Appendix 6: Implementation Strategies
An advisory committee of key players involved in MedRec in primary care or those who may be affected by implementing new MedRec processes was held. Below is a summary of their perspectives on the current state of MedRec in Ontario and what they hope to gain from a more standardized approach to MedRec.
At present, there is variability in the extent to which MedRec is performed in the primary care setting. Much of this variability depends on the availability of resources in various practice settings - for example many FHTs and CHCs have pharmacists on staff to help with MedRec. Some primary care providers find it challenging to fit MedRec into practice, as well as timely updating of patients' charted medication lists, while still addressing patients' primary medical concerns. Primary care providers without hospital privileges do not have access to the Ontario Drug benefit Drug Profile Viewer and feel that this would be a useful source of information when doing MedRec. While it is important for specialists to participate in MedRec, care providers agree that in primary care, MedRec should be the responsibility of primary care providers and community pharmacists. To facilitate MedRec referral forms received by specialists should include a complete and up to date medication list, and consultation notes sent from specialist to primary care providesr should include details on any changes made to medications.
Collaboration with community pharmacists is perceived as a leverage point that could help primary care providers increase capacity for MedRec. A complete, accurate medication list generated by community pharmacists, possibly through the MedsCheck program, could help primary care providers in the MedRec. This may require improved infrastructure, training, and standards with respect to MedRec /MedsCheck in community pharmacies. At present, financial incentives are not aligned to promote primary care providers' involvement in MedRec; while pharmacists are paid for MedsCheck, there are no MedRec specific primary care billing codes for primary care providers.
Healthcare providers recognize the important role patients can play in the MedRec process. Through consultation with their providers, patients must be made aware when changes are made to their medication regimens and understand the indication for each medication they take. Importantly, patients should be engaged whenever changes to their medications are made, and assume ownership of their medication regimens, for example by maintaining an up to date medication list. Patients can also engage in the medication reconciliation process by bringing their medication vials to appointments to help facilitate the collection of BPMHs.
Make it Meaningful
Demonstrate that implementing a more structured process for collecting medication histories is needed. It is important to communicate that implementing MedRec is not implementing a completely new concept but that it is providing more structure to an existing process. Be mindful that the messaging doesn't imply that previously people were doing something wrong, but only that improvements are necessary. Show where the deficiencies are in the old process and what the potential impact of those deficiencies could result in.
Provide evidence from a global context and from a local context.
To clearly contextualize the deficiencies in individual practice settings, complete a baseline audit of patient charts in your practice setting.
Consider hiring a medical, nursing or pharmacy student to assist with this process
Assemble a Team
No one person can make this happen all on their own. To be successful, a QI initiative needs the support of the whole team — from office managers and administrative staff, to physicians and other healthcare providers.
Identify a leader who is respected and has credibility among peers. Be open to including constructive skeptics who have legitimate concerns but are open to change.
Consider choosing team members from outside your service group who may be interdependent with the processes that you implement (e.g. a community pharmacist in your area, a patient).
Consider the following checklist when forming a team:
Define the Aim:
Clearly state what it is that you are trying to accomplish. A good aim statement will be clear, set specific time parameters, define a stretch goal and ensure that there is value added to patients.
What is the goal of implementing MedRec? How do you want to accomplish this? Over what time period?
Based on the resources available (e.g., pharmacist available, an electronic medical record) and the number of patients on your roster may influence what the goal of MedRec implementation is for your practice.
Ideally, a formalized process for MedRec would be available to all patients, however this may not be feasible or may take a long time to accomplish for certain settings. Decide what is practical for your setting, defining an over ambitious aim may set yourself up for failure and in turn lose buy-in from the team.
In an effort to implement MedRec in a manageable approach consider selecting a subset of patients first, for example:
For more information on quality improvement methodology, refer to HQO's Quality Improvement Guide
If resources permit expand to other lower risk subset of patients. By using a stratified approach and expanding slowly over time a goal of 100% of patients receiving MedRec may be attainable. Complete medication reconciliation within 14 days of patient being discharged from hospital.
Example aim statements:
"We will implement MedRec for all patients in our clinic in a step-wise approach. We will accomplish this within 2 years and decrease the number of discrepancies in patients' charts by XXX."
"We will perform MedRec within 7 days of discharge for 90 % of patients recently discharged from hospital by June of 2015."
Clearly communicate the aim. Ensure everyone being affected by the change understands that a new process is being implemented and believes in the potential benefit of it. Use the aim statement to create buy-in.
To determine if the MedRec process that you are implementing will be successful define specific measures to capture the impact of MedRec.
QI initiatives should use three types of measures to help create targets and achieve their aims:
Refer to Appendix Five for more information on measures in primary care MedRec.
Define Best Practice Change Ideas
Change ideas — are actionable, specific changes that focus on improving specific steps of a process. They are practical ideas that can be readily tested.3333
Change ideas can come from research, best practices, or from other organizations that have recognized a problem and have demonstrated improvement on a specific issue. Change ideas can be tested to determine whether they will result in improvement and are often revised as a result of these tests.
When beginning to implement a new process it may be easiest to begin with change ideas that you have the most influence or control over and then move to change ideas that require more resources to implement or are dependent on factors outside of your control. Below are examples of change ideas that may be helpful in implementing a sustainable MedRec model.
If possible test change ideas that have been validated in the literature or are recommended by experts. Examples of change ideas (under Table 1).
Before implementing change ideas try to envision what possible barriers might impede successful implementation. Barriers could include both structural and organizational barriers.
Examples of barriers based on change ideas above could include:
Moving from Choosing Change Ideas to Testing Ideas
Once there is a clear understanding of the opportunities for improvement, teams can begin brainstorming and testing ideas through Plan-Do-Study-Act (PDSA) cycles. This is an exciting phase that provides teams the opportunity to exercise creativity and challenge the status quo by trying different improvement ideas. The PDSA approach allows teams to try ideas on a small scale. Testing ideas on a small scale allows teams to smooth out any concerns in the process before sharing the success or failure of the tried change more widely. It builds confidence in the change process and creates buy-in by involving individuals that are truly affected by the proposed changes. (Refer to Appendix Six for Health Quality Ontario Quality improvement resources)
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