Making a p di f-ference - results of the pdif quality improvement initiative

www.saferhealthcarenow.ca
Making a PDiF-ference –
Results of the PDiF Quality
Improvement Initiative
March 2014

Welcome also to our
francophone attendees
Bienvenue à nos participants
francophones
Hélène Riverin
Conseillère en sécurité et en amélioration
Safety Improvement Advisor
Bienvenue!

www.saferhealthcarenow.ca3
Objectives of today’s call
Colleen Cameron:
• Describe the PDiF initiative, its outcomes and
key lessons learned.
• A few practical “challenges” to consider.
Marg Colquhoun:
The MedRec Journey from 2005 and onwards.

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Making a PDiF-ference –
Results of the PDiF Quality
Improvement Initiative
Colleen Cameron, RPh, Pharm.D.
PDiF Coordinator, Grand River Hospital
ISMP Canada/Safer Healthcare Now!
April 8, 2014

Objectives
 Describe the PDiF initiative, its outcomes and key
lessons learned.
 A few practical “challenges” to consider.

WW LHIN
(775,000
people)
Grand
River
Hospital
St.
Mary’s
General
Hospital
Cambridge
Memorial
Hospital
North
Wellington
Health
Care
St.
Joseph’s
Health
Centre
Groves
Memorial
Hospital
Guelph
General
Hospital

PDiF =
Pharmacy Discharge Facilitator

Two stories
PRE
Metformin
ASA
Atorvastatin
Ramipril
Bisoprolol
POST
Metformin
ASA
Lipitor (Brand)
Perindopril
Bisoprolol
Clopidogrel
Lantus
Rapid
Ezetimibe
Esomeprazole
Docusate
Senokot
Nitro Patch
$$$
$$$
$$$
- 63 year old male
- 3rd cardiac event.
- Discharged post-stent
insertion.

Two stories
Losartan 100mg
Irbesartan 300mg

Losartan 100mg
Irbesartan 300mg
Two stories
200

The most unpredictable variables in the entire
equation

Pharmacy Discharge Facilitator
Project
 What is it?
 Quality Improvement Initiative
 Uniquely included 2 local CEOs in its
development
 Possibly helped to keep the project’s profile and
momentum
 January-September 2013
 Facilitate medication discharge for high-risk
medicine patients with a goal of improving care
and outcomes
 PDiF team = pharmacist + University of Waterloo
pharmacy co-op student

Pt Admitted
To Hospital
BPMH Completed / AMR
(Best Possible Medication
History/
Admission Med Red)
Medication
Therapy
In Hospital
Discharge
preparation
and
coordination
Discharge
Medication Care Map in Hospital
MD
Patient
Pharmacy

Pt Admitted
To Hospital
BPMH
Completed
(Best Possible
Medication
History)
Medication
Therapy
In Hospital
Discharge
preparation
and
coordination
Discharge
MD
Patient Pharmacy
PDiF 1
On admission –
Identify
High-Risk
Patients
Components of PDiF

Pt Admitted
To Hospital
BPMH
Completed
(Best Possible
Medication
History)
Medication
Therapy
In Hospital
Discharge
preparation
and
coordination
Discharge
MD
Patient Pharmacy
Components of PDiF
PDiF 2
During hospital
stay –
Modify
medications that
will be practical
and make sense
for discharge

Pt Admitted
To Hospital
BPMH
Completed
(Best Possible
Medication
History)
Medication
Therapy
In Hospital
Discharge
preparation
and
coordination
Discharge
MD
Patient
Pharmacy
Components of PDiF PDiF 3
At time of
discharge –
1. Communicate
with involved
health care
providers about
medication
changes and
rationale for
those changes.
2. Talk to patient/
caregiver to
ensure they
understand
directions.

Pt Admitted
To Hospital
BPMH
Completed
(Best Possible
Medication
History)
Medication
Therapy
In Hospital
Discharge
preparation
and
coordination
Discharge
MD
Patient Pharmacy
Components of PDiF
PDiF 4
Post-discharge -
Call patient 24-
72 hours post-
discharge to see
if they are able
to follow the
instructions we
gave them.

