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IHI ExpeditionExpedition: Improving Medication Safety from the Patient’s Perspective

Session 1: Improving Polypharmacy

February 26, 2015

These presenters have

nothing to disclose

E. Robert Feroli Jr., PharmD, FASHPAmanda Brummel, PharmD, BCACPFrank Federico, RPhJoelle Baehrend

Today’s Host2

Dorian Burks, Project Coordinator, Institute for

Healthcare Improvement, is a current coordinator for

web-based Expeditions. He also contributes to the IHI

work in the Triple Aim and Improvement Capability

focus areas, as well as the Leading Quality

Improvement series. Dorian is a member of the

Diversity and Inclusion Council at IHI, where he and

fellow staff members develop strategies to enhance

IHI’s inclusive culture, both internally and externally.

Dorian graduated from Massachusetts Institute of

Technology in Cambridge, MA where he received his

Bachelor of Science degree in Biology and humanities

concentration in Anthropology.

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What is an Expedition?

ex•pe•di•tion (noun)

1. an excursion, journey, or voyage made for some specific

purpose

2. the group of persons engaged in such an activity

3. promptness or speed in accomplishing something

Expedition Director

Joelle Baehrend, Fellowship Director, IHI, is also a

developer for IHI’s Patient Safety Focus Area. She was

previously a project manager for the 100,000 Lives

Campaign and platform lead for the 5 Million Lives

Campaign. Baehrend’s other work at IHI has included

participation on IHI’s business team, product

development, including the satellite broadcast of IHI’s

National Forum on Quality Improvement in Health Care,

as well as project management for the Improving Flow

Through Acute Care Settings IMPACT Community.

Baehrend received a Master of Arts in English literature

from Indiana University of Pennsylvania in 1996 and

served as adjunct faculty at Massasoit Community

College before joining IHI in 2000.

11

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12

What is your goal for participating

in this Expedition?

Please send your message to All Participants

Today’s Agenda13

Ground Rules & Introductions

Pre- Survey Debrief

Improving Polypharmacy

Action Period Assignment

IHI’s Model for Improvement

Ground Rules14

We learn from one another – “All teach, all learn”

Why reinvent the wheel? - Steal shamelessly

This is a transparent learning environment

All ideas/feedback are welcome and encouraged!

Expedition Objectives

At the conclusion of this Expedition, participants

will be able to:

Explain the importance of including patients and their

families in efforts to improve medication safety

Identify different approaches to improve medication

safety

Describe examples of medication safety improvement

efforts at other organizations

Plan tests of change to begin or continue medication

safety improvement

15

Schedule of Calls

Session 1 – Improving Polypharmacy

Date: Thursday, February 26, 1:00 – 2:30 PM Eastern Time

Session 2 – Health Literacy and Medication Safety

Date: Thursday, March 12, 1:00 – 2:00 PM Eastern Time

Session 3 – Improving Medication Adherence

Date: Thursday, March 26, 1:00 – 2:00 PM Eastern Time

Session 4 – Medication Reconciliation

Date: Thursday, April 9, 1:00 – 2:00 PM Eastern Time

Session 5 – Safe Management of Newly Released Anticoagulants and High-Alert

Medications

Date: Thursday, April 23, 1:00 – 2:00 PM Eastern Time

16

Pre-Work Assignment & Survey Results

• Complete the IHI Open School Course QI 102: The

Model For Improvement: Your Engine for Change

• Complete the Expedition: Improving Medication

Safety from the Patient’s Perspective Pre- Survey

17

Survey Results - Themes

Top three barriers to improving medication safety:

• Staff resources

• Medication reconciliation (at transitions in levels of care;

resolving discrepancies; identifying the most reliable list)

• Cultural challenges; resistance to change

Top two barriers to engaging patients in this work:

• Patient education and health literacy

• Time

18

Survey Results - Themes

Points of pride in improving medication safety:

• Medication reconciliation form in patients’ admin records

• Unit based pharmacists

• Technology – computerized medication systems, smart pumps CPOE, barcoding

• Color coding for high risk medications

What are you hoping to learn in this Expedition?:

• General improvement ideas

• More reliable processes for medication reconciliation

• Ways to engage patients in improving medication safety

• Learn from others doing this work

19

Survey Results - Current State

My hospital has a process to address medication

management and reduce polypharmacy where appropriate.

