MARQUIS IMPLEMENTATION MANUAL A Guide for Medication Reconciliation Quality Improvement ADDENDUM ADDED AUGUST 2017 INCLUDES: * NEW COMMUNITY ENGAGEMENT GUIDELINES * UPDATED SOCIAL MARKETING MATERIALS * NEW DISCHARGE MED REC COUNSELING MATERIALS Prepared by MARQUIS Investigators October 2014 Funded by AHRQ grant 5 R18 HS019598 Copyright ©2014 by Society of Hospital Medicine. All rights reserved. No part of this publication may be reproduced, stored in retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written consent. For more information or to obtain additional copies contact SHM at: Phone: 800-843-3360 Email: [email protected] Website: www.hospitalmedicine.org/MARQUIS MARQUIS Implementation Manual A Guide for Medication Reconciliation Quality Improvement Prepared by MARQUIS Investigators October 2014 Funded by AHRQ grant 5 R18 HS019598 For more information about MARQUIS, visit www.hospitalmedicine.org/MARQUIS. Table of Contents Introduction Contributors Acknowledgments Section A: Setting the MARQUIS Team Up for Success I. First Steps ………………………………………………………………………………………………………………………………… 4 A. Overview of MARQUIS (Multi-Center Medication Reconciliation Quality Improvement Study) ………………………………… 4 B. Pre-Implementation Actions ………………………………………………………………………………………………………… 4 C. Clarifying Key Stakeholders ………………………………………………………………………………………………………… 5 D. Assigning Roles and Responsibilities to Clinical Personnel ……………………………………………………………………… 6 E. Obtaining Support and Approval from the Institution ……………………………………………………………………………… 7 F. Summary ……………………………………………………………………………………………………………………………… 8 II. Medication Reconciliation: Definition ………………………………………………………………………………………………… 9 III. Medication Reconciliation: Process ................................................................................................................................... 10 A. Overview …………………………………………………………………………………………………………………………… 10 B. Admission ………………………………………………………………………………………………………………………… 11 Step 1: Take a Best Possible Medication History (BPMH) to create the Pre-Admission Medication List (PAML). Record the PAML in the patient’s chart ............................................................................................................................ 11 Step 2: Write admission medication orders based on the PAML and the patient’s clinical condition ...................................... 14 Step 3: Compare the PAML with admission orders, and identify and correct any unintentional discrepancies in admission orders ............................................................................................................................................................ 15 C. Transfer .......................................................................................................................................................................... 16 Step 1: If applicable, write transfer medication orders, using the PAML and current inpatient (pre-transfer) medications as a guide ........................................................................................................................................................................ 16 Step 2: Compare PAML medications, pre-transfer medications and transfer medications, amd identify and correct any unintentional discrepancies in transfer orders. …………………………………………………………………………………… 16 D. Discharge …………………………………………………………………………………………………………………………… 17 Step 1: Write the Discharge Medication List (DML) using the PAML and current inpatient medications as a guide. Document the DML........................................................................................................................................................... 17 Step 2: Compare the PAML, current inpatient medications and the DML. Identify and correct any unintentional discrepancies in the DML.................................................................................................................................................. 18 Step 3: Provide a copy of the medication list and review the DML with the patient and family/caregiver. Highlight and explain stopped, changed or new medications compared with the PAML and the reasons for those changes. ................ 