Applying DMAIC Methodology to

Medication Reconciliation

Prepared For

[Date]

By
 Process Improvement Methodology (DMAIC)
DMAIC Provides An Easily Managed Systematic Process To Deliver Measurable
Results and Accelerate Change

Define Measure Analyze Improve Control

Who are the customers and What are the most How do we ensure that
what is the problem from important drivers of poor we sustain the improved
their perspective? performance? performance?

How is the process How do we remove the

performing today and how drivers of poor
is it measured? performance?
 Improvement Teams
Proper Team Establishment Increases Probability For Success

Project Executive Sponsor

Clinical / Academic Sponsor

Project Sponsor
(As Required)

Improvement Leader Process Owner

Improvement Team
 Defining Problem: Analysis of Root Causes
Medication Order,
Dispense, Educate,
History, Transcribe, Administer Monitor
Deliver Discharge
Reconcile Clarify

Identified failure modes (FMEA) Identified root causes

• Incomplete and/or incorrect
medication orders on admission
• Inadequate or missing information
on the patient's admission profile
• No formalized approach/process to
obtaining and documenting a
medication history
D M A I C
• Incomplete/inaccurate medication history
(omission, different dose, route or frequency,
look alike-sound alike)
 Patient’s ability to recall, especially upon
admission
 Time constraints
 Interview skills of clinician
• Multiple locations to document (free text)
• Pharmacist not formally integrated in process
Defining Problem: Challenges to Obtaining Medication Histories

• Patient’s and/or surrogate’s ability to recall medications, doses and/or frequency of use
• Stress of transitioning through the healthcare system
• Health literacy
• Language barriers; cultural beliefs
• Relationship with healthcare clinician obtaining history
• Interview skills of clinician
• Time constraints
• Accuracy and completeness of medication histories obtained from other resources;
accessibility

D M A I C
 Medication History / Reconciliation: Pilot Results
Direct Admits to Med/Surg Units*
(N=204)
• 54% of patients had at least one medication discrepancy
• 42% of the discrepancies requiring intervention was complete
omission of a medication
• 35% of the discrepancies requiring intervention was a different
dosage, route or frequency with what the patient reported taking
before admission
• Of the discrepancies requiring clarification, in the absence of a
pharmacist intervention, 22% may have resulted in patient harm
during hospitalization and 59% may have resulted in patient harm
if continued beyond discharge

* Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C and Noskin GA.
D M A I C Reconciliation of Discrepancies in Medication Histories and Admission Orders of Newly
Hospitalized Patients. Am J Health-Syst Pharm. 2004; 61:1689-95
 Medication History / Reconciliation:
Most Effective Interventions
Medication Order,
Dispense, Educate,
History, Transcribe, Administer Monitor
Deliver Discharge
Reconcile Clarify

• Single source of truth: Medication list with technology support

• Reconciliation process with technology support
• I/T design and continuous monitoring
– Compliance, sustainability of new process
– Identify rate, etiology and potential harm of medication discrepancies for
process improvements
• Active patient involvement
• Active pharmacist involvement

D M A I C
 MATCH Improvement Initiatives
Implement a system that achieves the below:

• Increase accuracy and completeness of medication history

– Create “one source of truth”
– Complete medication description (drug name, dose, route or frequency – no free text)

• Reconcile home medications with patient and/or family

• Reconcile all medications (home and current medication orders) at admission, transfer
and discharge
– Multi-disciplinary approach with physicians, nurses and pharmacists

D M A I C
 Approaches to Evaluate
Medication Reconciliation Process

• Determining compliance rates

• Type and etiology of medication discrepancies requiring
interventions
• Medications / medication classes involved in discrepancies
requiring interventions
• Potential harm averted through intervention
• Retrospective v/s prospective review
Questions and Discussion