Defining The Problem - Dmaic

Applying DMAIC Methodology to Medication Reconciliation Prepared For

[Date] By

Process Improvement Methodology (DMAIC) DMAIC Provides An Easily Managed Systematic Process To Deliver Measurable Results and Accelerate Change

Define

Measure

Who are the customers and what is the problem from their perspective?

Analyze

What are the most important drivers of poor performance?

How is the process performing today and how is it measured?

Improve

Control

How do we ensure that we sustain the improved performance?

How do we remove the drivers of poor performance?

Improvement Teams Proper Team Establishment Increases Probability For Success Project Executive Sponsor Clinical / Academic Sponsor (As Required)

Improvement Leader

Project Sponsor

Process Owner

Improvement Team

Defining Problem: Analysis of Root Causes Medication History, Reconcile

Order, Transcribe, Clarify

Dispense, Deliver

Administer

Monitor

Educate, Discharge

Identified failure modes (FMEA)

Identified root causes

• Incomplete and/or incorrect medication orders on admission

• Incomplete/inaccurate medication history (omission, different dose, route or frequency, look alike-sound alike)

• Inadequate or missing information on the patient's admission profile • No formalized approach/process to obtaining and documenting a medication history

 Patient’s ability to recall, especially upon admission  Time constraints  Interview skills of clinician • Multiple locations to document (free text) • Pharmacist not formally integrated in process

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Defining Problem: Challenges to Obtaining Medication Histories • • • • • • • •

Patient’s and/or surrogate’s ability to recall medications, doses and/or frequency of use Stress of transitioning through the healthcare system Health literacy Language barriers; cultural beliefs Relationship with healthcare clinician obtaining history Interview skills of clinician Time constraints Accuracy and completeness of medication histories obtained from other resources; accessibility

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Medication History / Reconciliation: Pilot Results Direct Admits to Med/Surg Units* (N=204)

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54% of patients had at least one medication discrepancy 42% of the discrepancies requiring intervention was complete omission of a medication 35% of the discrepancies requiring intervention was a different dosage, route or frequency with what the patient reported taking before admission Of the discrepancies requiring clarification, in the absence of a pharmacist intervention, 22% may have resulted in patient harm during hospitalization and 59% may have resulted in patient harm if continued beyond discharge

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* Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C and Noskin GA. Reconciliation of Discrepancies in Medication Histories and Admission Orders of Newly Hospitalized Patients. Am J Health-Syst Pharm. 2004; 61:1689-95

Medication History / Reconciliation: Most Effective Interventions Medication History, Reconcile

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Order, Transcribe, Clarify

Dispense, Deliver

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Monitor

Educate, Discharge

Single source of truth: Medication list with technology support Reconciliation process with technology support I/T design and continuous monitoring – Compliance, sustainability of new process – Identify rate, etiology and potential harm of medication discrepancies for process improvements

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Administer

Active patient involvement Active pharmacist involvement A

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MATCH Improvement Initiatives Implement a system that achieves the below:

• Increase accuracy and completeness of medication history – –

Create “one source of truth” Complete medication description (drug name, dose, route or frequency – no free text)

• Reconcile home medications with patient and/or family • Reconcile all medications (home and current medication orders) at admission, transfer and discharge –

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Multi-disciplinary approach with physicians, nurses and pharmacists

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Approaches to Evaluate Medication Reconciliation Process • • • • •

Determining compliance rates Type and etiology of medication discrepancies requiring interventions Medications / medication classes involved in discrepancies requiring interventions Potential harm averted through intervention Retrospective v/s prospective review

Questions and Discussion