Once the business case has been made for medication reconciliation and leadership support has been obtained, the next steps toward building the foundation for your project include:
- Identify and assemble an interdisciplinary team.
- Create a flowchart of the current medication reconciliation process.
- Develop a project charter or work plan for improvements.
- Establish measurement strategy.
The above steps build on one another and are essential in establishing a solid foundation to support improvement efforts.
Step 1: Identify and Assemble an Interdisciplinary Team
Assembling a medication reconciliation team is an important first step. The team will be responsible for reviewing the current medication reconciliation process, identifying gaps and opportunities for improvement, and taking the lead on process design/re-design within the health care facility.
The medication reconciliation team may be subdivided into three core groups:
- Leadership Team.
- Design Team.
- Additional Stakeholders.
A "stakeholder's analysis" helps identify key people in the facility who will be affected by the project; these individuals can range from hospital leadership to frontline staff to patients. List each stakeholder's role, impact, and interest in the project.
Roles and Responsibilities of Team Members
To gain support, team members must be clear about their role on the committee; being specific about the expectations of the project will allow each member to decide if they can handle the assignment before it is given. This will also allow each member to make a commitment to the team and carry out this responsibility to the end. Examples of establishing defined roles may include: conducting baseline audits, collecting and analyzing subsequent data, and leading the task of flowcharting.
Leadership Team. The Leadership Team provides oversight for the medication reconciliation project. The leadership team should include Executive Sponsors, Project Sponsors, and Improvement Leaders. The characteristics, roles, and responsibilities include the following:
- Member(s) of the senior management team (e.g., physician, nursing, and executive leaders in the organization).
- Provide executive oversight.
- Provide guidance and accountability and endorse recommendations.
- Identify and remove organizational barriers.
- May represent inpatient and outpatient practice settings depending on the project's scope; representation from both settings may help bridge the gap during transitions from hospital to home.
- Leader(s) from various disciplines such as the pharmacy director, nursing director, hospitalists, department chiefs, director of information systems, chair of the pharmacy and therapeutics committee, etc.
- Provide support for a timely and successful implementation.
- Provide insights from the perspective of the practices they represent.
- Remove discipline-specific barriers.
- Approve final recommendations.
- Possess operational and quality improvement expertise as well as patient safety and medication management knowledge to lead medication reconciliation efforts.
- Ensure project goals and training are met within established timeframes.
- Help integrate operational changes into clinical workflow.
Design Team. The Design Team will play an integral role in the development or redesign of the medication reconciliation process. When assembling this team, it is important to include individuals with actual knowledge of the current medication reconciliation process. The Design Team should be comprised of multidisciplinary members with a strong knowledge of current workflow, recognition of the problem, and buy-in for improvement. Members may include:
- Physicians, nurses, pharmacists, discharge planners, and others representing areas of focus (e.g., inpatient units, outpatient clinics, procedural areas).
- Representatives from information systems, the emergency department, and patient safety and quality departments.
- Patients, to ensure the design is approached from their perspective.
The Design Team's makeup may evolve over time as you work through the process and determine additional resource requirements.
The tool "Questions to Ask When Developing the Design Team and Rationale" is located in the Appendix.
Additional Stakeholders. Additional stakeholders who will be directly or indirectly involved with enforcement of the new or redesigned process once implemented should be engaged early on. Engagement of these key stakeholders is important to gain facility-wide support for the medication reconciliation project. Additional stakeholders in the facility may include:
- Managers or directors that oversee frontline staff to ensure final design is carried out.
- Department chiefs, chairs, and clinical program leaders overseeing physician participation in the design and implementation.
- Leaders from medical records to ensure forms and documentation are consistent with hospital policies.
- Individuals overseeing quality, licensure, and accreditation to ensure the process meets regulatory requirements.
- Frontline staff, quality committees, patients, etc., that may require periodic communication and progress reports in preparation for implementation.
Establish a reporting mechanism to keep stakeholders informed on the team's progress. It will be easier to understand barriers from their perspectives and work to develop solutions early on than it will be much later during rollout and implementation.
Step 2: Create a Flowchart of the Current Medication Reconciliation Process
The second step in creating an infrastructure to support improvement of the medication reconciliation process is to create a flowchart of the current process. A flowchart serves as a guide for developing the charter (go to Step 3). In addition, it may help you determine whether to design a new process or redesign the existing medication reconciliation process.
A flowchart outlines current workflow and helps identify:
- Successful medication reconciliation practices.
- Current roles and responsibilities for each discipline at admission, transfer, and discharge.
- Potential failures.
- Unnecessary redundancies and gaps in the process.
A flowchart of current practices can be modified during the design or redesign to highlight:
- Elimination of unnecessary steps (i.e., simplification of process).
- Defining roles and responsibilities in policy and procedure.
- Standardization across disciplines and/or practice settings.
- How new design steps integrate into existing workflow.
The tool "Develop a Flowchart of Your Current Medication Reconciliation Process" in the Appendix provides questions to guide you in developing the flow diagram for medication reconciliation at each critical handoff point: admission, intra-facility transfer, and discharge.
Benefits of Creating a Flowchart
After creating a flowchart of current practices, facilities reported the following findings:
- Multiple disciplines obtained independent medication histories from the patient.
- Each independent medication history was documented in various discipline-dependent sections throughout the medical record.
- No prompts were in place to cross-reference information or documentation.
- Multiple medication histories were often conflicting.
The sample process maps at Figure 1 and Figure 2 demonstrate how flowcharting the process can highlight and identify redundancies as well as gaps in the medication reconciliation process.