Outcomes
 Qualitative
 Patient / caregiver satisfaction
 Primary Care Provider satisfaction
 Community Pharmacist satisfaction
 Hospitalist satisfaction
 Quantitative
 7, 30 and 90 day ER visits
 7, 30 and 90 day readmissions
 Conservable Bed Days…unexpected

Demographics
 # of patients seen – 148 (+)
 Average age – 74.2 years
 7 patients died during index
hospital admission
0
5
10
15
20
25
30
35
40
45
50
20-40 41-60 61-80 81-96
Age Ranges
%
79%

Age
Range
% of
Patients
Heart
Failure
(# of pts)
Diabetes
(# of pts)
Warfarin
(# of pts)
20-40 3.4%
(N=5)
0 2 2
41-60 17.6%
(N=26)
5 16 9
61-80 35.1%
(N=52)
14 23 26
81-96 43.9%
(N=65)
20 22 39
Total 148 pts 26% 43% 51%

Qualitative Outcomes
Did we achieve Patient / Caregiver
satisfaction?
Did we achieve Primary Care Provider
satisfaction?
Did we achieve Community Pharmacist
satisfaction?
Did we achieve Hospitalist satisfaction?

Quantitative Outcomes (#, $)
 ER/Readmission Rates
 7, 30 and 90 day ER visits
 7, 30 and 90 day hospital readmission rates
 Data disclaimer
Historical =
All comers –
young
patients, DKA,
pneumonias,
acute
ingestions,
dialysis
PDiF patients

GRH Readmission Rates - Historical
0
2
4
6
8
10
12
14
16
7 day 30 day 90 day
FY 09-10
FY 10-11
FY 11-12
FY 12-13
%
CIHI 13.3%

GRH Readmission Rates
0
2
4
6
8
10
12
14
16
7 day 30 day 90 day
FY 09-10
FY 10-11
FY 11-12
FY 12-13
PDiF
%
CIHI 13.3%

ER Visit Rates - Baseline
0
5
10
15
20
25
30
7 day 30 day 90 day
FY 09-10
FY 10-11
FY 11-12
FY 12-13
%

ER Visit Rates
0
5
10
15
20
25
30
7 day 30 day 90 day
FY 09-10
FY 10-11
FY 11-12
FY 12-13
PDiF
%

What do these numbers have the
statistical power to prove?
 Anything? – probably not
 Causality? – certainly not
 Benchmarking? - maybe
 Is that the only information that matters?
What if patients subsequently go elsewhere for care?

 Hospital Readmissions and ED Visits
 At first glance, our PDiF numbers look great…

 Hospital Readmissions and ED Visits
 At first glance, our PDiF numbers look great… BUT

 Conservable Bed Days
 Definition…relevance
 Over 9 months, PDiF realized 8 weeks of
conservable bed days
 Medications involved – Warfarin, Methadone
 Unexpected, but fascinating
 Consequently – have started targeting patients on
medications that are more likely to delay
discharge
 Warfarin / NOACs
 Insulin

Top 5 lessons learned…
1. Dare to look at your patients’ experience
post-discharge.
 Are they seeing their family doctor post-
discharge?
 Are they getting their prescriptions filled as
expected?
 Are they going to other local hospitals for
subsequent visits?
 Follow-up phone calls are quick, and incredibly
valuable!

2. Drugs delay discharge
 Warfarin, LMWHs, insulins, methadone
 We now assess 100% of patients on warfarin for
timely and safe discharge from Medicine
program
 Assist with LMWH coordination post-discharge
 Educate injection technique while in hospital
 Phone call follow ups
 Anticoagulation summary of INRs & warfarin doses,
 Ensure patient has appt with PCP as well as plans to
go to lab

2 ½ . Where there is warfarin (or NOACs) there are
other medication misadventures looming
 Warfarin and NOACs are predictors of other high-
risk medications (insulin, digoxin, spironolactone,
amiodarone etc)
 Most computer systems can search for certain
medications.
 This is the best place to start!

