrade
THEME: Staff education on medical records
Problem Solving Report
Rationale: Need resolution to provide safest patient
Why? Disconnect between support and customer service revenue
Date: 10/3-5/07 Team: M issy & Beth H
PROBLEM SITUATION: COUNTERMEASURE(S)
Standard: Internal transfers require medication reconciliation Containment: Cross the departmental barriers (with armour)
Long term System Solution:
Develop policies and procedures for interdepartmental transfers
Extent:
Why Recommended?Rationale Currently we do not have and need this process to meet guidelines.
GOAL IMPLEMENTATIONWhat Who When Where Status
Do What: Standardize the prcoess Policy / Procedures MRec group ???? TBD pending
To What: Medication reconciliation Education to all clinical providers all effected? P&P done
dept levels pending
How Much: With all transfersBy When:????
CAUSE ANALYSIS
Potentia l Causes: How Checked? Result?Computer limitations Interview/visual Ineffective process
Limited communication Interview
Breakdown in communication
system
FOLLOW-UP
Most Likely Cause(s) Check method: chart auditsCheck frequency: goal: monthly, at least 30
Problem Statement: Who will check? TL or designee of each deptWhy? Orders not faxed to pharmacy Target
Why? No process in place Actual Why? Lack of awareness
Why? Disconnect between physician guides and others Why? We don't know.
J F M A M J J A S O N DRoot Cause: Recommended Actions:
Lack of communication between processes Develop new process/policies and monitor monthly for compliance.
THEME: Pharmacy Involvement
Problem Solving Report
Current Situation: Policy exists for medication
discontinuation for surgical patients; Need policy for transfer between units.
Discrepancy: Inconsistency in transfer processes. Orders not a lways discontinued.
BEFORE AFTER IMPACT
Physician Order Form (#1)
No consistent process for use and chart placement; physicians ask nurses to complete.
Continue to use current form; education unit clerk/physician; qtrly review
Increased usage and compliance - 18 of 18
Med Reconcile report: (#3)
Form contained all home meds and all medications administered during the hospital stay
Form can be modified so all home meds and only current medications ordered at time of discharge will show; continue or discharge boxes available for orders; nursing option for all meds or current only meds; hard-code med name/type/route
Less medication errors, improved patient safety, less risk with compliance to applicable regulations.
Standing Orders (#4)
Some in place - 17 top 25 DRGs; patient safety and compliance not optimal
Meeting 100% standards for care involving the top 25 DRGs. Improves education/awareness for new team members, thus overall by-in for use of product.
Improved patient care/safety. Increases standardization which maximizes productivity and improves customer satisfaction by decreased waiting times.
90 Days (#5)
System can restore after 98 days (copy-forward); current usage unknown
Nursing will be educated on process for bringing information forward without having to re-type. Speeding up processes. (Unless an outpatient event)
Smoother process for medication list of home medications with minimal computer data entry by nursing. Saving time and more reliable listing.
Scope of Practice for Nursing (#7)
Lack of physician compliance with providing med list results in nursing making medical decisions in addition to 'hunting for information' via family, pharmacy, or other resources.
Develop Policy and Procedure for physician call-back from unit pages; complete listing of medications will be provided to all upon referral or transfer; external pharmacy to be used as a last resort in the event other resources unable to provide needed info.
Returns nursing scope of practice to acceptable legal parameters. Decreases time for nursing, pharmacy, and physician to resolve home medication issues upon arrival.
ER med list entering into CPSI (#8)
Currently home meds are not being entered into the computer system by ER team. Current questions about medications are free texted rather than in electronic flow sheet.
All ER patients will get home medication list started in ER.
Decreases time for medication reconciliation
RESULTS
BEFORE AFTER IMPACT
Computer usage #11 – system not being utilized to its maximum potential
All incoming patients would have their home medication lists started at the earliest entry point – with focus on ER.
Computer system usage maximized and patient care improved via speedy medication reconciliation.
Pharmacy missing does; floor review; stopped orders (#12) – medications are not being discontinued prior to transfers
Pharmacy has only one terminal with trigger for transfers between floors – but no surgical trigger. Typically not looked at by the pharmacy team. Pharmacy using personal decisions on what medications to continue due to lack of new orders written by physician upon transfer.
All pts will have their orders discontinued upon transferred and new orders received as the physician feels appropriate on med rec form for that patient’s continued care.
Orders for transfer will be complete and include medication reconciliation between units as per the HFAP standards. Surgery to fax all post-op orders to pharmacy.
Medication lists will be printed between transfers and used as a guide for which meds to continue. Ideally the physician will provide this information. Nursing and pharmacy will work in conjunction to review and assess for potential patient safety issues.
Meets hospital policy and improves patient safety.
Medication errors reduced.
Conforms to federal guidelines.
RESULTS
Results SummaryCATEGORY RESULTS BASELINE ACHIEVED COMMENTS
Steps:
Lead Time / Process Efficiency
16 10
Standard works: written
0 +1
Quality Standard orders improve care;
Pharmacy review/process MRR;
Physicians use revised MRR to confirm meds
Enter ECF meds into CPS
Decrease medication errors
Time / Productivity Fewer pharmacy calls;
Fewer nurse calls to physician;
Nurses have less confusion on whose orders to follow
Med orders more clearly understood;
Fewer calls to physicians for discharge instructions;
Discharge nurses do not have to enter into CPSI.
Other Increase nursing morale with better work flow.
Improve communication between nsg / docs