• Do not know current status of this practice: 5%

• Do not currently have this practice in place: 11%

• Have a process that supports this practice: 47%

• Process is reliably applied: 11%

• Need further clarification on this practice: 26%

20

Faculty21

Frank Federico, RPh, Executive Director, Strategic Partners,

Institute for Healthcare Improvement (IHI), works in the areas of patient safety, application of reliability principles in health care,

preventing surgical complications, and improving perinatal care. He is faculty for the IHI Patient Safety Executive Training Program and co-chaired a number of Patient Safety

Collaboratives. Prior to joining IHI, Mr. Federico was the Program Director of the Office Practice Evaluation Program and a Loss Prevention/Patient Safety Specialist at Risk Management

Foundation of the Harvard Affiliated Institutions, and Director of Pharmacy at Children's Hospital, Boston. He has authored numerous patient safety articles, co-authored a book chapter in

Achieving Safe and Reliable Healthcare: Strategies and Solutions, and is an Executive Producer of "First, Do No Harm, Part 2: Taking the Lead." Mr. Federico serves as Vice Chair of the

National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP). He coaches teams and lectures extensively, nationally and internationally, on patient safety.

Improving PolypharmacyE. Robert Feroli and Amanda Brummel

22

Faculty23

E. Robert (Bob) Feroli Jr., PharmD, FASHP has been a

pharmacist at Johns Hopkins Hospital for 36 years and has

served as a Medication Safety Officer for the past 11 years.

He established a Medication Use Safety Pharmacy

Residency (accredited by ASHP). Dr. Feroli teaches on topics

of safe medication use practices and rational therapeutics,

and has faculty appointments at the Johns Hopkins University

Schools of Medicine and Nursing, and the University Of

Maryland School Of Pharmacy. Dr. Feroli also participates in

error prevention efforts, investigations of errors, and serves

as chairman of the Medication Error Reduction

Implementation Team (MERIT). He also works with 12

international hospitals that have formed affiliations with Johns

Hopkins on using the medication use system to improve

safety, efficiency, therapeutic appropriateness, and

compliance with Joint Commission International (JCI)

standards.

Faculty24

Amanda Brummel, PharmD, BCACP serves as the Director of

Clinical Ambulatory Pharmacy Services. Dr. Brummel has been

employed by Fairview Pharmacy Services since 1999 when she

graduated from the University of Minnesota. While at Fairview, she

has built and practiced Medication Therapy Management (MTM) in

multiple clinic locations, was the clinical supervisor for the MTM

department, the MTM Operations & Program Manager. Currently Dr.

Brummel has responsibility for the MTM program, the clinical

development and integration of pharmacy services in the Fairview

Health Network including our transitions of care approach and our

retail clinical services. She works closely with the Fairview Medical

Group and the Fairview Network in our population health approach

and new payer product development. Dr. Brummel is also an Adjunct

Associate Professor at the University of MN. She has published

multiple articles on MTM and pharmacy’s role in the care team. She

has chaired and served on multiple committees and is a current

member of the Minnesota Pharmacists Association, the American

Society of Health-System Pharmacists, the American College of

Clinical Pharmacy and Pharmacy Quality Alliance (PQA).

Polypharmacy

Bob Feroli, PharmD, FASHP, FSMSOMedication Safety Officer

Department of Pharmacy

Johns Hopkins Hospital

Polypharmacy

National Center for Health Statistics Data Brief No.42 Sept 2010

Polypharmacy

• As patients get sicker (regardless of age), the number of clinically appropriate medications generally goes up.

