Improving Medication Management in Supportive Living Using a Self-Assessment Checklist Dale Wright Senior Project Lead

Quality Forum 2014 Promoting and improving patient safety and health service quality across Alberta

ACKNOWLEDGEMENTS

Cheryl Knight Executive Director, Senior’s Health Alberta Health Services

Project partners:

OVERVIEW

Checklist development

Medication management in supportive living

Checklist tool & self-assessment process

Early adopter initiative & results

THE CHECKLIST PROJECT

Objectives

To identify medication safety risks, good practices, and challenges with medication management in supportive living (SL 3, 4 and 4D).

To develop a self-assessment tool that operators of supportive living sites can use to assess the safety of medication practices in their site and identify quality improvement opportunities.

THE CHECKLIST PROJECT

Phase 1 – August 2010 to June 2011 • Literature review • Medication incident report analysis (ISMP Canada) • On-site reviews in 8 SL3, 4 & 4D sites

Phase 2 – July 2011 to June 2012 • Draft checklist developed • Pilot test in 9 SL 3, 4/4D sites • Revise and publish July 2012

Early Adopter Initiative – Nov 2012 to Jan 2013

MEDICATION MANAGEMENT

“All the processes required to ensure safe and effective medication therapy for a client.”

Checklist Glossary

Assessment Prescribing Communication of medication orders Medication reconciliation Dispensing Delivery Storage Medication Support Documentation Monitoring and follow-up

MEDICATION MANAGEMENT IN SL

Assessment

Prescribing

Dispensing

Distribution Administration

(Support)

Use

Monitoring

In the community

Within the site

THE CHECKLIST TOOL

THE CHECKLIST TOOL

Goal: To help SL sites . . . Learn about safe

medication systems and leading practices in medication safety

Identify vulnerabilities in their medication system and stimulate quality improvement activities

THE CHECKLIST TOOL

74 checklist items – leading practices for medication safety 8 key elements – components of the medication system

Assessment

Prescribing

Dispensing

Distribution Administration

(Support)

Use

Monitoring

Client assessment (7)

Client med info (10)

Communication (6)

Medication support activities (16)

Quality & safety program (4)

Pharmacy services (15)

Medication storage (7)

Provider competence (7)

THE CHECKLIST TOOL

SELF-ASSESSMENT PROCESS

Assessment

Prescribing

Dispensing

Distribution Administration

(Support)

Use

Monitoring

A team discussion!

USING THE RESULTS TO IMPROVE

1. List identified vulnerabilities in the med system Items scored ‘Partly’ or ‘No’

2. How easy would it be to make a change? Easy (‘quick fix’), moderate, difficult

3. Select 3 issues to work on Quick fix High-impact changes Opportunity to engage community partner Issues related to known medication incidents

4. Implement a quality improvement plan Brainstorm possible solutions – with the team! Select a solution and try it on a small scale Revise and test until solution is workable Implement Measure to determine if a change is an improvement

EARLY ADOPTER INITIATIVE

Objectives: To encourage SL sites to

use the checklist in a team self-assessment process to identify medication safety improvement opportunities.

To establish a baseline for medication management practices in SL in Alberta.

EARLY ADOPTER INITIATIVE (EAI)

Method AHS contracted SL (147) & PCH (30) Voluntary with $ incentive Multi-mode communication strategy Facilitator kit

– Instructions, checklist booklets, data collection form, return envelope, information contact

Follow-up interviews with site contacts and case managers

EAI RESULTS: Participation

North 6/16

Overall Participation: 56/147 SL sites 10/30 PCH* (Edmonton/Calgary)

Edmonton 17/60*

Central 8/32

Calgary 19/38*

South 16/31

EAI Results: Strengths

Items rated as fully in place by > 90% of sites 1.5 – Site policies describe medication support

2.5 – Management of suspected ADRs

4.6 – Adjustment to med packages done by Rx 4.9 – Method of recording med support kept at site 4.15 – Rx collects outdated & discarded meds

EAI Results: Strengths

Items rated as fully in place by > 90% of sites 5.1 – Meds stored in secure place 5.4 – Lighting levels are adequate

6.6 – Guidance to handle missing or dropped meds 6.10 – MA/AR for each client and available to all providers 6.15 – Proper disposal of materials with client info

7.4 – Clear communication channels and lines of authority

EAI Results: Challenges

Items rated as fully in place by < 50% of sites or not in place for > 15% of sites

1.6 Care plan related to PRN medications

2.6 Care conference 6 to 8 weeks after admission 2.10 Single client record kept at site

3.2 Faxing medication orders 3.4 Med orders include explicit instructions (PRNs) 3.6 Changes in meds communicated to client/family

EAI Results: Challenges

Items rated as fully in place by < 50% of sites or not in place for > 15% of sites

4.2 Service agreement with pharmacy provider(s) 4.5 After hours service from pharmacy provider(s) 4.12 Delayed start policy

5.2 Refrigerator temperature check

6.2 Interruptions during med support minimized 6.13 Documentation for patches and injections

EAI RESULTS: Follow-up Interviews

To determine: Effectiveness of

communication strategies about the EAI

Experience with the checklist and team self-assessment process

Experience with following through with a quality improvement process

EAI RESULTS: Follow-up Interviews

1. Effectiveness of communication strategies E-mail preferred

– presentations also helpful esp. for case managers

Incentive appreciated but did not drive participation Spring or fall timing preferred Non-registered sites:

– 7 completed checklist process; 7 not aware of initiative; 5 did not have time; 2 believed checklist did not add value

Case managers: – Many had not heard about the EAI - 6/25 working with sites

who completed the self-assess, 14/17 working with sites who did not register

EAI RESULTS: Follow-up Interviews

2. Experience with checklist & self-assessment Difficulty finding a time that worked for CM and Rx Effective, valuable process Gained knowledge of role & respect for others Pharmacist is essential to the process Instructions clear, format user friendly, background

info helpful – QI planning tools rarely used

Case managers unsure of role, often did not receive checklist in advance

EAI RESULTS: Follow-up Interviews

3. Experience with improvement activities Development of improvement plan integrated with

the meeting – “Partially” or “not in place” items triggered a discussion of

solutions – Concrete ideas for improvement resulted

Self-assessment is a new process but useful – Consider for other areas of practice

Case managers did not have a clear sense of improvement goals, follow-up activities or how they would be involved – ‘Relationships are important’

EAI RESULTS: Recommendations

Site Level Reinforce team approach to med management Be proactive with pharmacy service provider(s) Communication and PRN medications are a

challenge – review with community partners Use the checklist as a model for proactive quality and

safety improvement AHS Guidance on best practices for PRNs, order

communication (faxing) Support development of QI programs Logistics for future initiatives

FOR MORE INFORMATION

For more information, to order copies of the Checklist, or to receive Early Adopter Initiative reports, contact:

Dale Wright Senior Project Lead

403-355-4439 dale.wright@hqca.ca