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Assembling a Design Team and Developing a Medication Reconciliation Charter

This section provides information and tools on how to assemble a design team and develop a charter, or work plan, for designing a new or redesigning an existing medication reconciliation process.

A. Determining and Assembling a Design Team

Your organization may already have a quality improvement methodology in place to provide the framework for designing or redesigning a medication reconciliation process. If not, you may consider using the DMAIC methodology (Define, Measure, Analyze, Improve and Control).

If you've been appointed as the medication reconciliation improvement leader at your organization, your first step will be to assemble your design team. To begin, you should conduct a "stakeholders analysis" to identify key people that will be affected by your project. These individuals can range from hospital leadership to front-line staff to patients. You should list each stakeholder's role, impact and interest in your project. This exercise will help you identify:

  • Members for your medication reconciliation leadership team
  • Members for your design team or work group
  • Individuals requiring consistent communication and feedback throughout the entire project
  • Individuals who may require periodic communication and progress reports

The make-up of your Medication Reconciliation Leadership Team and DMAIC Design Team members, including roles and responsibilities, could look something like this:

A1. Medication Reconciliation Leadership Team

Executive Sponsor(s):

  • Member(s) of your senior management team (ex. physician leaders in your organization)
  • Provide executive oversight
  • Provide guidance and accountability and endorse recommendations
  • Identify and remove organizational barriers
  • May represent inpatient and/or outpatient practice settings depending on the project's scope. Representation from both settings may help bridge the gap during transitions from hospital to home.

Project Sponsor(s):

  • Leader(s) from various disciplines such as the Pharmacy director, Nursing director, a Hospitalist, the Chief of Surgery, Director of Information Systems, Chair of your Pharmacy and Therapeutics Committee, etc.
  • Provide support for a timely and successful implementation
  • Provide insights from the perspective of the practices they represent
  • Remove discipline-specific barriers
  • Approve final recommendations

Improvement Leader(s):

  • Possess operational and quality improvement expertise as well as patient safety and medication management knowledge to lead medication reconciliation efforts
  • Ensure project goals and training are met within established timeframes
  • Help integrate operational changes into clinical workflow

A2. Medication Reconciliation Design Team

Multidisciplinary team members:

  • May include physicians, nurses, pharmacists, discharge planners, and representatives from Information Systems, the Emergency Department, Patient Safety and Quality departments
  • Should involve a patient(s), if possible, to ensure the design is approached from the patient's perspective
  • Have a strong knowledge of current workflow, recognition of the problem, and buy-in for improvement

The design team's make-up may evolve over time as you work through the process and determine additional resource requirements. Below are questions that may be helpful for developing your design team.

Questions to Ask When Developing your Design Team (PDF format)

A3. Additional Stakeholders

Your stakeholder analysis will also identify others who have an interest in your medication reconciliation project and should be engaged early on. Other stakeholders may include:

  • Managers or directors that oversee front-line staff to ensure final design is carried out
  • Department chiefs, chairs and clinical program leaders overseeing physician participation in the design and implementation
  • Leaders from medical records to ensure forms and documentation are consistent with hospital policies
  • Individuals overseeing quality, licensure and accreditation to ensure the process meets regulatory requirements
  • Front-line staff, quality committees, patients, etc. that may require periodic communication and progress reports in preparation for implementation

A reporting mechanism should be established to keep stakeholders informed on the team's progress. It will be easier to understand barriers from their perspectives early on and work to develop solutions, than it will be much later during roll-out and implementation.

B. Developing Your Charter

Your team should develop a medication reconciliation charter, which provides a work plan for your design team. Your charter will be a dynamic document as you define your process, develop your metrics and strategize resources.

The elements of your charter should consist of:

  • Roles and responsibilities for team members
  • Scope of the project
  • Goals and objectives
  • Measurable goals specific to the design process
  • Achievements throughout the project (i.e., milestones)
  • Timeline

Below is a sample DMAIC charter that can be utilized for designing your medication reconciliation process.

