Quality Improvement & Patient Safety Projects – 2007

For more information on these projects as they relate to Grace Cottage Hospital practices and patients, please contact
Effie Chamberlin,
Director of Compliance, Quality Improvement and Risk Management
(802) 365-7357 voice (802) 365-9500 fax
ec@otishealthcarecenter.org e-mail
PO Box 216, Townshend VT 05353

Anticoagulation Therapy Program

Project Description:
The Anticoagulation Therapy Program at Grace Cottage, initiated during the summer of 2004, is a comprehensive approach to counseling and monitoring patients receiving oral anticoagulation therapy.

Problem:
The growing aging population – nationally and locally – has created a larger number of patients taking narrow-range medications. These medications, such as Warfarin (coumadin), when taken incorrectly, can have adverse effects that are serious and life threatening.

Project goals:

• Improve anticoagulation control
• Reduce number of blood tests required to maintain good control
• Improve patient safety
• Improve efficiency in the use of physician/nurse/staff time
• Improve efficiency in the use of resources
• Improve drug use
• Provide patients with ongoing education regarding medications

Intervention process:

• Primary care provider enrolls the patient in the Grace Cottage Anticoagulation Therapy program
• Clinical pharmacist counsels the patient regarding dietary restrictions, drug-drug interactions, and activity precautions
• Clinical pharmacist reviews the blood test results with the patient to ensure that an appropriate therapeutic range is maintained; makes dosage changes if appropriate; follows up with the patient’s primary care provider
• Patient is encouraged to contact the clinical pharmacist whenever starting a new medication to lessen the chances of an adverse drug interaction

Evaluation:

1. Pharmacists’ time and physicians’ time regarding anticoagulation therapy will be tracked.
   Pharmacists’ time dedicated over the past year amounted to 740 hours.
   Physicians’ time dedicated over the past year amounted to 370 hours.
2. The number of blood tests per patient regarding anticoagulation therapy will also be tracked.
   The total number of blood tests over the last year was 1,478.
3. Dosing errors will be tracked and individual patients will be counseled.
   A dosing error is a missed dose, usually caused by patient confusion about the medication regimen. The pharmacist monitored for missed doses and added incidents to patient records, which helped patients to be more attentive with their medication.
4. Patient self-care skills and knowledge and satisfaction with the program will be measured by survey.
   Patients’ responses to an oral survey uniformly indicated satisfaction with the program and increased confidence with knowledge and self-care skills.
5. Increase community use of the program and clinical pharmacist
   There are now more than 50 new patients working with the clinical pharmacist.
   10 newly-diagnosed patients, plus seasonal residents, are taking advantage of this program.

Computerized Point-of-Care

Project Description:
This project, initiated in the spring of 2004, encompasses the purchase, installation, and implementation of the Point-of-Care computer program, a module of the computerized Hospital Information and Patient Care system currently being used by Grace Cottage Hospital. Point-of-Care allows nurses to enter patient data at bedside, which automates medical information records, thereby eliminating duplicate entry of information, and reducing the risk of medication errors.

Problem:
Entering patient data by hand is inefficient. Time that could better be used for direct patient care is spent on written and duplicate documentation.

Project goals:

• Increase efficiency of nursing staff, pharmacists, and physicians
• Improve patient safety by reducing care plan and/or medication errors
• Improve quality of care/service for patient as a result of greater work efficiency (i.e. more time spent on direct care)

Intervention process:

• Install Point-of-Care software system and related hardware; provide initial training, follow-up and on-going support to nursing staff (completed July 2004)
• Utilize system for 12 months for evaluation regarding patient care and staff performance

Evaluation:
In 2006 Grace Cottage Hospital completed the implementation of the Point of Care system for the initial components that were purchased. Following the implementation, the staff identified related components that needed to be purchased to complete the process. Staff recommended purchase of an automated medication system called PYXIS, which would be better able to define and quantify medication errors and, through improved medication administration, increase efficiency and patient safety. Another component identified by staff was a software system, Profile, which allows the CPSI-based Point of Care system to interface with PYXIS. Hospital staff continued to evaluate the Point of Care computerized records system as it impacted staff efficiency, effectiveness and direct time with patients, and came to realize that the system needed to be updated and that an official training/evaluation visit by CPSI professionals needs to be scheduled for the first or second quarter of 2007.