• As number of medications goes up, potential medication related problems go up

– Adverse drug effects

– Drug – Drug interactions

– Drug – Disease interactions

– Possibility of medication errors

– Poor adherence

– Cost of therapy

– Poor quality of life (e.g., pill burden)

Polypharmacy

• So what is “Polypharmacy”?

Polypharmacy

Polypharmacy

Homoeopathy

Polypharmacy - A prescription of many drugs in one compound

Polypharmacy

Illinois and Indiana Medical andSurgical Journal, Volume 1, Issue 1 (1846)

Reform Practical Therapeutics

Agenda item #6 – “To endeavor to substitute for the monstrous system of Polypharmacy now universallyprevalent, one that is, at least, vastly more simple, moreintelligible …”

I take aspirin for the headache caused bythe Zyrtec I take for the hayfever I got fromRelenza from the uneasy stomach from theRitalin I take for the short attention spancaused by the Scopederm Ts I take for themotion sickness I got from the LomotilI take for the diarrhea caused by theZenikal for the uncontrolled weight gainfrom the Paxil I take for the anxiety fromthe Zocor I take for my high cholesterolbecause exercise, a good diet, and regularchiropractic care are just too much trouble.

Dr. Jonathan Lazar (Lazar Spinal Care, P.C.)Image reproduced with permission

Polypharmacy

Polypharmacy

Bushart RL, Massey EB, et.al.,Polypharmacy; Misleading, but manageable.

Clinical Interventions in Aging 2008:3(2) 383-389Review of literature Jan 1997 – May 2007

• Over 24 distinct definitions Clin. Intervent. In Aging 2008:3(2) 383-389

– Potentially Inappropriate

Polypharmacy



• Over 24 distinct definitions Clin. Intervent. In Aging 2008:3(2) 383-389

– Potentially Inappropriate

• Medication used to treat a side effect of another medication

Polypharmacy



Polypharmacy• Over 24 distinct definitions Clin. Intervent. In Aging 2008:3(2) 383-389

Potentially Inappropriate





• Using many (2,3,5,6 . . .) medications

• More than one medication to treat the same condition

• Using a medication that interacts with one another medication

• Medications prescribed more that twice daily

• Taking an OTC medication

• Obtaining medications from more than one pharmacy



• Medication does not match a diagnosis

• Dose of medication does not match renal or liver function

• Equally effective less costly (& not more toxic) alternative is available

• Unnecessary duplication of therapy

• Complicated regimen affecting adherence


Potentially Inappropriate?













– Therapeutically appropriate therapy vs.

patient's ability to adhere to therapeutic regimen










» The simplest most appropriate therapeutic regimen for a particular patient may be too complex for them to follow.










» The simplest most appropriate therapeutic regimen for a particular patient may be too complex for them to follow.

» We must use a risk : benefit approach to find the mostappropriate therapy given the patient’s values and ability to adhere to the chosen regimen.

Polypharmacy• Medication regimens should optimize for:

– Clinical Appropriateness– Safety– Affordability– Ease of use– Patient’s ability & willingness to adhere

• Concurrent method to promote rational therapeutics– Reconciliation: Based on the response from medications taken

“yesterday.” What, if any, changes are appropriate going forward.

• Retrospective - “triggers” to identify potentially inappropriate therapy – Polypharmacy (e.g., patient on more than x drugs)– IHI trigger tool– Beer’s criteria– STOPP (Screening Tool of Older People’s Prescriptions)– START (Screening Tool to Alert to Right Treatment)

Seek the “sweet spot”

Comprehensive Medication Management

Amanda Brummel PharmD, BCACP

Director, Clinical Ambulatory Services

Fairview Pharmacy Services

45

February 26, 2015

Practitioners’ responsibilities:

• To identify a patient’s drug-related needs and commit to meet those needs

• To ensure that all of a patient’s drug therapy is appropriately indicated, the most effective, the safest and the patient is compliant

