Mandatory training programs, leadership involvement, and frequent audits helped Northwestern Memorial Hospital in Chicago increase its medication reconciliation compliance more than 60% in some areas, such as inpatient admissions. Currently, in all units, medication reconciliation is above The Joint Commission (formerly JCAHO) standard of 90%. Not only that, but when evaluated, it was found that compliance had a direct effect in lowering potential patient harm.
Molly McDaniel, PharmD, former quality leader for patient safety at Northwestern, was involved in a research grant regarding medication reconciliation at the hospital supported by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality. McDaniel served as a speaker at the December 2007 HCPro audioconference "Medication Reconciliation Update: Must-haves for Joint Commission compliance in 2008."
Taking a close look at the hospital's medication reconciliation practices, McDaniel found Northwestern's patient histories, like many other hospitals, were obtained by multiple clinicians and documented at various places on the medical record. She also learned that 86% of 651 general medicine patients had medicine discrepancies that originated in the patients' histories.
Electronic master file
To fix that specific problem, McDaniel and her staff members created one electronic file in which all staff members can view and update the home medication list. Each time a staff member updates the list, all other staff members who use the list will use the most recent version. McDaniel calls this file the "one source of truth."
"At any time, we might find out more information; the nurse might find it out, the pharmacist might find it out, so we really wanted a team approach to create this home medication list," said McDaniel. Current medications ordered during the patient stay are also shown above the home medication list on the electronic file so staff members can see all of the patient's home medications and all medications the patient is currently taking. Keeping both of these lists on one view screen that everyone can see and edit simplifies communication in the medication reconciliation process, and it helps immensely with compliance with The Joint Commission.
"This is actually the only documentation that's required-that med list," said Patricia Pejakovich, RN, BSN, MPA, CPHQ, senior consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and cospeaker for the December 2007 audioconference.
"Everyone [should] work off the same pieces of paper within the organization. Whether you are electronic or you have a paper process, those are the two pieces that we're always going back to," said Pejakovich.
Letting staff members have the power to add to the list is an example of empowering them to create a better medication reconciliation process. McDaniel says standardizing a medication reconciliation flow, especially by unit, creates better outcomes, but she says each unit has a different way of doing things. Better compliance, she said, will come out of a standard approach that reflects staff's work style. "Work with the staff, understand their work flow, and try to integrate med reconciliation into the work flow as much as possible," said McDaniel. She also ensured that electronic records prompted clinicians to reconcile meds at key points in care to make sure they weren't completing medication reconciliation documentation at the end of the day.
Leadership support and compliance
Implementing a multidisciplinary team approach was the next step to medication reconciliation, especially when all staff members could access the home medication list. However, it soon became apparent that leadership support and involvement remained crucial to actual compliance. Biweekly medication reconciliation leadership meetings were soon put in place. "I'm not sure that when we first all got together, we were all believers. Getting all of leadership to truly believe in med rec, it just wasn't there," said McDaniel. "But once they got engaged and supportive, it was so helpful. We couldn't have done it without our leadership." Nursing, physician, and pharmacy leadership were all present.
Computer classroom training sessions, which provided the greatest boost in compliance, were also multidisciplinary and explained the roles and responsibilities of medication reconciliation, which McDaniel said "holds people accountable" because each individual knows his or her role in the process, as well as everyone else's. In less than two years, Northwestern's medication reconciliation compliance has risen to meet and surpass Joint Commission standards. Better yet, when evaluating whether the compliance actually resulted in patient safety, McDaniel found a 26% decrease in potential patient harm.
Editor's note: To order a recording of "Medication Reconciliation Update: Must-haves for Joint Commission compliance in 2008," which includes further information about this case study and other medication reconciliation advice, go to www.hcmarketplace.com/prod-5949.html.