Chapter 1: Building the Project Foundation: Gaining Leadership Support Within the Organization

An essential first step in implementing a successful medication reconciliation performance improvement project is to gain support within the organization. To be successful, you need the support of leadership, physicians, nurses, pharmacists, and other stakeholders that play a role in medication management practices.

This section presents talking points for making a sound argument for undertaking a medication reconciliation project. Making the connection to other ongoing patient safety initiatives, regulatory/accreditation requirements, and operational efficiencies are important elements that can help you obtain support. Talking points should address all or part of the following components:

• Medication reconciliation as a patient safety issue.
• Resource justification to produce a successful project.
• Linking medication reconciliation with other initiatives.

Medication Reconciliation as a Patient Safety Issue

A review of the literature notes several decades worth of articles describing medication discrepancies or lack of concordance, while few have addressed solutions to the problem. A publication in 2001 by Rozich and Resar¹ quantified discrepancies during key transition points such as hospital admission, intra-hospital transfer, and discharge. Additional studies have validated vulnerabilities during these transition points:

• Variances between medications patients were taking prior to admission and their admission orders ranged from 30 percent to 70 percent in two literature reviews.^2,3
• A study of medication reconciliation errors and risk factors at hospital admission noted that 36 percent of patients had errors in their admission medication orders with the majority of these occurring during the medication history gathering phase.⁴
• A study utilized 12 years of administrative records of all hospitalizations and outpatient prescriptions for almost 400,000 patients age 66 older to determine (1) continuous use of at least 1 of 5 medication classes and (2) failure to renew prescriptions within 90 days post-hospital discharge.⁵ Patients prescribed chronic medications were at higher risk for unintentional discontinuation following hospital discharge, and ICU stay during hospitalization increased the risk of medication discontinuation even further.

Findings from these studies as well as many others reinforce the need for a structured process of comparison and resolution—such as medication reconciliation—to help ensure patient safety and medication continuity during care transitions.

Resource Justification to Produce a Successful Project

Most health care facilities today are operating with limited resources, including financial and staffing limitations. A sound project plan helps to identify roles, responsibilities, and staff resources. A strong business case outlines the financial incentives for the facility.

Examples of two models to calculate potential gross savings of a newly designed or improved medication reconciliation process are provided. Specifically, the first model demonstrates a cost-benefit analysis of reducing preventable adverse drug events (ADEs); the second model demonstrates a cost-benefit analysis of the use of pharmacists or other staff to perform medication reconciliation.

The first is a financial model developed by Steven B. Meisel, PharmD, Director of Medication Safety at Fairview Health Services in Minneapolis, Minnesota. This example is also contained on the MATCH Web site and reproduced with permission in this toolkit.

Published data from the Institute of Medicine⁶ and others demonstrate discrepancies in medication regimens among people admitted to health care facilities, and some of those discrepancies will lead to an ADE that could seriously harm a patient. The estimated cost of a preventable ADE was $4,800 per event, based on a 1997 study done by Bates et al.⁷ Some organizations have calculated an ADE cost as high as $10,375.⁸ Dr. Meisel's internal data show that an effective medication reconciliation process can detect and avert up to 85 percent of medication discrepancies. Conducting effective medication reconciliation on admission is estimated to take 15 to 30 minutes. With these assumptions in mind, Meisel outlines the following calculations:

Model 1: Financial Model for Medication Reconciliation

Number of discrepancies per patient X     Number of patients per year that one person can reconcile X     Percent of patients with discrepancies that would result in an ADE X     Percent effectiveness of process X     Cost of an average ADE =     Annual gross cost savings -     Salary of Employee =     Annual Net Savings

Source: Presented by Steven B. Meisel, PharmD, at the Joint Commission/Institute for Safe Medication Practices Medication Reconciliation Conference, Nov. 14, 2005.

To calculate the net cost savings, subtract the cost of the anticipated resource investment (staff, equipment, IT) from the gross cost savings. Net savings will vary depending on the type of staff designated to perform medication reconciliation (nurse, pharmacist, pharmacy technician, or physician), as shown in Table 1.

