Published on March 7, 2014
Improving Medication Management in Supportive Living Using a SelfAssessment Checklist Dale Wright Senior Project Lead Promoting and improving patient safety and health service quality across Alberta Quality Forum 2014
ACKNOWLEDGEMENTS Cheryl Knight Executive Director, Senior’s Health Alberta Health Services Project partners:
OVERVIEW Checklist development Medication management in supportive living Checklist tool & self-assessment process Early adopter initiative & results
THE CHECKLIST PROJECT Objectives To identify medication safety risks, good practices, and challenges with medication management in supportive living (SL 3, 4 and 4D). To develop a self-assessment tool that operators of supportive living sites can use to assess the safety of medication practices in their site and identify quality improvement opportunities.
THE CHECKLIST PROJECT Phase 1 – August 2010 to June 2011 • Literature review • Medication incident report analysis (ISMP Canada) • On-site reviews in 8 SL3, 4 & 4D sites Phase 2 – July 2011 to June 2012 • Draft checklist developed • Pilot test in 9 SL 3, 4/4D sites • Revise and publish July 2012 Early Adopter Initiative – Nov 2012 to Jan 2013
MEDICATION MANAGEMENT “All the processes required to ensure safe and effective medication therapy for a client.” Checklist Glossary Assessment Prescribing Communication of medication orders Medication reconciliation Dispensing Delivery Storage Medication Support Documentation Monitoring and follow-up
MEDICATION MANAGEMENT IN SL In the community Assessment Monitoring Prescribing Within the site Use Dispensing Administration (Support) Distribution
THE CHECKLIST TOOL
THE CHECKLIST TOOL Goal: To help SL sites . . . Learn about safe medication systems and leading practices in medication safety Identify vulnerabilities in their medication system and stimulate quality improvement activities
THE CHECKLIST TOOL 74 checklist items – leading practices for medication safety 8 key elements – components of the medication system Client assessment (7) Quality & safety program (4) Assessment Monitoring Client med info (10) Prescribing Communication (6) Use Dispensing Provider competence (7) Administration Medication support activities (16) (Support) Distribution Pharmacy services (15) Medication storage (7)
THE CHECKLIST TOOL
SELF-ASSESSMENT PROCESS A team discussion! Assessment Monitoring Prescribing Use Dispensing Administration (Support) Distribution
USING THE RESULTS TO IMPROVE 1. List identified vulnerabilities in the med system Items scored ‘Partly’ or ‘No’ 2. How easy would it be to make a change? Easy (‘quick fix’), moderate, difficult 3. Select 3 issues to work on Quick fix High-impact changes Opportunity to engage community partner Issues related to known medication incidents 4. Implement a quality improvement plan Brainstorm possible solutions – with the team! Select a solution and try it on a small scale Revise and test until solution is workable Implement Measure to determine if a change is an improvement
EARLY ADOPTER INITIATIVE Objectives: To encourage SL sites to use the checklist in a team self-assessment process to identify medication safety improvement opportunities. To establish a baseline for medication management practices in SL in Alberta.
EARLY ADOPTER INITIATIVE (EAI) Method AHS contracted SL (147) & PCH (30) Voluntary with $ incentive Multi-mode communication strategy Facilitator kit – Instructions, checklist booklets, data collection form, return envelope, information contact Follow-up interviews with site contacts and case managers
EAI RESULTS: Participation Overall Participation: 56/147 SL sites 10/30 PCH* (Edmonton/Calgary) North 6/16 Edmonton 17/60* Central 8/32 Calgary 19/38* South 16/31
EAI Results: Strengths Items rated as fully in place by > 90% of sites 1.5 – Site policies describe medication support 2.5 – Management of suspected ADRs 4.6 – Adjustment to med packages done by Rx 4.9 – Method of recording med support kept at site 4.15 – Rx collects outdated & discarded meds
EAI Results: Strengths Items rated as fully in place by > 90% of sites 5.1 – Meds stored in secure place 5.4 – Lighting levels are adequate 6.6 – Guidance to handle missing or dropped meds 6.10 – MA/AR for each client and available to all providers 6.15 – Proper disposal of materials with client info 7.4 – Clear communication channels and lines of authority
EAI Results: Challenges Items rated as fully in place by < 50% of sites or not in place for > 15% of sites 1.6 Care plan related to PRN medications 2.6 Care conference 6 to 8 weeks after admission 2.10 Single client record kept at site 3.2 Faxing medication orders 3.4 Med orders include explicit instructions (PRNs) 3.6 Changes in meds communicated to client/family
EAI Results: Challenges Items rated as fully in place by < 50% of sites or not in place for > 15% of sites 4.2 Service agreement with pharmacy provider(s) 4.5 After hours service from pharmacy provider(s) 4.12 Delayed start policy 5.2 Refrigerator temperature check 6.2 Interruptions during med support minimized 6.13 Documentation for patches and injections
EAI RESULTS: Follow-up Interviews To determine: Effectiveness of communication strategies about the EAI Experience with the checklist and team selfassessment process Experience with following through with a quality improvement process
EAI RESULTS: Follow-up Interviews 1. Effectiveness of communication strategies E-mail preferred – presentations also helpful esp. for case managers Incentive appreciated but did not drive participation Spring or fall timing preferred Non-registered sites: – 7 completed checklist process; 7 not aware of initiative; 5 did not have time; 2 believed checklist did not add value Case managers: – Many had not heard about the EAI - 6/25 working with sites who completed the self-assess, 14/17 working with sites who did not register
EAI RESULTS: Follow-up Interviews 2. Experience with checklist & self-assessment Difficulty finding a time that worked for CM and Rx Effective, valuable process Gained knowledge of role & respect for others Pharmacist is essential to the process Instructions clear, format user friendly, background info helpful – QI planning tools rarely used Case managers unsure of role, often did not receive checklist in advance
EAI RESULTS: Follow-up Interviews 3. Experience with improvement activities Development of improvement plan integrated with the meeting – “Partially” or “not in place” items triggered a discussion of solutions – Concrete ideas for improvement resulted Self-assessment is a new process but useful – Consider for other areas of practice Case managers did not have a clear sense of improvement goals, follow-up activities or how they would be involved – ‘Relationships are important’
EAI RESULTS: Recommendations Site Level Reinforce team approach to med management Be proactive with pharmacy service provider(s) Communication and PRN medications are a challenge – review with community partners Use the checklist as a model for proactive quality and safety improvement AHS Guidance on best practices for PRNs, order communication (faxing) Support development of QI programs Logistics for future initiatives
FOR MORE INFORMATION For more information, to order copies of the Checklist, or to receive Early Adopter Initiative reports, contact: Dale Wright Senior Project Lead 403-355-4439 firstname.lastname@example.org
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