Chapter 4: Developing and Pilot Testing Change: Implementing the Medication Reconciliation Process

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation

Pilot-Testing the Solution

If you have applied all of the steps and guiding principles outlined in Chapters 1-3 to your own work, you should have designed or redesigned medication reconciliation process that addresses gaps identified in the flowchart and assessment of your existing process, while helping to maintain current work flow. At this point, resist the urge to implement the redesigned process facility-wide and instead, pilot test the solution.

A pilot test provides an opportunity to implement a new process on a small scale and receive input. Any weaknesses in the process can be addressed before implementation facility-wide. While this process may seem like it will delay improvement overall, it can actually ensure success when you implement facility-wide. Before instituting the pilot, you should consider the following questions:

  • Where would you like to pilot test the process?
  • Are the areas chosen for the pilot already engaged and bought into the process?
  • What mechanism will be in place to give and receive feedback from frontline staff during the pilot?
  • What structure will be put in place to support staff during the pilot period?
  • What roles can the leadership team play in the pilot?
  • Are the stakeholders engaged, and have roadblocks been identified and removed prior to piloting in those practice settings?
  • What are the process measures (i.e., quantity, adherence to process) to determine compliance during the pilot?
  • What are the quality measures to determine impact on patient safety?

There are many potential settings for pilot testing. Some ideas include:

  • A unit that directly admits patients.
  • One medicine unit and one surgical unit.
  • One team of physicians or one service, such as hospitalists.
  • Engaging a few clinicians to use the form for a few days on their patients.

Regardless of the approach, the goal is to test the process for a short period of time—in most cases, less than a week or within a certain timeframe contingent on resources and scope of the project—to identify and correct major gaps within the process, and confirm its utility within current workflow. The process should continue to be enhanced and the pilot testing expanded as appropriate.

Although design team members are often eager to pilot their work, you should also include frontline staff who were not involved in the design. They will be able to:

  • Provide additional insight into how intuitive the new design is.
  • Identify training requirements.
  • Identify additional areas for improvement.

To allow for feedback during a pilot, small focus groups can be held on nursing units for approximately 15-30 minutes. This may be an effective means to exchange dialog about the revised process. This could also be used as an opportunity to thank those who agreed to participate in the pilot.

 

Sample questions that may be used during focus groups with physicians are provided in Figure 8. These can be adapted for use with various disciplines and practice settings to elicit feedback on the process during the pilot phase.

Incorporating a structured, robust auditing and feedback method to identify design flaws and to understand underlying root causes for medication reconciliation failures (i.e., knowledge deficits, lack of buy-in, system design issues, etc.) is important during the pilot. It is equally important to highlight successes and compliment individual contributions. For more information on measurement, go to Chapter 6: Assessment and Process Evaluation.

Preparing for Implementation

You have designed the process, piloted-tested the solution, and made any necessary enhancements. Now you are ready for a full-scale rollout. Some may choose to develop a committee to handle facility-wide implementation; others may use the original team to carry out implementation. There are advantages and disadvantages to both approaches:

  • Design team members may find it difficult to accept when "their design" isn't working as planned, despite pilot testing.
  • New members may be more open to change and may contribute new suggestions for improvement.
  • Depending on the scope of the project, additional members, identified through a stakeholder analysis, may be needed to help facilitate implementation.

As you move into the implementation phase, you may want to consider developing an implementation charter to supplement the design charter. This will provide a framework for:

  • Defining implementation goals and objectives.
  • Identifying key metrics for implementation.
  • Determining implementation resources and support system requirements.
  • Developing a training curriculum.
  • Establishing continuous feedback mechanisms for receiving suggestions from, and providing followup to, staff throughout implementation.

Developing the Implementation Strategy

Planning and Communication of Implementation Strategy. To successfully coordinate an implementation strategy, mandatory meetings, led by the leadership team, should be held with stakeholders representing physicians (i.e., clinical program leaders, departmental chiefs, and chairs) and patient care (i.e., nursing directors and managers, pharmacy director and managers).

During this meeting, implementation plans and training curricula can be presented. A multidisciplinary training approach (i.e., physicians, nurses, and pharmacists attending training classes together) should be recommended and is encouraged. A number of dates and time periods should be determined based on the needs and availability of various disciplines. Classes should be offered early in the morning, during the day, in the evening, and on weekends to accommodate a variety of schedules.

Email reminders and memos sent from discipline-specific leadership to staff may be an effective method to increase attendance and participation while highlighting leadership support for the process. The Appendix offers customizable memos to announce and promote training sessions and educational efforts to the staff: "Sample Letter to Discipline-Specific Leaders on Meeting Regarding Training and Implementation Strategy for Medication Reconciliation" and "Sample Communication from Discipline-Specific Leadership to Staff on Medication Reconciliation Educational Training Sessions."

Rollout Strategies. Just like pilot testing, there are several different strategies to roll out the process. Depending on the scope of the project, some implementation strategies may include:

  • By unit (e.g., all ICUs).
  • By service (e.g., surgical services).
  • By discipline (e.g., rollout process to all physicians, then to all nurses, and then to all pharmacists).
  • Hospital-wide, all disciplines.

You should establish an implementation timeline. This helps ensure a timely rollout while maintaining flexibility if unanticipated issues arise. Go to the Appendix for "Example Timeline Hospital-Wide Rollout by Discipline."

Staff should be well informed and given adequate notice regarding training dates and implementation strategies prior to rollout. Staff communication may need to occur through a variety of channels such as Emails, brief announcements at staff meetings, and memos posted in nursing units, report rooms, conference areas, etc. A flyer can be one way of communicating the rollout plans. Go to the Appendix for "Sample Staff Flyer to Announce Rollout/Implementation of Medication Reconciliation Process." For Email announcements, consider having departmental or discipline leaders send prepared messages directly to their colleagues to convey the importance of implementation and adoption of the process.

Chapter 4 Lessons Learned

Lessons learned from staff of facilities that have implemented MATCH and facilities that received technical assistance on MATCH through the AHRQ QIO Learning Network include:

  • It is critical to put in as much time planning the implementation as you spent on the design (maybe even more) to ensure successful adoption.
  • Stakeholders need to be "on board" to support the effort throughout the rollout. The leadership team will play a key role in addressing roadblocks and approving needed changes resulting from broader implementation. Other considerations for a successful implementation include:
    • Adequate resources for rollout.
    • Timely staff communication regarding training and go-live.
    • Multidisciplinary training sessions (i.e., team training) followed by coach support.
  • It is easy to fall into the mindset of "we designed a great process, the pilot was successful; therefore, everything else will follow suit." Through our experience, we found that it's not always that simple, especially when many staff perceived medication reconciliation would add extra work without added benefit.
Current as of August 2012
Internet Citation: Chapter 4: Developing and Pilot Testing Change: Implementing the Medication Reconciliation Process: Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. August 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/match/match4.html