Table 1: Net Savings for Medication Reconciliation

1.5 (discrepancies per patient admitted to Fairview) X     6000 patients (average of 20 minutes/patient to complete medication reconciliation) X     0.01 (1% of Fairview admissions experience discrepancies that would result in an ADE) X     0.85 (85% of discrepancies avoided through medication reconciliation process) X     $2500 (conservative cost of an ADE) =     $191,250 annual gross savings -     $45,000 (salary and benefits of an incremental pharmacy technician) =     $146,250 annual net savings (325% return on investment in a new staff member)

The second model, developed by Steve Rough, M.S., R.P.H., Director of Pharmacy at the University of Wisconsin Hospital and Clinics, includes a template for pharmacist justification to collect and reconcile medication history on admission to a facility. Table 2 indicates average time requirements for pharmacists performing various levels of interaction with patients, records, and interventions.

Below is an adaptation of the template based on sample data collection at Northwestern Memorial Hospital.

Model 2: Pharmacist Justification for Medication History Collection and Reconciliation on Admission

Average # of discrepancies/medication errors per patient	2.2
Number of inpatient admissions per year	43,312 (2006)
Potential medication errors per year that can be avoided	95,286 (2.2 x 43,312)
Percent of medications that were potentially harmful to patient during hospitalization*	2.5%
Number of harmful medication errors avoided per year	2,382
Annual gross savings to hospital ($4,800 per harmful error)*	$11,434,320
Average pharmacist time requirement per admission*	21 minutes
Additional pharmacist FTE needed to provide service (based on 115 admissions daily)	~ 5 FTE
Cost of additional pharmacist FTE (salary + benefits)	$625,000
Annual Net Savings / Cost Avoidance	$11.4M

Source: This template was presented by Steve Rough, MS, RPh, at the American Society of Health-System Pharmacists Summer Meeting, June 26, 2006. Used on MATCH Web site with permission.

Table 2: Time Requirements for Pharmacist-Obtained Medication Histories and Reconciliation*

Average time to obtain medication history	9 minutes/patient
Average time to obtain medication history and provide necessary interventions/documentation	12 minutes/patient
Average time for chart review prior to medication history, medication history interview and necessary interventions/documentation	21 minutes/patient

* Based on an evaluation of 651 general medicine patients interviewed by a research pharmacist at Northwestern Memorial Hospital, Chicago, IL, who obtained a complete medication history and reconciled medications with other documented medication histories and current orders.

These templates can be applied to other disciplines, as well as other transitions in care, using published error data or by looking at error data at your own institution.

Linking Medication Reconciliation with Other Initiatives

Making the connection to other ongoing quality and patient safety initiatives, regulatory/accreditation requirements, and operational efficiencies is important for garnering support and achieving a successful medication reconciliation process. Other initiatives that can be linked to your medication reconciliation efforts may include: The Joint Commission National Patient Safety Goals, Centers for Medicare & Medicaid Services (CMS) process of care (core) measures, the Survey of Patients Hospital Experience, hospital readmissions, and other national quality improvement activities.

The Joint Commission Accreditation and Other National Quality Improvement Activities. TJC continues to recognize the importance of medication reconciliation, despite the need for several iterations to its NPSGs. The revised NPSG 03.06.01, which went into effect July 1, 2011, requires facilities to "maintain and communicate accurate patient medication information."⁹ This revised goal preserves the intent of the original NPSG while creating a more reasonable approach to tailor the process to meet specific medication management needs for a patient within a particular care setting. The MATCH toolkit can help facilities work toward meeting this patient safety goal.

Recent revisions to TJC NPSG take into account feedback from accredited organizations of the complexity of meeting the retired goal #8. Scoring for NPSG 03.06.01 resumed July 2011, and the elements of performance are noted below:

• Obtain and document or verify patient's medication list when admitted or seen as an outpatient. Medications to inquire about should include current prescription and over-the-counter (OTC) medications, such as vitamins, supplements, eye drops, creams, ointments, and herbals.
• Define the types of medication information to be collected in non-24-hour settings and different patient circumstances.
• Compare medication information the patient brought to the hospital with those ordered to identify unintended discrepancies (e.g., those not explained by the patient's clinical condition or formulary status). A qualified individual conducts the comparison, per TJC requirements. Discuss unintended discrepancies with the physician for resolution.
• Provide the patient/family with written information on the medications the patient should be taking when discharged from the hospital, or at the end of an outpatient encounter.
• Explain the importance of managing medication information to the patient when discharged or at the end of an outpatient encounter. Instruct the patient to:
  • Give a list to their primary care provider.
  • Update the list when medications are discontinued, doses are changed, or new medications (including OTCs) are added.
  • Carry medication information at all times in case of an emergency.