Sample DMAIC Charter (PPT format)

B1. Regulatory Requirement Considerations

While developing your medication reconciliation charter, The Joint Commission's National Patient Safety Goal (NPSG) #81,2, "accurately and completely reconcile medications across the continuum of care," and other pertinent local laws and/or regulatory requirements must be considered. You will want to ensure that:

  • Process design meets these requirements
  • Practice settings affected are included in your design plans
  • Individuals responsible for accreditation and licensure in your organization are integrated into your team

B2. Building Your Charter - Determining the Scope, Goals, and Objectives

Based on The Joint Commission's NPSG #8, patients seen within accredited practice settings receiving medications require medication reconciliation.1,2 Before determining the scope of your project, you may find it helpful to create a list of all areas within your facility where patients receive medications. Creating a list of practice settings that administer medications and organizing by the type of patients they serve (inpatients, outpatients, both) and whether they admit and/or discharge patients may assist in prioritization. The template below can help you create your list.

Determining the Scope of your Medication Reconciliation Project: Identifying Areas in your Organization that Administer Medications (PDF format)

Below are additional questions to consider when determining the scope of your medication reconciliation project.

Questions to Consider for Determining the Scope of your Medication Reconciliation Project (PDF format)

If you have not done so already, it may be helpful to create a flow chart of your current process. A flowchart serves as a guide for developing your charter. In addition, it may help you determine if you need to design a new process, or if you should redesign your existing medication reconciliation process.

A flowchart outlines current workflow and helps identify:

  • Successful medication reconciliation practices
  • Current roles and responsibilities for each discipline at admission, transfer and discharge
  • Potential failure modes
  • Unnecessary redundancies and existing gaps

A flowchart of current practices can be modified during the design or redesign to highlight:

  • Elimination of unnecessary steps (i.e., simplification of process)
  • Standardization across disciplines and/or practice settings
  • How new design steps integrate into existing workflow

Below is an outline to help you build a flow diagram for medication reconciliation.

Building a Medication Reconciliation Flowchart Diagram (PDF format)

For example, by creating a flowchart of current practices at our organization, the following was identified:

  • Multiple disciplines obtained independent medication histories from the patient
  • Each independent medication history was documented in various discipline-dependent sections throughout the medical record
  • No prompts were in place to cross-reference information or documentation
  • Multiple medication histories were often conflicting3

As an example, below are high-level overviews of our organization's flowchart for admission and discharge prior to our redesign.

Admission Medication Reconciliation Process BEFORE Redesign (PDF format)

Discharge Medication Reconciliation Process BEFORE Redesign (PDF format)

Based on these findings, an example of a design charter is provided below.

Medication Reconciliation Project Example: Initial Design DMAIC Charter (PPT format)

Lessons Learned

  • Medication reconciliation involves all patients who receive medications, multiple disciplines, and numerous practice settings. Therefore, a project of this magnitude may require more than just an organizational endorsement. It requires a sustained organizational commitment of resources, time, and personnel.
  • A leadership team with continual involvement, focus, and commitment is integral to the success of a medication reconciliation project.
  • The leadership team's mission should be to weave medication reconciliation into culture and practices for safe medication management.
  • A multidisciplinary design team, including patient involvement, ensures the design is approached from diverse perspectives and practice settings.
  • It is important to obtain insights from areas utilizing a paper process or both (i.e., paper and electronic formats) when designing your process.
  • Gaining an understanding of your technology's infrastructure is critical for areas utilizing an electronic medical record (EMR).

References:
1. The Joint Commission: 2007 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: Joint Commission Resources, 2007, p. NPSG-6-7
2. Frequently Asked Questions for The Joint Commission 2007 National Patient Safety Goals: Questions about Goal 8 (Reconcile Medications) (PDF). Accessed June 10, 2007.
3. Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C and Noskin GA. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health-Syst Pharm. 2004; 61:1689-1695.


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