Step 3: Develop a Project Charter or Work Plan for Improvements
A project charter provides a summary and high-level roadmap for your work. The importance of utilizing a charter throughout the project is often underappreciated, but its use is paramount in keeping the project focused, and it provides a work plan for the design team. The charter will be a dynamic document that encompasses the following elements:
- Problem statement.
- Goals and objectives.
- Regulatory and accreditation requirements.
- Project scope.
- System capabilities/deliverables.
- Resources needed for a successful project.
- Project milestones (achievements throughout the project) and timeline.
Go to "Developing Your Charter" in the Appendix for a template charter that can be used as a starting point for the project.
Problem Statement. A problem statement is a concise description of the issues that need to be addressed by the team and should be presented to them or created by them. A good problem statement should consider the nature of the problem and how it impacts patient care.
Goals and Objectives. The team should establish goals and objectives that directly relate to the above problem statement. This component of the charter will keep the team focused on the strategies that were determined by the design team to improve medication reconciliation. Goals should be specific, measurable, attainable, realistic, and timely. A template for recording goals and objectives is available in the Appendix.
Regulatory and Accreditation Requirements. While developing the medication reconciliation charter, medication policies and procedures and regulatory and accreditation requirements must be considered. Ensure that:
- Individuals responsible for accreditation and licensure in your organization are integrated into the team.
- The process is designed to meet these requirements.
- The design plan incorporates practice settings affected by these criteria.
Project Scope. Before determining the scope of the project, you may find it helpful to create a list of all areas within your facility where patients receive medications. Create a list of practice settings that administer medications, and organize it by the type of patients they serve (inpatient, outpatient, both) and whether they admit and/or discharge patients to assist in prioritization.
"Determining the Scope of the Project," located in the Appendix, will assist in defining the scope of the project.
Additional questions to consider when determining the scope of the medication reconciliation project include:
- Should the project encompass the entire facility, one practice setting, or several departments?
- Should the project focus on one specific area of identified risk (i.e., inpatient only) or more?
- Should the project focus on one service or unit at a time or more?
- Should the focus start with an admission process then move to discharge or should your project concentrate on both at the same time?
- Should the initial scope include patients admitted through the emergency department or from procedural areas, such as ambulatory surgery?
These questions can guide the development of the scope and charter of the project based on the individuality of the facility and areas with the greatest need.
System Capabilities/Deliverables. The team should understand system level capabilities and/or barriers that may impact the project and use the charter to communicate this information to all team members. An example of this may be leveraging the charter for communicating upcoming conversions from a paper medical record to an EHR or EHR updates and how the medication reconciliation process integrates into these conversations and necessary steps to be taken to make this happen. The charter also outlines upcoming deliverable dates to keep the medication reconciliation project on track.
Resources Needed for a Successful Project. As you begin the journey to improve your facility's medication reconciliation process, you should address resource support with the leadership team from the beginning of the project. Depending on the area of focus, process design or redesign plans, budget constraints, and resource availability, it is crucial to think through each discipline's role (currently and ideally), current workflow practices, and how medication reconciliation can be better integrated in a more efficient, effective manner. For example, for pre-scheduled surgeries that will result in a planned admission post-operatively, is there a better way to obtain a patient's current medication information during presurgical workups and medical clearance appointments, rather than trying to gather this type of information on the day the patient presents for surgery, when they may be anxious about their procedure?
Project Milestones and Timeline. Milestones are frequently used to monitor progress. Broad project milestones can be developed initially and modified as the team begins to better understand the issues at hand. Reviewing project timelines and milestones achieved also keeps the team energized and focused as progress is made.
Step 4: Establish a Measurement Strategy
At the start of the project, create a list of data that will be needed and the departments and people who should be in charge of developing the measurement strategy. For organizations with an established EHR, inviting a representative from the facility's Information Technology (IT) department from the beginning of project planning is strongly advised. Share with the IT representative the list of data needed to drive decisions regarding the needs of the facility and staff, or to understand where to direct the project attention first to explore ways to leverage your EHR to collect this type of information electronically. Data that can serve as a starting point could be the facility's readmission rates (the Finance department usually creates these data), adverse drug events (ADEs) for the facility (the Pharmacy department usually collects these data), or data specific to the facility's current process for medication reconciliation. Consider using the audit tool and measures that are used in this toolkit. Chapter 6 reviews project metrics in greater detail.
Collecting baseline data will allow you to determine where to focus the project initially. Your initial proposal should include baseline data you collected in order to strengthen and support the business case you present to senior leadership.
Integrating team members who can assist with performance measurement will allow each team member to carry out their role in the project with ease.
Chapter 2 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:
- A multidisciplinary team fostered a facility-wide team environment for process improvements. Frontline staff felt more "ownership" and involvement in the change.
- Facilities that developed a project charter, articulated a problem statement, and set goals and objectives were better prepared to stay on task with the project.
- Using the project charter to provide periodic reports to the leadership team supported the dynamic use of the document.
- Including a review of the project charter at each project meeting kept the team on task.
- Process mapping is a critical element for success. Project participants found that walking through the medication reconciliation process and confirming each step with frontline staff was an eye-opening experience. Many times the process that is on paper is not what is being done on the ward, and identification of workarounds is pivotal.
- Participants who used this toolkit found staff workarounds of a process were not necessarily negative findings.
- Determining the size or scope of the project should be done early in the planning stage. Keeping the initial project focus reasonable in size and scope is pivotal to the success of the project. Broad scale efforts consume many resources and can make it difficult to secure and maintain leadership support. Implementing a successful project on a limited scale often leads to a larger effort.
- Measurement of baseline data was a necessary and crucial element of the project. This helped identify areas of focus, explored depth of issues, and provided the team with a realistic idea of the improvements they were proposing.