Centers for Medicare & Medicaid Services Process of Care (Core) Measures. Process of care (core) measures demonstrate how often hospitals adhere to recommended treatments for certain medical conditions, such as acute myocardial infarction, heart failure, and pneumonia, or for surgical procedures. Hospital performance is publicly reported on the CMS Web site, Hospital Compare (http://www.hospitalcompare.hhs.gov/). Soon, several of these measures will move from a pay-for-reporting structure to reimbursement based on performance (value-based purchasing), rewarding hospitals for their achievements as well as improvements. Higher performance scores may be realized by applying medication reconciliation elements, for example:

• Incorporating a reconciled medication list into the discharge instructions for heart failure patients.
• Obtaining a vaccination history to determine eligibility to receive influenza vaccination or pneumococcal vaccination.
• Determining whether patients were taking a beta-blocker prior to surgery and reconciling post-operative orders to ensure beta-blocker continuation after surgery.

Survey of Patients Hospital Experience. Hospitals use the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS there was no national standard for collecting and publicly reporting information about patient experience of care that allowed valid comparisons to be made across hospitals locally, regionally, and nationally. In the future, other health care settings (e.g., nursing homes; home health) will have similar requirements.

HCAHPS contains 18 patient perspectives on care and patient rating items that encompass eight key topics: Communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, and quietness of the hospital environment.

Sample survey questions pertaining to medications include:

• During this hospital stay, did you need medicine for pain?
• During this hospital stay, how often was your pain well controlled?
• During this hospital stay, were you given any medicine that you had not taken before?
• Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?
• Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

A complete list of HCAHPS survey questions is at http://www.hcahpsonline.org/home.aspx .

Meaningful Use of Electronic Health Records. Many health care providers utilize paper-based medical record systems. New government incentives and programs are encouraging health care providers across the country to convert to or adopt electronic health records (EHRs). Specifically, the Health Information Technology for Economic and Clinical Health (HITECH) Act provides the U.S. Department of Health and Human Services (HHS) with the authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health information technology (IT), including EHRs and private and secure electronic health information exchange. Under HITECH, eligible health care professionals and hospitals can qualify for Medicare and Medicaid incentive payments when they adopt certified EHR technology and use it to achieve specified objectives. With respect to EHRs, health care providers are required to succeed in each of these three areas:

1. Gathering of complete and accurate information.
2. Achieving improved access to patient information.
3. Empowering patients.

The MATCH toolkit can be implemented through an EHR (for example, go to the examples in Chapter 3) or to help health care providers meet these goals. It provides a framework to capture complete and accurate medication information, improves communication of that information among health care providers, and empowers the patient to know what medications are needed after leaving a care setting.

For more specific details on Meaningful Use, visit the HHA Office of the National Coordinator for Health IT (ONC) Web site at http://healthit.hhs.gov/portal/server.pt?open=512&objID=2996&mode=2. The ONC Health IT Web site also includes information on how to qualify for Medicare/Medicaid incentive payments related to Meaningful Use.

Reducing Readmissions and Other National Initiatives. A successful business case should help leadership make the connection between clinical quality, medication reconciliation, and medication safety by highlighting outcomes such as a reduction of ADEs or hospital readmissions due to medication discrepancies carried across the continuum of care. In 2011, the HHS launched the largest national quality improvement initiative in the history of our health system. The Partnership for Patients initiative has challenged hospitals to improve the quality, safety, and affordability of health care for all Americans. This public-private partnership has two main goals: To keep patients from getting injured or sicker from the care they receive by reducing preventable hospital acquired conditions and to help patients heal without complication by improving the transition process. More information on the Partnership for Patients is available at: http://www.healthcare.gov/compare/partnership-for-patients/.

Chapter 1 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:

• Leaders who attended MATCH trainings were able to achieve a high level of success as well as generate excitement around their medication reconciliation initiatives in their facilities.
• Leadership support should encompass more than an organizational endorsement; the support requires a sustained commitment of resources and time through the continuum of care.
• A leadership team with continual involvement, focus, and commitment is integral to the success of a medication reconciliation project.
• A multidisciplinary team, including patient involvement, ensures the project design incorporates diverse perspectives and practice settings.
• The leadership team should promote the concepts of this toolkit into culture and practice for safe medication management in the facility.
• Follow the steps in the toolkit sequentially to establish a foundation for the project. Overlooking one step can hinder progress toward the established goal(s).

Return to Contents
Proceed to Next Section