Effective medication reconciliation is a central element of ensuring patient safety during transitions of care. Given evidence that discrepancies on medication orders—ie, duplications, omissions, contraindications, unclear information, and changes—can affect patient outcomes, medication reconciliation is one of TJC’s National Patient Safety Goals. Nevertheless, medication discrepancies remain highly prevalent. Data indicate that up to 67% of inpatients have at least one error in their medication history at the time of admission.¹ Clearly, there is significant room for improvement in medication reconciliation efforts. 

In 2013, administrators at Novant Health Kernersville Medical Center (NHKMC), a 60-bed community hospital located in Kernersville, North Carolina, recognized a need to improve admission medication reconciliation. We are part of Novant Health Network, which consists of more than 1,100 physicians and 24,000 employees at more than 450 locations, including 14 medical centers, three hospitals, and hundreds of outpatient facilities and physician clinics. Since opening in 2011, the NHKMC has experienced census growth and increasing inpatient acuity. The rapid growth of the hospital prompted a reevaluation of our medication reconciliation process with a goal of utilizing lean methods to identify waste and areas of non-value. 

Our Prior Medication Reconciliation Process
Although medication reconciliation was completed for all admitted medical/surgical patients at NHKMC, ownership of various medication reconciliation tasks was unspecified and concern existed that some patient needs could go unnoticed and unchecked. Under the previous system, pharmacy technicians were notified to compile a patient medication list through a variety of triggers (ie, telephone, printed admission tickets, and pharmacy technicians monitoring the ED electronic information system). Once notified, the pharmacy technician would obtain a list of medications the patient was currently taking by consulting old medication lists, discussion with the patient’s pharmacies and provider, and face-to-face conversation with the patient and family. The pharmacy technician then created a best-guess medication list based upon information gleaned from these sources and entered the information into the electronic health record. 

A printed medication list was then provided to the pharmacist, who compared the medications the patient should be using—and was actually using—to the new medications that were ordered for the patient, and resolved any discrepancies. The pharmacist also assessed the medication list for operational concerns that might affect the patient (eg, non-formulary medications, strengths not carried in pharmacy). Then the medication list was placed in the patient’s chart for the attending physician to review and sign. Afterward, the document was scanned back to the pharmacy and entered into the pharmacy information system.  

A clear drawback to this approach was that there was no standardized method used to notify pharmacy technicians that they were needed to obtain medication lists. When notification was delayed, this often led to delays in completing the reconciliation. Moreover, the process for obtaining the medication list was haphazard; all available medication information sources were utilized, regardless of quality. In the absence of a standard procedure for medication reconciliation, the process had become inefficient, due in part to staff turnover and competing staff priorities. To improve collaboration among providers, pharmacy, and nursing, we chose to take a lean approach to optimize the process.

Exploring Lean Processes
We looked to the lean approach to achieve an efficient, streamlined, and sustainable workflow with less waste, reduced risk, and fewer mistakes. In the hospital setting, lean efforts are often leveraged to help multidisciplinary teams provide more efficient care, leading to improvements in patient safety, reductions in cost, and greater staff satisfaction. A 2012 report from the Institute of Medicine about the high cost of health care cited lean as a strategy that could improve both value and quality.2 Our scientific approach included data-driven decisions, thoughtful experiments, communication of results and action steps, and ongoing monitoring. 

To improve medication reconciliation, we utilized several lean tools, including a Kaizen event, a SIPOC (Supplier, Input, Process, Output, Customer) evaluation, the adoption of just-in-time processes when appropriate, a muda (the process of uncovering and eliminating waste), and PDSA (Plan, Do, Study, Act) cycles. All of these supported the ultimate goal of creating processes that provide value while simultaneously eliminating waste.

Conducting the Kaizen Event
At the core of the lean approach is conducting a Kaizen event in which individuals from across the organization convene to focus on a specific process, using data to identify areas in which improvements can be made and waste eliminated. The main goals of our Kaizen event were to increase efficiencies and reduce waste in our reconciliation process. 

