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Gwinnett Medical Center creates a three-tiered approach to address medication security questions


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Gwinnett Medical Center in Lawrenceville, GA, is preparing to roll out a new, three-tiered approach to improving medication security.

By determining who has access to what medications and when—and why they have that access—the facility is launching an online learning tool to improve security and medication management.

“We recognized that medication security and access to medications is extremely important, not only for our hospital system, but also to The Joint Commission [formerly JCAHO]. We felt we needed to formally address the issue,” says Kellee Lively, PharmD, clinical pharmacy coordinator at Gwinnett.

Lively and others began to examine what types of employees had access to or were around medications.

“Everyone from nursing to pharmacy, who are in contact with those medications every day as part of their normal job, to a housekeeper who might be cleaning a room where an IV medication is hanging—they have access, but never touch the medication,” Lively says.

To address this, Gwinnett devised three levels of medication access: full, partial, and limited authorization.

Tracking who has access

Full access indicates unrestricted access. This category contains primarily nurses and pharmacists.

Partial authorization is the largest category, containing significant portions of the hospital staff. This group can touch medication (e.g., picking up medications from the pharmacy or, via the facility’s tube system, transporting medications from the tube to the nurse) but may not administer it.

“This is the group that is supposed to hand the medication over to the correct licensed person immediately or put the medication in a secure place,” Lively says.

This category includes volunteers and transporters, as well as biomed staff members, who “repair and adjust machines, so, theoretically, they could touch medications,” Lively explains.

Finally, there is the limited access group, which primarily consists of environmental services, nutrition services, and engineering staff members—people who may enter a room to repair, clean, or deliver. They may be in close proximity to medications but should never touch or move them.

Building an education tool

“We have a pretty standard staff development process that we use. The question is always: Who is our target audience?” says Susan Stubbs, RN, BA, BSN, MEd, director of learning resources at Gwinnett.

Gwinnett’s learning management system can group staff members by job description.

Once the three levels of medication access were identified and the jobs involved were earmarked, it was a matter of an automated push to get the learning process started.

“Our second question is: What do we want them to do differently after they get this education?” Stubbs says. “What do we want them to be able to do, and what do we want them to do. That is the performance statement.”

Many facilities will use the term “outcome statement,” Stubbs says, but Gwinnett’s preference is “performance statement” because the goal of the education process is to identify and develop behaviors it wants employees to perform once the education has taken place.

“We ask, ‘What behavior do we want them to do differently after being exposed to this information?’ And we come away with a very specific performance statement for each of the three groups,” Stubbs says, adding that Gwinnett’s learning resources department is trying to move away from the terms “education,” “training,” and “learning.”

“If we can get the subject matter experts to think about performance, we’ve got them thinking about outcomes, not activity,” Stubbs says. “When we think of education, most of the time we’re thinking about activity. That’s not what matters. What matters is the outcome, what comes after the learning activity.”

To foster this, Stubbs pushes the content experts working on a given learning topic to think about the behavior they want to see occur and talk about strategies that will result in that performance or behavior.

“If people talk about education and training, they spend a tremendous amount of time planning the activity, but the focus is wrong,” she says. “The desired outcome is not to produce a training event. The outcome, the real needed outcome, is not that we do great classes; it’s on what behavior we want to see.”

Tip: Ground the topic. “If you want people to perform, you need to have a process that works,” says Stubbs.

If your process is unclear, you can educate people over and over again and they are still not going to be able to perform that process. To help ensure a successful process, identify your locks and your security process, Stubbs says. “You’re never going to get medication security where you want it to be if you’re not putting the right locks in place,” she says. Also, make sure people understand the process.

Reaching staff members

“We have found that one of the best ways to reach large audiences and document [their training] is to use a computer-based learning [CBL] module,” Stubbs says. “We chose to use a CBL module because the behavior is very simple.”

About 3,500 associates were determined to be in the target audiences, reinforcing the rationale for using a computer-based approach.

Two major categories in educating staff members are information sharing and skill training, Stubbs says. For example, if you are teaching someone to knit, you should give the person yarn and demonstrate how it’s used rather than hand him or her an article to read. There is practice involved.

“This is not that kind of education,” Stubbs says. For medication security, it is a matter of what staff members can handle and what they should not touch. “You don’t have to extensively train someone to not pick up an IV bag,” she says.

After much discussion about how to distribute the information, it was determined that a CBL module for all three levels should be used to teach employees not only about their own level of access, but about the roles of others.

This also saved the time it would have taken to craft three separate CBLs. The material was set at a third-grade level to make it understandable for all CBL participants. The average healthcare professional reads at a sixth-grade reading level, and environmental and nutritional service staff members typically read at a third-grade level.

“We’ve been very successful pushing this kind of information out,” Stubbs says. “We’ve been reaching our target audience and we’re optimistic, based on historical performance [of this method of education], that our medication security CBL will be successful.”

Overcoming challenges

“The biggest challenge we faced was looking at job titles and who actually should have access to medications in order to do their job,” Lively says. “The list kept growing. A lot of people have access to medications in order to do their daily work, but we did not realize it until we put a formal education process in place.”

It was easy to overlook technicians, students, and other personnel who might encounter medication. As more people looked at the growing list, more job titles were added to it, she says.

Tip: make sure to bring members of the nursing staff on board when crafting the list of job titles.

“Show this list in several committees and people—Pharmacy-Nursing Collaborative, Pharmacy and Therapeutics Committee, and don’t forget non-clinical associates,” says Lively.

“You have to talk to the groups involved,” agrees Stubbs. “The content expert and educator do not know what security does regarding medication security. Not just the managers—talk to security guards, nurses, environmental services. Observe how medications are managed.”

“We had to think through that middle category. If they touch medications what do they do with it?” says Lively. “Just think through the logical steps.”

Also, remember naming the tiers of access counts. “We had to be sensitive how we labeled the groups,” says Stubbs. Initially, the limited access group was known as “restricted” access, which was deemed insulting.

Having a strong education department and a working electronic teaching tool helps.

“I think it would be more difficult to formalize the process if you don’t have computer-based learning,” says Lively. “The massive amounts of employees this will involve will be a challenge. I feel like it will be easy to implement, but would not be without the right technology in place.”

Gwinnett’s associates are currently taking the CBL. “I have gotten a few e-mails asking, do I have to do this CBL?” says Lively. “And it has been easy to determine the answer when I ask the associate what they do as a part of their normal job.”