Medication Reconciliation

Project Description:
In June 2005, Grace Cottage Hospital began participating in the Institute for Healthcare Improvement’s “100,000 Lives” nationwide campaign. This medication reconciliation campaign encourages the use of computerized software in the in-patient and out-patient setting, and the use of a wallet-sized medication card to be carried by the patient. A registry of current medications for all patients arriving for in-patient or out-patient care will be developed at Grace Cottage Hospital. Wallet-sized medication cards are being given to patients to carry with them, so that their medication records are available and accurate.

Problem:
Studies reveal that over half of all hospital medication errors occur at specific interfaces of care, particularly when patients first arrive at the hospital, when patients are transferred from one hospital to another hospital, when patients are transferred from one level of care to another level of care within the same hospital, and when patients are discharged. Without written or computerized medication records, patients frequently do not remember the name of a medication, reporting to medical staff only that they are taking “a green pill”.

Project goals:
Prevent adverse drug events by

• providing all patients with a wallet-sized medication card
• ensuring that the card will list all current medications
• providing a specific section of the card in which to include over-the-counter purchased items such as vitamins and herbal medications, which could prevent many omissions and reactions
• developing an accurate system for the transfer of medication information at all transition
  points
• reconciling all medications that patients were taking prior to hospital admission with current medications ordered

Intervention process:
The information on these cards and in the hospital’s computerized records is then reconciled with medications ordered while in the hospital to be sure that the patient’s medication history is fully assessed. Patient participation in the medication reconciliation project is vital, as everyone should know what medications they are taking and why. Wallet-sized cards are provided to all patients upon discharge, if requested, if the patient has a major medication change or if the patient cannot state clearly an understanding of their medication. The distribution of Medication Reconciliation cards is not mandatory.

Evaluation:
During 2007:

• chart audits will be conducted to confirm that the medication reconciliation record is completed upon the patient’s admission and if and when there is a change in patient’s status.
• Patients & staff will ensure that all appropriate medication records are available and current.
• Staff & patients will determine that the information is reviewed at all interfaces.
• By conducting chart audits, staff will confirm that the reconciliation record is completed for 75% of all patients.

CONTINUOUS QUALITY IMPROVEMENT

Project Description:
Grace Cottage Hospital is in the process of establishing four Continuous Quality Improvement (CQI) workgroups that will focus on Patient Registration, Medication Process, Care Plans, and Emergency Room Documentation. Each team will use a similar process involving an in-house facilitator to guide the use of the Strategies and Methods of CQI process.

Problem:
Patient Registration issues involve maintaining the HIPAA standards regarding privacy and confidentiality. The medication process currently shows communication problems between the hospital’s computer programs and the person using them. Patient personalized care plans are not always developed in a timely manner. Emergency Room documentation is inconsistent and sometimes incomplete.

Project Goals:

• Make Patient Registration more customer-friendly, accessible and private
• Maximize the effectiveness of the use of PYXIS and CPSI in medication administration
• Provide each patient with a personalized care plan within twenty-four hours of admission
• Document Emergency Room process 100% completely and consistently

Intervention process:

1. The Patient Registration process and physical space will be evaluated and reconfigured
2. The Medication Process for accomplishing medication reconciliation and recording of allergies will be consistently applied 24/7
3. The flow of the current care plan development process will be charted and evaluated.
4. The Emergency Room documentation process will be flow charted to identify areas for improvement

Evaluation:

1. Patient Registration section of satisfaction surveys, such as Press Ganey, will fall within the 95th percentile ranking
2. Medication process will be error free
3. Care Plans will be reviewed weekly and summary reports indicating the percentage completed will be provided to the Director of Nursing
4. Emergency Room Documentation will be complete and accurate according to monthly internal review and scoring on the ER audit form and audited records will be 100% complete