The NHKMC Kaizen event took place in September 2013. Data collected before the Kaizen event showed that while approximately 60% of medication reconciliations were completed within six hours, 27% required 11 hours or more to finalize. This delay was identified as a major point of frustration and became the starting point for our discussions. Three goal statements for the process were established: 

• A good faith effort will be made to compile a medication list in a timely manner
• Pharmacy technicians are best trained to collect a patient’s home medication list and should be used in this role when possible
• Stakeholders must be accountable for their role in the medication reconciliation process

Utilizing the SIPOC Tool
To better understand the existing medication reconciliation process, we used a tool called SIPOC (Supplier, Input, Process, Output, and Customer), wherein steps in the medication reconciliation process are linked to suppliers/inputs and customers/outputs. After mapping the processes in use, the SIPOC analysis served as a springboard for identifying sources of variation and their influence on process outputs. Pharmacists, physicians, and nursing leadership formed three separate groups to identify their staff’s activities and note those that add value, establish ideal staff responsibilities, and determine how much time is spent on value-adding activities. The first step for each group was to create a process flow map, which we did using sticky notes (see Photo). Thereafter, additional detail and directionality was added to the flow map and decision points were defined. The analysis provided a global view of the process and identified who qualified as a customer. In addition, it revealed that our current process for medication reconciliation was highly variable and entailed multiple steps that added no value. 

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Eliminating Waste
A core principle of the lean approach is the elimination of waste, or muda—a Japanese term defined by Taiichi Ohno, the originator of the Toyota production system. Muda comprises waste in various areas: defects that necessitate rework, overproduction, wasted time, underutilizing staff, unnecessary movement of products and materials, excessive or insufficient inventory, unnecessary staff motion, and excessive work above and beyond what is required to satisfy the job requirements. Not only is reducing waste important financially, but it also has a significant impact on improving employee morale. Thus, reducing waste in our system became a central focus of the lean initiative.

The New Medication Reconciliation Process 
After thoroughly evaluating our old process, a new system was developed that dramatically improved workflow and eliminated waiting, interruptions, and delays. Three significant areas of inefficiency were identified during the NHKMC Kaizen event: 

Eliminating rework. Overproduction was identified in our medication reconciliation process when we realized that patient medication lists and home medications brought to the ED were not being added to the patient chart. As a result, this information was not transferred with the patient once they were admitted to the medical/surgical unit. This required significant duplication of effort on the part of pharmacy technicians, as these lists then had to be recreated. The wasted effort was significant, given that the majority of patients are admitted from the ED. To address this rework, the ED nurses were reeducated by nursing leadership about the value of the patient medication lists, which has improved the transfer of this information considerably. These efforts were particularly critical as the rework negatively impacted staff satisfaction.

Reducing wait time. We discovered that critical medications were sometimes inappropriately delayed while the medication reconciliation was being completed. To eliminate wait time, nurses now assess newly arrived patients’ need for critical medications for conditions such as hypertension or pain. These medications can now be ordered prior to the completion of medication reconciliation. Considerable emphasis was placed on this step in the process, which has significantly improved patient and provider satisfaction. In fact, our patient satisfaction scores related to pain management have increased dramatically since this change was made.

Implementing standardized, just-in-time admission notices. SIPOC mapping helped us to determine that the process for notifying technicians of an admission were highly variable, including telephone calls and printed admission tickets, as well as the technicians themselves monitoring the ED electronic information system. This lack of standardization was a challenge to completing reconciliation in a timely manner. 

In addition, for 60% of patients, technicians were notified of admission after 4:00pm. At that time of the day, collecting medication information from provider offices, pharmacies, and family members was a challenge, and technicians’ efforts were often expended to no avail. Implementing standardized, just-in-time admission notices has led to earlier notification, which has made it easier for technicians to collect medication information. 