3. Use the hospital admission to optimize chronic
medications
 Clinical inertia
 Look for adherence issues!!!
 ODB DPV has picked up on MANY misadventures
 Incorporate practical medication discharge
assessment upstream

4. Medication knowledge transfer contributes to
efficient and safe patient care
 GRH has an electronic discharge prescription
but….
 PCPs and Community Pharmacists need
information about medications, including
rationale and plans of care.
 What is your eHealth system?
 Fusion software (transcription software)
 Clinical Connect (LHIN EHR)
 Medication-Focused Discharge Summaries

Medication-Focused Discharge Summary
One of the most valuable interventions from the
PDiF project!

Medication-Focused Discharge
Summaries
Standardized document including
 Date of Admission/Discharge
 Adherence Issues Identified**
 Drug Cost Issues Identified
 Numerical List of medications
 comment if same, increased, decreased or new
 Medications discontinued or held
 Additional information
 Commentary including plan of care, monitoring plans,
concerns
 My name and telephone extension

5. Discharge medication reconciliation is time
consuming!
 Track outcomes/stories to strengthen your
argument for more funding
 Go to your program director with proposal
 Develop a business case?
 Dr. Schnipper’s data
 Be creative in staffing
 Pharmacist : patient ratio
 Pharmacy students
 Pharmacy Technicians
Financially:
1 pharmacist ≈ 2 technicians ≈ 4 co-op students

Summary
Was the PDiF project successful? Did we improve outcomes?
Unequivocally
Are there simple strategies every hospital can implement to
help these patients?
Absolutely
Medication misadventures
We don’t even know the magnitude
of the problem yet

©2014 Institute for Safe Medication Practices Canada (ISMP Canada)
The MedRec Journey
Margaret Colquhoun, B.Sc.Phm., FCSHP, R.Ph.,
Project Lead, ISMP Canada
http://www.ismp-canada.org/medrec/

Objectives
• To talk about the MedRec from 2005 –
2014
• Highlight SHN tools and resources
• Highlight your accomplishments
• To announce changes in 2014-2015

Thanks to………
• Canadian Patient Safety Institute
• 2005 MedRec Intervention

MedRec 2005
• Unknown – did
not know what
we did not know
• Systems not in
place
• Measures not in
place
• Studies not
driving practice
change

Things I am Proud of!!!
• Creation of new language and knowledge
• Being used around the world
• Whole country worked together and
learned together as a team
• Tools and Resources
• Webinars, kits, questions
• Unbelievable sharing though our network
of MedRec teams across Canada

Action for Safer Medical Care – Medication Reconciliation, CMPA/ACPM, 2103

www.ismp-canada.org/medrecwww.saferhealthcarenow.ca

www.ismp-canada.org/medrec

National Team Sharing through
Webinars
200-400 lines for each webinar
Showcase the Success of our Teams
Well received by attendees
Relevant and Timely

London Health Sciences Centre describes:
The challenging elements of MedRec implementation in one
of Canada's largest, acute care teaching hospitals
1. How LHSC overcame these challenges by focusing on
interdisciplinary collaboration
2. How LHSC is evaluating and sustaining the process
The Stepping Stones to MedRec Success

Square Peg in a Round Hole: MedRec in
Ambulatory Clinics Requires a Different Model
Vancouver Health Authority and University Health Network, Toronto
• Describe how ambulatory clinic patients require a different system to enable
medication reconciliation & review.
• Understand the longitudinal team approach to improve accuracy & error
reduction through regular review.
• Describe two approaches to medication reconciliation in the ambulatory
clinic setting.
• Identify opportunities of a patient registry as it relates to patient care
(medication reconciliation), the organization (drug usage review) and
outcomes research.
• To share the findings of medication discrepancies and drug therapy
problems identified in a post discharge medication reconciliation pilot study.