• To work in collaboration with all members of a patient’s care team

Pharmacy StrategiesFoundation of Comprehensive Medication Management (CMM)

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Comprehensive Medication ManagementBuilt upon the philosophy and process of “pharmaceutical care practice”

ASSESSMENT CARE PLAN EVALUATION

•Ensure all drug therapy isindicated, effective, safeand convenient

•Identify drug therapy problems

•Resolve drug therapy problems

•Establish therapeutic goals

•Prevent drug therapyproblems

•Record actual patient outcomes

•Evaluate progress inmeeting therapeutic goals

•Reassess for new problems

Continuous Follow-upWorking in collaboration with all members of the healthcare

team

ESTABLISH A THERAPEUTIC RELATIONSHIP

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Assessment

• Establish therapeutic relationship

• Understand patient’s goals of therapy

Meet the patient

• Reason for encounter

• Patient history, medication experience, clinical information

Elicit relevant information

• Indication, efficacy, safety, convenience

Make drug therapy decisions

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• Unnecessary drug therapy?

• Additional drug therapy needed?INDICATION

• Ineffective drug?

• Dosage too low?

• Drug interaction reducing efficacy?EFFICACY

• Adverse drug reaction?

• Dosage too high?

• Drug interaction increasing toxicity?SAFETY

• Willingness to take medications?

• Ability to take medications?COMPLIANCE

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Care Plan

• Clinical goals

• Drug therapy goalsEstablish goals of therapy

• Non-drug therapy, education

• Patient-specific drug choices

Interventions: DTP resolutions, achieving goals of therapy, achieving

patient goals prevention of DTP

• Patient specific and clinically appropriate

• Method of follow-upSchedule follow-up evaluation

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Follow-up evaluation

• Evaluate effectiveness of drug therapy

Compare actual patient outcomes to goals

• Evaluate safety and patient’s ability to adhere to therapy

• Explore reasons for non-adherence

Monitor for adverse effects and compliance

• Assess for changes in condition status and drug therapy

Assess for new drug therapy problems

• Continuous careSchedule next follow-up

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Drug Therapy Problems Identified

2014

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Dosage Too Low 31 %

Needs Additional Drug Therapy 21 %

Noncompliance 15 %

Adverse Drug Reaction 11 %

Dosage Too High 10 %

Unnecessary Drug Therapy 8 %

Ineffective Drug 6 %

19,963 Drug Therapy Problems Resolved

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Confirmation of DTPs

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Estimated Cost Interventions

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Fairview Published Results

• An average 12-to-1 return on investment in terms of reduced overall health-care costs, documented in “Clinical and Economic Outcomes of Medication Therapy Management Services: The Minnesota Experience” (Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211)

• MTM contributed to optimal care in complex patients with diabetes documented in “Optimal Diabetes Care Outcomes Following Face-to-Face Medication Therapy Management Services” (Brummel A.R. et al, Population Health Management: 2012)

• Medication therapy management: 10 years of experience in a large integrated health care system. (Ramalho de Oliveira, D., Journal of Managed Care Pharmacy : JMCP, 16(3), 185-195.)

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Health Care Costs After MTM

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

Facilities

(-57.9%)

Professional

(-11.1%)

Prescriptions

(+ 19.5%)

Total Cost

(-31.5%)

1 YearbeforeMTM

1 YearafterMTM

Isetts, et al., J Am Pharm Assoc. 2008;48(2):203-211

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Optimal Diabetes Care Outcomes

2006 Pre-MTM, 2007 MTM, 2008 Post-MTM

“Optimal Diabetes Care Outcomes Following Face-to-Face Medication Therapy Management Services” (Brummel A.R. et al, Population Health Management: 2012)

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Activation, Engagement, and Shared Decision-Making

• Patient activation

Measure of patient’s knowledge, skills, and

ability to manage their health

• Patient engagement

Steps patients take on their own

Combines ‘activation’ with interventions

Promote positive patient behavior

Obtaining preventive care or exercising

• Shared decision making—Patients and providers together

Patient’s condition, treatment options, the medical evidence behind treatment options, risks and benefits, and patients’ preferences, arrive at treatment plan

Robert Wood Johnson Foundation. Patient Engagement. February 14, 2013. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_86.pdf. Accessed September 5, 2014.

