Ambulatory Medication Reconciliation: Using a Collaborative Approach to Process Improvement at an Academic Medical Center.

BACKGROUND: Incomplete medication reconciliation has been identified as a source of adverse drug events and a threat to patient safety. How best to measure and improve rates of medication reconciliation in ambulatory care remains unknown. METHODS: An institutional collaborative improvement effort to develop and implement medication reconciliation processes was designed and facilitated across all 148 Brigham and Women's Hospital (Boston) ambulatory specialty practices: 63 underwent a more rigorous approach, a modified approach was undertaken in another 71 specialty practices, and a less intensive approach took place in the 14 primary care practices. The level of intervention varied on the basis of preexisting improvement infrastructure and practice prescription rates. Two electronically measured metrics were created to evaluate ambulatory visits to a provider in which there was a medication change: (1) Measure 1: the percentage of active medications prescribed by that provider that were reconciled; and (2) Measure 2: how often all the medications prescribed by that provider were reconciled. After the collaborative was completed, performance data were routinely shared with frontline staff and hospital leadership, and medication reconciliation rates became part of an institutional financial incentive program. RESULTS: For Measure 1, specialty practices improved from 71% to 90% (September 2012-August 2014; 24-month period). Primary care practice performance improved from 62% to 91% (December 2012-August 2014; 20-month period). For Measure 2, overall performance across all ambulatory practices increased from 81% to 90% during the first 12 months of the financial incentive program (October 2013- September 2014). CONCLUSION: A collaborative model of process improvement paired with financial incentives can successfully increase rates of ambulatory medication reconciliation.

Implementing clinical pathways for patients admitted to a medical service: lessons learned.

In an attempt to improve quality of care for patients admitted to our medical service we have implemented the use of pathways. These are printed standards of care and a mechanism for daily multidisciplinary documentation. The goals of our pathways are to: improve quality using printed standards of care; improve documentation of the care delivered; improve communication about daily goals between all team members, patients and families; standardize our in-patient chart format throughout the hospital; and increase efficiency of care. Pathways were designed to provide physicians and nurses with the standards for care and provide a mechanism for multidisciplinary documentation on our in-patient charts. We now have 2 pathways in use on our medical service. One is a clinical care plan (CCP) and the other is a Pancreatitis Pathway (PP) for patients admitted with acute pancreatitis and the other a guideline for care for all patients. The pathways were developed by teams including attending physicians (General Internists and Gastroenterologists), medicine house officers, nurses, and care coordinators. The pathways are used for all patients admitted to our medical service if they are admitted to one of 2 floors. This paper includes a comparison of outcomes for our first 9 patients who were managed using the pancreatitis pathway versus 7 patients cared for without the pathway. Significant differences in the pancreatitis pathway treated patients included: 1) less intense pain on day 2, (P = 0.04); 2) less pain on day of refeeding (P = 0.004); and 3) less IV fluids administered (P = 0.05). We also describe several lessons we have learned about using pathways for in-patients on a medical service in an academic medical center. We have learned the following lessons. Nursing documentation is improved. Physicians need ongoing encouragement and education about the value of pathways. There is considerable work involved for unit coordinators, care coordinators, and nursing in using pathways on a medical-surgical floor. There must be physician and nurse champions. There must be ongoing feedback to users. There must be input from users and edits. We believe the use of pathways as a process to remind clinicians of quality standards will improve the care of our patients by decreasing variation, improving team communication, and enhancing patient and family education.