Different Strokes: Engaging Pharmacy
Technicians in MedRec
The Moncton Hospital, The Ottawa Hospital, Trillium Health
Centre, Peterborough Regional Health Centre
Describe the medication reconciliation model developed for
pharmacy technicians
• Review the training process involved for pharmacy
technicians in medication reconciliation
• Highlight the role of the pharmacy technician in the
Emergency Department and/or the pre-admission clinic

Got Med Wreck? Targeted Repairs from the
Multi-Center Medication Reconciliation
Quality Improvement Study (MARQUIS)
Dr. Jeffrey Schnipper
Results of a funded research study into what
works and what is the impact of MedRec
All past and future webinars available from:
SHN website:
http://www.saferhealthcarenow.ca/EN/events/NationalCalls/Pages/default.aspx
ISMP Canada website: http://www.ismp-canada.org/medrec/ (Education & Training)

Slide Courtesy of Dr.Jeff Schnipper
Safer Healthcare Now! Webinar Jan, 2014

All past and future webinars available from:
• SHN website:
http://www.saferhealthcarenow.ca/EN/events/NationalCalls/Pages/default.aspx
• ISMP Canada website: http://www.ismp-canada.org/medrec/
(under Education & Training)
MedRec
Webinars
2009-2014
Available online

2010- National MedRec Summit
To accelerate a
system-wide strategy
to implement
medication
reconciliation
(MedRec)
Healthcare CEOs, senior leaders, representatives from national organizations,
provincial quality councils, physicians, nurses and pharmacists identified themes that
would accelerate and optimize MedRec across the continuum of care

“Senior leadership commitment is critical to ensuring MedRec is
implemented successfully across an organization.
Accountability must rest with the CEO with clear reporting
expectations at the board level.”
REF: Optimizing Medication Safety at Care Transitions: A National Challenge, 2011
http://www.ismp-canada.org/download/MedRec/MedRec_National_summitreport_Feb_2011_EN.pdf

PR Campaign from North Bay
Regional Health Centre (ON)
Consumer Awareness and Tools

Interactive Map
Relatively few self-identified “MedRec All-Stars” who have MedRec in place
across admission, transfer and discharge

Paper to Electronic
Tools/Checklists
• Organizational Readiness
• Steps to support the safe transition to
eMedRec
• Ideal features of eMedRec,
• Evaluation of eMedRec

October 2013 was
National MedRec Quality Audit Month
2340
patients
29%
(acute care)
55%
(Long Term Care)
• 1906 Acute Care
• 329 Long Term
Care
• Met all 5 quality
criteria
• Met all 5 quality
criteria
103
Organizations

National Quality Audit Results
Summary Comments
• MUST critically evaluate admission to ensure
quality at discharge
• Canadian audit tool results demonstrate need for
ongoing and specific improvements
• People believe they are doing MedRec but they
may not be doing it well
• The foundation of the process – the BPMH
needs work

In 2014 we have NOT reliably
implemented MedRec!!!

Outstanding Issues in MedRec!
Getting to where we want to be
• Leadership
• Measuring and Monitoring Quality
• Role and use of technology
• Embedding roles and processes into system
• Consumer Engagement
• Primary care

Light….
at the end
of a lot
of hard work
The tipping point is that magic moment
when an idea, trend, or social behavior
crosses a threshold, tips, and spreads like
wildfire.

Changes in 2014-2015

Questions

Questions
1. Raise your hand and we
may be able to open your
phone line
2. Send feedback via
the “chat” box
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Upcoming MedRec Webinars
83
Thank you for attending
Join us on May 6, 2014 at 12 noon ET
for our next MedRec webinar
Safety, Sleuthing and Students: A Novel Collaborative
MedRec Event at the University of British Columbia

www.saferhealthcarenow.cawww.ismp-canada.org
84
We encourage you to report
medication incidents
Practitioner Reporting
https://www.ismp-canada.org/err_report.htm
Consumer Reporting
www.safemedicationuse.ca/

www.saferhealthcarenow.cawww.ismp-canada.org
Medication Safety Self-Assessment®
• Hospitals (acute care)(2006) – free for Ontario*
• Long-term care (2012) – free for Ontario*
• Complex Continuing Care and Rehabilitation
(2008) – free for Ontario*
• Community and Ambulatory Pharmacy (2007) –
free for Ontario*
• Operating Room Medication Safety Checklist
(2009) – free for Ontario*
• Oncology (2012)
• Anticoagulant Safety (VTE) – free for Ontario*
• HYDROmorphone Safety Self-Assessment (2014)
- $50
* Supported by the Ontario MOHLTC
For more information visit www.ismp-canada.org/MSSA or email mssa@ismp-canada.org

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Making a p di f-ference - results of the pdif quality improvement initiative

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