The standardized admission notice is printed in the pharmacy near the technician workstation, and triggers the pharmacy technician to begin the medication reconciliation. The medication reconciliation process is initiated upon admission to avoid any unnecessary efforts (eg, beginning the process on ED patients who will not be admitted) as well as needless waiting time (eg, delaying the medication reconciliation for hours after admission). Staff in the patient access and registration departments received training on the medication reconciliation process so that they understood the importance of timely notification. 

Once notified, the pharmacy technician obtains information about the patient’s current medications by reviewing old medication lists and patient home medications, contacting the patient’s pharmacies and providers, and interviewing the patient and family. To ensure the most appropriate sources of information are used, the multidisciplinary team developed guidelines to determine when the use of a single source for the medication list is appropriate.

• Appropriate: nursing home medication list, patient home medication list, electronic health record verified within 30 days, high cognitively functioning patient 
• Inappropriate: family member, retail pharmacy, low cognitively functioning patient 

Using the information gathered, the pharmacy technician then creates a best guess medication list and enters the information into the electronic health record. A printed medication list is given to the pharmacist, who compares it with the admission medication orders and resolves any discrepancies. At this time, the pharmacist also assesses operational issues such as non-formulary medications or strengths that are not carried in the pharmacy. The medication list, along with documentation of any discrepancies or issues, is placed in the patient’s chart for the attending physician to review and sign. After the physician has reviewed it, the document is scanned back to the pharmacy and the pharmacy technician enters it into the pharmacy information system. 

Refining Procedures 
After the Kaizen event, stakeholders were educated on the changes to the medication reconciliation process, their new roles, and the implementation plan. Departmental leaders educated staff, and just-in-time education, focusing on owning individual responsibilities, was provided to address any challenges encountered. Staff was encouraged to provide feedback on the new process to members of the multidisciplinary team. 

Since implementing the new medication reconciliation process, PDSA (Plan, Do, Study, Act) cycles have been used to address bottlenecks and other challenges identified by staff. For example, we discovered the need for a systematic way to communicate to the attending physicians that the pharmacists had finished reviewing a medication list. Therefore, a plan was developed and implemented to notify the physician once the medication reconciliation is ready to be signed. Also, during interdisciplinary rounds, the pharmacists and providers ensure that all medication reconciliation orders have been reviewed and signed. 

Results 
Data analysis showed that within six months of the Kaizen event, the time to complete medication reconciliations decreased considerably (see Table 1). Today, 85% of the medication reconciliations are completed within six hours, and only 5% take longer than 10 hours. The results show the effect of standardizing the medication reconciliation process, placing individuals in roles where they provide higher value, and holding individuals accountable. Our team continues to look for opportunities to improve the process for medication reconciliation. Given the success of this effort, the lean methodology may be used to redesign other processes at NHKMC.



References

1. Tam VC, Knowles SR, Cornish PL, et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173(5):510-515.
2. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx. Released September 6, 2012. Accessed April 9, 2014.

Sonia Tadjalli, PharmD, is a PGY1 pharmacy administration resident at Novant Health Forsyth Medical Center, a 921-bed community hospital located in Winston-Salem, North Carolina. She received her doctorate of pharmacy, with a concentration in management, from Belmont University College of Pharmacy in Nashville, Tennessee. Sonia will be continuing her post-graduate training in pharmacy administration as a PGY2 health-system pharmacy administration resident with Novant Health. She is an active member of ASHP and the American Pharmacists Association.

Jeffrey S. Reichard, PharmD, MS, BCPS, is the pharmacy manager at Novant Health Kernersville Medical Center, a 60-bed community hospital located in Kernersville, North Carolina. He received his doctorate of pharmacy from the University of North Carolina at Chapel Hill Eshelman School of Pharmacy. Upon graduation, Jeffrey completed a combined residency and MS degree in health-systems pharmacy administration at the University of North Carolina Hospitals. He is an active member of ASHP and the North Carolina Association of Pharmacists.