Improving Medication Reconciliation at National Jewish Health
A Collaborative, Multidisciplinary Quality Improvement Initiative
Medication reconciliation (MR) is the process of comparing and reconciling patients' medication lists at transitions of care, including outpatient clinic visits.
An interdisciplinary team convened at National Jewish Health (NJH) in 2013 to improve the MR process in a multispecialty clinic. Interventions were aimed at changing MR practices of physicians, nurses, and medical assistants. Interventions included changing how MR is documented in the electronic health record (EHR). New metrics designed to measure MR performance, and to validate the performance metrics, were derived from EHR data.
The project was funded by an educational grant from GlaxoSmithKline.
This video roundtable explains how the quality improvement process was carried out and provides practical ideas that other health care organizations may find useful.
Hello, I'm Dr. Esther Langmeck, Medical Director of Professional Education at National Jewish Health.
Welcome to our roundtable discussion of how one institution successfully improved its outpatient medication reconciliation process.
National Jewish Health is an academic, multi-specialty health care institution located in Denver, Colorado.
National Jewish treats more than 40,000 adults and children from around the world. Many of them have complex respiratory diseases and other medical diagnoses. Many patients are on multiple medications.
I'm joined today by several members of the National Jewish Health Care Team.
Carrie Fohl is the Clinic Operations Supervisor and MA Coordinator for the Cardiology and GI Clinics.
Dr. Gary Cot is Director of Quality and Safety.
Sarah Breschaw is a Cystic Fibrosis Nurse Coordinator.
And Dr. Betsy Kern is Director of Health Outcomes at National Jewish Health.
Dr. Cot, what is medication reconciliation and why is it so important for patients?
Simply stated, medication reconciliation is the process that should take place at every patient encounter with a health care provider.
The importance is to assure that you have a complete, up-to-date, and accurate medication list.
The reason that this is such a crucial endeavor in medicine is that it's simply related to patient safety.
Medication errors play a major role in the problems with patient safety in health care.
It's estimated that about 40 percent of all the medication errors that occur as a result of problems in the reconciliation of medications and subsequent transition of care from a patient from one location to the next.
And about 20 percent of those medication errors that are problems with reconciliations are deemed to be those that can be very impactful upon a patient.
So simply to improve patient safety, to have better outcomes, we have to do a better job with medication reconciliation.
How did National Jewish Health decide to improve its medication reconciliation process?
Well, to be complete, this is a process we've been doing for many years in various stages.
Back in the day of paper records, we had a process to try to make sure we had medications reasonably accurately placed in paper records.
As we transitioned to the EMR, we changed our process to a degree.
National Jewish Health has grown substantially in the last few years.
We have new care delivery areas.
We have new processes within our electronic medical records.
We have new staff members.
We felt that because of our changes and also because of changes that are taking place in health care regulations, where this is becoming a much more important part of patient safety, it was time for us to upgrade, to go from, if you will, the elementary education of medication reconciliation to the middle school, high school.
Maybe we're ready for some graduate degrees here, so to speak.
So we felt it was time for a broad institutional approach to try to satisfy all these means, including the regulatory issues that Joint Commission, Meaningful Use, Physician Quality, Safety through PQRS are all requiring of us.
It was time to take on a higher level endeavor.
I see.
So a process improvement project like this can really be a significant challenge for the entire organization.
Dr. Curran, how did your task force get started, and what tools did you use to guide you when you started out?
Well, I think the MATCH toolkit gave us a good start, it gave us a framework to approach the project.
We used the Joint Commission guidelines to point us to the different objectives that we were trying to achieve in medication reconciliation, but we used the MATCH framework to figure out how we're going to get there.
So if you just look at step one, the first thing was to just assess what we had in place, and what we found during that kind of discovery period was that we had a lot of variability in how different providers and clinic areas approached medication reconciliation, whether or not they were meeting these guidelines, some worse, some were not.
So that was the first part of the project, was just a needs assessment and figuring out where we were.
And then from there, we could kind of idealize our workflow as to where we wanted to go in order to meet the Joint Commission objectives.
What were some of the most significant gaps and barriers that you found when you took a look at what your current process was?
Some of the gaps were very clear, I mean, there was the requirement to print the updated medication list at the end of the visit.
That was practiced to a minimal degree, I would say, by various physicians who just took it on themselves to do such a thing.
There was no standardization.
We also had a team of providers.
Basically each clinic group had people who would do the intake, which is primarily medical assistants, nurses who were helping at various places along the way, and then the physician kind of as the last step in the process.
And we had to convince them to work as a team in this effort, as opposed to kind of staying in their own silos, this is my job sort of attitude.
So how did you go about making those changes? It sounds like there were a lot of them.
Yes there were. It was a big project.
And it took us actually, we're still doing it.
But I think one of the first tasks was to bring the medical assistants into the team.
I don't think they felt like they were so much a part of the entire clinic process.
And we also needed to educate them on the Joint Commission goals and give them some ownership over it.
We did, we used a variety of different ways to educate and train the medical assistants to do this.
And some of that included developing a web-based program for their education.
So Ms. Foll, you're a medical assistant supervisor, and it sounds like medical assistants really are a critical part of this process because you start out with the patient and go over their medication lists initially with them.
