Team Charter Glen Haven May 20-08

Team Charter Glen Haven May 20-08

MedicationReconciliationImprovementCharter

Glen Haven Guest Home

Intervention Teams:

Medication Reconciliation

/

Executive Sponsor:

Virginia Vacheresse
Draft #1
May 20, 2008 /

Team Leaders: Mary Lou Fulton, Ann DeCoste

CoreTeam Members:Sue Rankin, Kathy Otter, Debi Pettipas, Evie Mac Millian, Arlene Taylor,
Ad Hoc Team Consultants:Dr Forbes, Helen Gerrier
Consulting Team Members: Kelly MacInnis, (receive minutes, attend meetings as appropriate)
WHAT ARE WE TRYING TO ACCOMPLISH? / Purpose of Project:
To improve quality of care delivered to patients upon admission, transfer and discharge by reducing the opportunity for Adverse Drug Events (ADE’s) by March, 2009.
Scope and Boundaries:
To create an improved process to help caregivers easily and accurately access and interpret the current and past medication history of a resident.
  • The team will be responsible for the education of staff, residents, families and physicians on the implementation of Medication Reconciliation.
  • Medication Reconciliation will be completed on all new admissions
Data will be submitted to the Safer Healthcare Now! Campaign’s central measurement team monthly, for a minimum of 5 residents. The Medication Reconciliation Team is an Ad Hoc sub committee of the Nursing Pharmacy Liaison Committee and will be support and accountable to this committee.
Aim Statements:
  • To ensure that allresidents admitted have medications reconciled on admission by June 30, 2008.
  • To decrease the number of intentional and undocumented discrepancies to .5/admissionby Sept 2008
  • To decrease the number of unintentional discrepancies by .25/admission by September 2008
  • To ensure 100% of residents admitted have a Medication Reconciliation completed as part of the Admission process by June 30, 2008
  • To spread the improvements to discharges by September 2008.
  • To spread the improvements to transfers by December 2008.

HOW WILL WE KNOW A CHANGE IS AN IMPROVEMENT? / Measures:
  1. Mean number of undocumented intentional discrepancies per month (Type 2)
  2. Mean number of unintentional discrepancies per month (Type 3)
  3. Percentage of Residents with Med Rec completed on Admission
  1. Balancing measures:
  • Perceptions of improved accuracy of admission orders
  • Perceptions of improved clarity of admission orders
  • Perceptions of time spent on admission order processing is reduced by X minutes: 5-10 mins
  • Staff/Physician/Pharmacists satisfaction
/ Current Status:BASELINE
1.2.67/admission
2.0.67/admission
3.0.0 %
You may want to do a brief survey, include a small sample…possible 15-20, different disciplines / Goal or Target:
1. 0.5/admission
2. .25/admission
3. 100% of admissions
4.
WHAT CHANGES CAN WE MAKE THAT WILL RESULT IN IMPROVEMENT? / Ideas for Change
Phase One: Implement BPMH and Med Rec on all residents admitted to Glen Haven Guest Home by June 30 2008
Test and refine the BPMH and reconciliation form.
Test and refine BPMH interview and data collection processes ( show pills and clarify in interview, validate with family and pharmacy, standardize required referral information etc )
Test and refine several methods for staff education, input and feedback on implementation and improvements
Use PDSA cycles and huddles to test and refine changes
Test and refine resident, family, internal/external provider medication related communication
Phase Two:To spread the improvements to discharges by September 2008.
.
Phase Three: To spread the improvements to transfers by December 2008
HOW WILL WE MANAGE THE IMPROVEMENT PROJECT? / Roles & Responsibilities of team members:
Principles for working together
Mutual respect
Regular meetings: short and snappy and focused,use huddles on the spot as much as possible to assess small tests of change.
Track small tests of change
Share the workload
Look for the opportunities and the keys to success rather than focusing on the limitations.
Engage Executive Sponsor when barriers to implementation are beyond core team’s ability to address on their own
Share successes with each other, the organization, and the Communities of Practice
Include other interested partners as identified
Consult with Atlantic Node proactively and as needed (before team gets overwhelmed)
Roles and Responsibilities:
Team Leader : -organize and facilitate meetings, communicate with other team members, arrange/provide education/awareness
All Core Team Members Monitor and provide feedback for QI
Physician…input on process issues as required and communication with physicians
Executive Sponsor : Facilitate, resource and support adaptation of innovations, receive accountability reports, report to Nursing Pharmacy Liaison Committee
Hospital Pharmacist: Collaborate and develop strategies to improve Medication related communication between the Hospital and Home.
Meeting Commitments
Will be coordinated around current meeting schedule of the Med-Nsg Cttee
Use Safer Healthcare Now website and Community of Practice
National med rec conference calls
Key Dates:(Monthly report deadlines, Learning session dates etc.)
Phase 1 –June 30, 2008
Phase 2 –September 2008
Phase 3 –December 2008

Date: May 20, 2008 Revised:

Glen Haven Guest Home

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