Immediately after implementation, auditing is critical to assess adoption. Auditing should be done at all the transitions of care and should include each discipline involved in the process. For example, if physicians and nurses are responsible for medication reconciliation at your organization, it is necessary to look at overall compliance as well as the individual disciplines' compliance. Knowing how each discipline is performing will help tailor feedback to leadership and identify discipline-specific issues that need to be addressed.
Depending on resources available at your organization, auditing can be accomplished electronically or manually, prospectively or retrospectively. Some audits address quantity while others address quality; it is important to look at both. The quantity audit gives insight to adoption and adherence to your defined process. The quality audit shows the impact on patient safety, such as potential harm avoided through reconciliation. A comparison of audit techniques is provided in Figure 11.
Example of Metrics and Auditing Tools
There are several effective methods to audit data in hospitals. This toolkit promotes a method that has proven to be valuable to measure the effectiveness of a medication reconciliation process by examining data before redesign, after redesign, and during implementation, as well as associated outcome measures. The model uses two process measure and one outcome measure. The use of a generic data run-chart to track the data measures is suggested. This will trend your project before, during redesign and implementation, and in the future to measure sustainability.
Examples of Metrics on Admission: Illinois Hospital Association (IHA) Medication Reconciliation Collaborative. Through their medication reconciliation statewide collaborative, the IHA developed the following three measurements for medication reconciliation compliance:
- The first measure identifies the percentage of patients who have a home medication list documented in the medical record using the correct tool for documentation.
- The second measure identifies the percentage of individual home medications that have been reconciled with admission orders.
- The third measure identifies adverse drug events (ADEs) from unreconciled medication on admission.
These measures can be applied to transfer within the facility and discharge.
Examples of Manual Audit Tools. Manual retrospective audits conducted on patient charts by unit, specialty, etc., will be the standard method for most facilities without EHR systems to measure their process and outcome data. A sample of a paper-based audit tool that can be used when performing a manual audit for medication reconciliation can be found in the "Medication Reconciliation Audit Form" in the Appendix.
Reporting Audit Results
In addition to performing the audits, auditors will need to communicate the results. Table 4 is an example of how to display medication reconciliation audit results for a given day. Depending on the size of the organization, the number of charts reviewed may vary.
Post-Implementation Strategies to Increase and Sustain Compliance
Post-implementation audits can help identify areas with low compliance to the new medication reconciliation process. With any new process or procedure, it is important to understand the root cause (i.e., knowledge deficit, lack of training, no buy-in) of compliance issues and tailor improvement strategies to address them. This section outlines three examples of improvement strategies that can increase or sustain compliance for the new medication reconciliation process:
- Identifying and addressing barriers for low compliance.
- Conducting focus groups.
- Taking medication reconciliation "on the road."
Identifying Challenges and Addressing Barriers. It is helpful to outline challenges faced during implementation and actions that have been or will be taken to address each challenge. Table 5 is a template that can be used to clearly list each challenge, observations associated with the challenge, a proposed action, and the next steps or responsible party for followup. This will keep you and the medication reconciliation leadership team updated on the progress of each identified roadblock to effective medication reconciliation. The Appendix also has a template for identifying challenges and addressing barriers.
Conducting Focus Groups. During monitoring efforts, if you identify certain areas or disciplines with low adherence to the process, it may be necessary to circle back to frontline staff to find out what is working and what is not working. Proactively seeking this information will decrease the amount of frustration the frontline staff feel about the newly implemented medication reconciliation process. For more information about focus groups and how to facilitate one, refer to Chapter 4: Developing and Pilot Testing Change: Implementing the Medication Reconciliation Process.
Taking Medication Reconciliation "on the Road." If physician compliance is a troubling issue, consider a medication reconciliation road show. Similar to the concept of executive walk rounds, having organizational leadership on the floors talking to frontline staff about the importance of medication reconciliation is a way to help increase compliance. To get a road show started, it is a good idea to provide leadership with examples of close calls the organization has had with medication reconciliation. By leadership telling the story to frontline staff of potentially harmful situations related to medication reconciliation, it might help reinforce the need. The objectives of the road show are:
- Create a clear level of accountability for performing medication reconciliation.
- Emphasize that the new medication reconciliation process is not optional.
- Reinforce the importance of obtaining a complete and accurate medication history, documenting the medication history in the appropriate place in the medical record, and facilitating a thorough transfer and discharge process across the continuum of care.
- Obtain feedback from frontline staff to learn what is perceived as obstacles to performing medication reconciliation.
- Assess the impact that medication reconciliation is having on patient safety of each identified roadblock to effective medication reconciliation.
Special Considerations: The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)
NCC MERP developed categories for classifying medication errors. This index considers factors such as whether the error reached the patient and, if the patient was harmed, to what degree.
Table 6 explains the different categories of medication error classification. Different categories of medication error classification were adapted into the table below. Examples of medication reconciliation errors are included to illustrate how this index can be used to classify each example based on the NCC MERP index. For more information about the classification of medication errors visit http://www.nccmerp.org.
Chapter 6 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:
- Electronic audits are an easy and efficient way to show adherence to the medication reconciliation process.
- Manual audits are time-consuming but help identify the quality of the medication reconciliation process and the potential impact on patient safety.
- Prospective audits are ideal for medication reconciliation since interventions can be made if medication reconciliation was not done appropriately.
- Post-implementation, medication reconciliation audits should be performed and communicated frequently.
- Feedback should be communicated to senior leadership, to all management levels, and to frontline staff.
- Audit data can be used to obtain discipline-specific support for the project.
- Concurrent review of interventions and continual feedback can be an effective way to improve compliance.
Users of this toolkit from the QIO Learning Network Collaborative offered many ways to use the data they collected in the medication reconciliation project as a method of feedback to staff:
- Using tri-board posters to display audit data to staff during training and education sessions to further stress the importance of an accurate medication history and reconciliation.
- Posting data run charts in the break rooms, unit staff rooms, and physician lounges to communicate the progress the process changes are delivering to quality measures.
- Use data to create a "competitive" atmosphere to drive acceptance of process change.