MARQUIS IMPLEMENTATION MANUAL

1 1 MARQUIS IMPLEMENTATION ManualMARQUIS IMPLEMENTATION MANUALT able Of ContentsIntroduction 3 Contributors 4 Section A: Setting the MARQUIS Team Up for Success 5I. First Steps 51. Overview of MARQUIS (Multi-Center Medication Reconciliation Quality Improvement Study) 52. Pre- IMPLEMENTATION Actions 53. Clarifying Key Stakeholders 64. Obtaining Support and Approval from the Institution 75. Summary 8II. Medication Reconciliation: Definition 9 III. Medication Reconciliation: Process 10 Step 1: Take a Best Possible Medication History (BPMH) to create the Preadmission Medication List (PAML). Record the PAML in the patient s chart. 11 Step 2: Write admission medication orders. 14 Step 3: Compare the PAML with admission orders, identify and correct any unintentional discrepancies in admission orders.

2 14 Step 4: If applicable, write transfer medication orders, using the PAML and current inpatient (pre-transfer) medications as a guide. 15 Step 5: Compare PAML medications, pre-transfer medications and transfer medications, identify and correct any unintentional discrepancies in transfer orders. 16 Step 6: Write the Discharge Medication List (DML) using the PAML and current inpatient medications as a guide. Document the DML. 16 Step 7: Compare PAML, current inpatient medications and the DML. Identify and correct any unintentional discrepancies in the DML. 17 Step 8: Review the DML with patient. Highlight and explain stopped, changed or new medications compared with the PAML and the reasons for those changes. 18 Step 9: Forward a second copy of the DML to post-discharge providers.

3 Explain stopped, changed or new medications compared with the PAML and reasons for those changes. 19IV. Medication Reconciliation: Brief Literature Review 20V. Assembling the Team and Developing a Strategy 241. Identify Team Members 242. Establish Team Rules and Guidelines 273. Set General Goals 294. Map Your Current Medication Reconciliation Process 315. Identify Your Measurement Strategy 356. Turn General Goals into Specific Goals 387. Follow a Framework for Improvement 398. Complete MARQUIS Site Assessment 402 Section B: MARQUIS Intervention Components 41I. Assigning Roles and Responsibilities to Clinical Personnel 41II. Improving Access To Preadmission Medication Sources 43 III. Patient-Owned Medication Lists 47IV.

4 Provider Education: Guidelines for Taking a Best Possible Medication History 49V. Discharge Counseling: Patient Education and Teach Back Guidelines For Educational Materials 52VI. Risk Stratification 55 VII. Intervention Components: Intense vs. Standard 58 VIII. Improvements In Information Technology: Inpatient Electronic Medication Reconciliation Applications 63IX. Phased IMPLEMENTATION 66X. Social Marketing and Engagement of Community Resources 68 Appendices1. Making the Business Case for Medication Reconciliation 712. MARQUIS Site Assessment 773. Best Possible Medication History Toolkit 934. Examples of Patient-Friendly Discharge Materials 1015. Recommendations for Content of Patient-Owned Medication Lists 105a.

5 Sample Paper Form 106b. Electronic Patient-Owned Medication Lists (with Vendors) 1086. Sample of Paper Medication Reconciliation Forms 1137. Selected Vendors of Electronic Medication Reconciliation Products 1198. Samples of Social Marketing Materials 1239. Selected References 1333 MARQUIS IMPLEMENTATION ManualIntroductionUnintentional 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.

6 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 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 point and individual strengths and weaknesses. I would like to thank all those who contributed to the development of this MANUAL . The MARQUIS team comprises an incredible group of clinicians, support staff and advisors whose tireless dedication to this project has made this MANUAL a reality.

7 We hope this collection of best practices will assist you in your efforts to improve your medication reconciliation process, and help keep your patients safe throughout all their transitions in L. Schnipper, MD, MPH, FHM Principal Investigator, MARQUIS4 ContributorsJeffrey L. Schnipper, MD, MPH, FHM Director of Clinical Research, BWH Hospitalist Service, Associate Physician, Division of General Medicine, Brigham and Women s Hospital, Assistant Professor of Medicine, Harvard Medical School, Boston, MA. MARQUIS Principal InvestigatorPeter B. Angood, MD, FRCS(C), FACS, FCCM Senior Advisor on Patient Safety, National Quality Forum, Washington, DC. MARQUIS Steering Committee MemberAndrew Auerbach, MD, MPH Associate Professor of Medicine in Residence, UCSF Division of Hospital Medicine, San Francisco, CA.

8 MARQUIS Site LeadDaniel Cobaugh, PharmD, FAACT, DABAT Vice President, ASHP Research and Education Foundation, Bethesda, MD. MARQUIS Steering Committee MemberEd Etchells, MD, MSc, FRCP(C) Associate Director, University of Toronto Centre for Patient Safety, Medical Director, Information Services and Staff Physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Associate Professor of Medicine, University of Toronto, Toronto, ON. MARQUIS Steering Committee MemberJeffrey Greenwald, MD, SFHM Inpatient Clinician Educator Service, Department of Medicine, Massachusetts General Hospital and Associate Professor of Medicine, Harvard Medical School, Co-Investigator Project RED and Project BOOST, Boston, MA. Chair, MARQUIS Steering Committee Lakshmi Halasyamani, MD, SFHM Vice President, Quality and Systems Improvement, St.

9 Joseph Mercy Health System, Ann Arbor, MI. MARQUIS Steering Committee MemberDave Hanson, MSN, RN, CCRN, CNS Past President AACN, Professional Development & Nursing Excellence, Northwest Community Hospital, Arlington Heights, IL. MARQUIS Steering Committee MemberPeter Kaboli, MD, FHM Director, Midwest Rural Health Resource Center, VA Office of Rural Health, Iowa City VA Medical Center, Iowa City, IA. MARQUIS Co-InvestigatorSunil Kripalani, MD, MSc, SFHM Associate Professor, Chief, Section of Hospital Medicine, Associate Director, Effective Health Communication Program, Emphasis Program Area Director, Healthcare and Public Health Research and Management, Vanderbilt University Medical Center, Nashville, TN. MARQUIS Co-Investigator Taylor M. Griffith, BS Project Coordinator, Center for Hospital Innovation and Improvement, Society of Hospital Medicine, Philadelphia, PA.

10 MARQUIS Project CoordinatorJacquelyn A. Minahan, BA Research Assistant, Brigham and Women s Hospital, Boston, MA. MARQUIS Research AssistantStephanie Mueller, MD General Medicine Fellow, Division of General Medicine, Brigham and Women s Hospital, Boston, MA. MARQUIS Co-InvestigatorNyryan V. Nolido, MA Research Project Manager, Brigham and Women s Hospital, Boston, MA. MARQUIS Data Project ManagerJoAnne Resnic, MBA, BSN, RN Senior Manager, Center for Hospital Innovation and Improvement, Society of Hospital Medicine, Philadelphia, PA. MARQUIS Project ManagerAmanda Salanitro, MD, MSPH Assistant Professor, Instructor, Geriatric Research, Education and Clinical Center, Tennessee Valley VA Healthcare System and Section of Medicine at Vanderbilt University, Nashville, TN.