Patients who had

decision-making

support

• Overall medical

costs were 5.3%

lower

• 12.5% fewer hospital

admissions

• 20.9% fewer

preference-sensitive

heart surgeries

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Activation Level and Cost

• PAM scores were predictive of billed costs of care

• With targeted interventions, least activated patients realize the greatest gains

• Care for patients with Level 1 Activation cost 8-21% more than patients with Level 2-4

Some variance by condition

Costs for Level 1 patients with hypertension were 14% higher than Level 4

Costs for Level 1 patients with asthma were 21% higher than Level 4

Caveat: Predicted costs were no different for patients at Level 2-4

Health Affairs, 32, no.2, 2013. Judith H. Hibbard. Patients With Lower Activation Associated With Higher Costs. http://content.healthaffairs.org/content/32/2/216.full.html. Accessed September 7, 2014.

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Key Points

• Comprehensively review a patient’s medication therapy

Look to make sure each medication is

Indicated

Effective

Safe

Convenient/Compliance

• Consider a patient’s medication experience

• Engage them in the decision making process when choosing their medication therapy

• Follow up to evaluate their outcomes and assess for new drug therapy problems

Questions/Discussion62

Raise your hand

Use the chat

Action Period Assignment

Research and consider what your facility has in

place to optimize medication use and minimize

polypharmacy.

– Please be prepared to share on our next session

Expedition Communications

• All sessions are recorded

• Materials are sent one day in advance

• Listserv address for session communications:

[email protected]

• To add colleagues, email us at [email protected]

64

Session 265

Thursday, March 12, 1:00 PM ET

Health Literacy and Medication Safety

Gail Nielsen,

BSHCA, FAHRA

Fellow and Patient

Safety Scholar at IHI

Thank You!66

Joelle Baehrend

[email protected]

Dorian Burks

[email protected]

Please let us know if you have any questions or

feedback following today’s Expedition webinar.

Consider video

Dr. Mike Evans Video: An Illustrated Look at Quality

Improvement in Health Care

http://www.ihi.org/resources/Pages/AudioandVideo/MikeEv

ansVideoQIHealthCare.aspx

67

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make that

will result in improvement?

Model for Improvement

Act Plan

Study Do

Aim of Improvement

Measurement of

Improvement

Developing a Change

Testing a Change

Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide:

A Practical Approach to Enhancing Organizational

Performance. San Francisco, CA: Jossey-Bass, 1996.

The Medical Model and the Model for

Improvement

Medical Model

Collect signs and

symptoms

Develop a treatment

plan

Prescribe the plan

Collect signs and

symptoms to determine if

there is improvement

Model for Improvement

Collect pre-data to

understand the extent of

the problem

Select process changes

to be tested

Test the changes

Collect post-data to

determine if there is

improvement

Why Test?

• Increase the belief that the change will result in

improvement

• Predict how much improvement can be

expected from the change

• Learn how to adapt the change to conditions in

the local environment

• Evaluate costs and side-effects of the change

• Minimize resistance upon implementation

Repeated Use of the PDSA Cycle71

Hunches

Theories

Ideas

Changes that Result

in Improvement

A P

S D

A P

S D

Very Small

Scale Test

Follow-up

Tests

Wide-Scale Tests

of Change

Implementation of

Change

Sequential building of knowledge under a wide range

of conditions

Spread

Multiple PDSA Cycle Ramps

Transfusion

Administration

Safety

Communication

and Awareness

Strategies

Engaging with

Leadership

72

Implementing

Transfusion

Guidelines

Final Questions/Discussion73

Raise your hand

Use the chat

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