Can you tell me a little bit about how you felt about the educational strategies and how you guys learned your new roles and responsibilities in this program?
Yes, like Dr. Kern mentioned, we incorporated the MAs in the decision making.
What was working, how the process was working, introduced them to ways to identify the medications, how to reconcile them, what to do.
We had a whole process in place.
Incorporating them in the whole process really made them feel empowered to be a part of this decision making.
Then we proceeded with the five modules.
They are required to take this class and pass it.
This is just the process on how we reconcile each medication, what the changes are, who the changes go to, how it is reconciled in the back office before it gets to the provider.
And Ms. Brayshaw, nurses also had to do a lot of education as well in order to contribute to this process of medication reconciliation and the changes that were being made.
Can you tell me a little bit about how the nurses were trained in this program?
Yes, we mostly used hands-on training in our clinics.
We also have some online modules that we used.
We also have a yearly skills lab that all the nurses at National Jewish are required to participate in once a year for any new training that's going on.
And we worked very closely with the MAs and developed a relationship that was really neat and felt more part of a team with them.
Thank you.
So Dr. Cot, physicians and pharmacists obviously play a role in the medication reconciliation process as well.
How did you go about training the physicians?
There's never a simple one step to train anybody, physicians in particular, I'll say.
So it was a multi-step kind of an approach.
Part of what we did initially was try to engage people.
We did that in part by meeting with each of the specialty groups, which included physicians, nurses and MAs working within that specialty group.
We discussed what the problems were, what the goals we were trying to achieve, let them air what they thought worked and didn't work, let them discuss their current process and then begin to work through the process.
And I think just taking that team approach just from designing for CF as an example, how they wanted to do this process, engaged people, got them interested, got them committed.
I think from a physician perspective, the physicians recognized that this was an important process, but we're all very busy people and it's for us to take time to do these kind of things.
Sometimes there's a little higher level of motivation that's necessary.
And I think when physicians realize that they're going to be judged by regulators outside of this institution, by how well we can maintain safety processes attached to them by name in some instances, that's a motivation that I think has a special appeal to the physicians.
So I think they were engaged right from the get-go.
We also had educational sessions where Betsy and I gave conferences talking about the whole process of medication reconciliation, the aspects of it.
And I think in a collective way, these got people engaged and got them motivated to do it.
And as we're going to talk about in a minute, then it's telling them how they're doing.
People always want to know how they are doing that keeps them engaged.
The pharmacists were a valuable resource for us, I think, more because of their expertise.
This particular process was a clinic process and our pharmacists, although not directly involved in the clinics themselves, are quite knowledgeable about all the processes that take place with each of the pharmaceuticals that we write for.
So we met with the pharmacists, discussed this particular process with them, got their input as to what we should be doing or not be doing to make sure they were part of the inclusion of a final product, if you will.
I understand that you offered, or professional education at National Jewish offered CME credit, MOC credits to physicians and then also pharmacy education credits as well as nursing education credits to everyone who participated as well.
So do you feel that those were looked at as important incentives or do you feel that people would have been motivated to participate in the training even if those weren't there?
I think the more carrots you can dangle, the more appeal a process has through various aspects.
Again, the better the engagement that people have.
With board recertifications and specialty needs requiring new certifications from physicians, the more the MOC process, the fact that they could get MOC credit by participation was an extra carrot.
I don't think any of these by themselves were singularly important, but the fact that the institution viewed it as important, gave them credits in these kind of concepts or set up the ability to get these kind of credits, I think was very meaningful for everybody.
So again, I think they were important, but it was important as a part of the package.
And before you started, Dr. Cutt, different subspecialty clinics, as you alluded to, for example, cardiology and pulmonary clinic, had very different clinical workflows.
So when you came into a clinic and said that you were going to introduce a new process for medication reconciliation that was going to involve a lot of people changing a lot of their behaviors, how did you approach those individual clinic groups?
Well, as I commented, we met specialty by specialty by specialty and aired what it was we were trying to do, why we were doing it, educating them as to what the requirements were for some of the medication reconciliation regulatory issues, and then opening it up and letting them say, here's what we do, here's how we do it.
And every specialty had some nuances, some differences.
Clearly they deal with different medications as different specialties.
In CF, they have special needs to set up the ability to prescribe certain drugs before they can even be introduced to patients.
So there were steps that had to be considered in every process.
So I think the fact that the MAs, the nurses, and the physicians could all sit at a table and talk together about this brought and engaged the group together.
And then we designed what we thought would be the best flow for each group, brought it back to them to discuss again how we could meet the regulations based on best flow for each of those groups, and then implement it, and then changed it.
So it was an ongoing, continuing quality improvement project in every area to assure we could meet the needs and the regulations and the goals that we were trying to set.
Ms. Breschaw, how has the medication reconciliation process changed in your area?
I think it's made us a lot more systematic in our clinic.
We definitely have an order that we are trying to go in now, which is making the clinic a little less chaotic.
And we definitely are closing the clinic the same way, so every patient is getting an education piece that they get to take home with them for questions.
It also has been really helpful for ways that we didn't even anticipate with prior authorizations and medications.