19 Step 4: Forward a copy of the DML to post-discharge providers. Explain stopped, changed or new medications compared with the PAML and reasons for those changes. …………………………………………………………………… 21 IV. Medication Reconciliation: Brief Literature Review ……………………………………………………………………………… 22 A. Pharmacist-Related Interventions ………………………………………………………………………………………………… 22 B. IT-Focused Interventions ………………………………………………………………………………………………………… 22 C. Other Interventions ………………………………………………………………………………………………………………… 22 D. Conclusions ………………………………………………………………………………………………………………………… 29 V. Assembling a Team and Developing a Strategy …………………………………………………………………………………… 30 A. Identify Team Members …………………………………………………………………………………………………………… 30 B. Establish Team Rules and Guidelines …………………………………………………………………………………………… 33 C. Set General Goals ………………………………………………………………………………………………………………… 35 D. Map Your Current Medication Reconciliation Process ………………………………………………………………………… 37 E. Identify Your Measurement Strategy …………………………………………………………………………………………… 45 F. Turn General Goals into Specific Goals ………………………………………………………………………………………… 48 G. Follow a Framework for Improvement …………………………………………………………………………………………… 50 H. Phased Implementation …………………………………………………………………………………………………………… 51 I. Complete MARQUIS Site Assessment …………………………………………………………………………………………… 53 Section B: MARQUIS Intervention Components I. Introduction …………………………………………………………………………………………………………………………… 55 A. Measurement ……………………………………………………………………………………………………………………… 55 II. Component I: The MARQUIS Intervention Bundle: Intense vs. Standard ……………………………………………………… 56 A. Medication Reconciliation Forms ………………………………………………………………………………………………… 59 B. Measurement ……………………………………………………………………………………………………………………… 60 C. Risk Stratification …………………………………………………………………………………………………………………… 61 D. Provider Education: Guidelines for Taking a Best Possible Medication History ……………………………………………… 63 E. Discharge Counseling: Patient Education,Teach-Back and Guidelines for Educational Materials …………………………… 67 III. Component II: Improving Access to Pre-Admission Medication Sources ……………………………………………………… 70 A. Introduction ………………………………………………………………………………………………………………………… 70 B. Sources of Pre-Admission Medication Information ……………………………………………………………………………… 71 C. Patient-Owned Medication Lists ………………………………………………………………………………………………… 74 IV. Component III: Other High-Risk/High-Cost but Potentially High-Reward Interventions ……………………………………… 76 A. Improvements in Information Technology: Inpatient Electronic Medication Reconciliation Interventions …………………… 76 B. Social Marketing and Engagement of Community Resources ………………………………………………………………… 81 V. Conclusion …………………………………………………………………………………………………………………………… 83 Appendices I. Making the Business Case for Medication Reconciliation ………………………………………………………………………… 85 II. MARQUIS Application for Prospective Sites ………………………………………………………………………………………… 89 III. MARQUIS Site Assessment …………………………………………………………………………………………………………… 99 IV. Best Possible Medication History Simulation and Evaluation for Certification …………………………………………………… 112 V. MARQUIS Monthly Surveys to Site Leaders Regarding Medication Reconciliation Interventions ……………………………… 118 VI. Samples of Paper Medication Reconciliation Forms ……………………………………………………………………………… 139 VII. Examples of Patient-Friendly Discharge Material …………………………………………………………………………………… 144 VIII. Recommendations for Content of Patient-Owned Medication Lists ……………………………………………………………… 147 IX. Selected Vendors of Electronic Medication Reconciliation Products ……………………………………………………………… 152 X. Samples of Social Marketing Materials ……………………………………………………………………………………………… 154 XI. MARQUIS Task Checklist ……………………………………………………………………………………………………………… 161 XII. Pharmacy Training Materials ………………………………………………………………………………………………………… 162 XIII. Selected References …………………………………………………………………………………………………………………… 208 Addendum A. Community Engagement ……………………………………………………………………………………………………………… 211 B. Social Marketing for Patients and Providers ………………………………………………………………………………………… 214 A. Discharge Med Rec Counseling ……………………………………………………………………………………………………… 225 Introduction Unintentional medication discrepancies during transitions in care (such as hospitalization and subsequent discharge) are very common and represent a major threat to patient safety. One solution to this problem is medication reconciliation. In response to Joint Commission requirements, most hospitals have developed medication reconciliation processes, but some have been more successful than others, and there are reports of pro-forma compliance without substantial improvements in patient safety. There is now collective experience about effective approaches to medication reconciliation, but these have yet to be consolidated, evaluated rigorously and disseminated effectively. Our goal in this manual and its accompanying online resources is to compile the best practices around medication reconciliation efforts and provide enough detail so that each site can adapt these to its environment. The other goal is to explain the fundamentals of quality improvement and how they can be applied to medication reconciliation efforts. We have striven to build in flexibility, recognizing that each site will have a different starting