Tuesday, January 6, 2009

Auditing Medication Reconciliation

BIDMC has a major focus on process improvement and lean approaches to workflow.

When we declare a goal we develop metrics to track our processes and remeasure our performance to ensure our changes have a lasting effect.

I was recently asked about our adherence to medication reconciliation, a Joint Commission requirement and a pay for performance goal for us.

We have 3 major medication reconciliation workflows - Emergency Department, Inpatient and Outpatient - which ensure we document a complete medication list at every transition and communicate that list to the next provider, ensuring continuity of care.

Our last audit was completed on November 19, 2008.

* A total of 1326 records across the various areas were reviewed
* We found 95% compliance with Communication of Updated List of Medications to Next Provider of Care.

Each time we do an inpatient review, we select a date and then review discharges from the prior two days. In the last round, the date selected was 11/19, and we reviewed 161 discharges from 11/17 and 11/18. There were 263 discharges on those days, so the % reviewed was 61%.

Our full results are below:

Service LineVisits ReviewedMedications AddedSent to Next Provider%
Same Day Surg55383592%

We will continue this quarterly monitoring into 2009 and the dates to save include:
Wednesday, February 11, 2009
Wednesday, May 20, 2009
Wednesday, August 19, 2009
Wednesday, November 18, 2009

When an audit is conducted, the number of charts reviewed per clinic varies based on the clinic's volume on the selected day:

Clinics w/ <30 visits review 100% of cases.
Clinics w/ 31-100 visits review 30 cases.
Clinics w/ >100 visits review 50 cases.

We've found that this level of monitoring rigor is necessary to demonstrate and sustain real process change.

As many have said "What gets measured gets done"


Unknown said...

Hi John,

Great post as usual. However, why do you announce the dates of the upcoming audits (or are these the dates of the publications of the audits).
To external skeptics, it may appear as if you are playing the quality game but are giving an incentive for your staff to focus their efforts around audit times.
I appreciate your efforts at BIDMC, and know that this is not the intent, but could you please comment on this?

John Halamka said...

We do a mixture of announced and unannounced audits. In my blog, I failed to mention that (and purposely did not post the surprise audit dates!)

Unknown said...


I just found your Blog.. it's very informative...I appreciate your willingness to share..I work in the industry and find that what you're blogging about dovetails very closely with the issues my clients are dealing with..

I do have one question regaring Meds Rec:

Are you using an automated process for Medication reconciliation?

Bill Bush

John Halamka said...

Yes, our medication reconciliation process is entirely automated in the inpatient, outpatient and ED settings using applications we built ourselves interfaced to RxHub and Surescripts.

Andy Steele said...

Interesting data. How do you define "Sent to Next Provider %", which is a great metric? If all automated, any reason you do not do 100% auditing from your data systems?

Suzanne said...

I would like to know the answer to Andy's question as well. Also, you measure number with medications added, but what about any changes (medications d/c'd, dose or sig changes)?

Anonymous said...

Along the lines of the last 2 comments, if the report to the next Provider is via a CCD, the Medication section would show filled and intended medications. If the provider doesn't look into the Plan of Care, the provider won't know whether the intended meds were prescribed, sent to the Pharmacy, or whether the prescription is pending, denied, or modified - e.g., another med is substituted. C32 doesn't require the Plan of Care, so it might not be sent. Seems like there is potential for the next provider to see medications in the list that were never received by the patient.

Dirk Stanley, MD, MPH said...

John - Also, thanks for the open posting - Just curious - I see you built your own medicine reconciliation that links to SureScripts etc. - Why did you build your own? Did you not find any products that were satisfactory to you?