Improving and Maintaining Medicines Reconciliation on Admission at North Bristol NHS Trust (NBT)

Our aim was to improve medicines reconciliation. Our objective was to exceed 95% of patients receiving Medicines Reconciliation within 24 hours of admission, in line with NICE recommendation 1.3.1 in NG5 (2015).

NICE guidance and other sources evidenced the benefits of carrying out medicines reconciliation. Our initial problem was what data to collect to prove our performance and how to collect this. It has taken time to clarify, reach our target and embed practices. Although "Medicines Optimisation" NG5 has just been published (3/2015) we feel further updated practical guidance would help hospitals implement, spread and improve consistency between hospitals.

The first issue is the target of "within 24 hours of admission". This is easy to measure for Trusts who have electronic prescribing, as data can be accurately extracted. For Trusts without this, the admission date covers 00.01-23.59. Electronic admissions data is not always accessible or accurate and does not show actual time of prescribing. For clarity we defined that if a patient was admitted on day 1, then reconciliation had to be completed by 5pm on day 2. NHS England subsequently confirmed this definition.

The second issue is the definition of 'medicines reconciliation'. Two stages of basic and full reconciliation were defined by the National Prescribing Centre (2008). This is again easy to measure for Trusts with electronic prescribing. For Trusts without it, urgent changes to the prescription will be actioned immediately but non urgent changes will be highlighted and the doctor could address these at any time between Pharmacist visits. Our work with SPI2 promoted using the easiest method of data collection. To avoid unnecessary visits to check on this, we defined the completion of medicines reconciliation as the time when all changes were highlighted but not necessarily acted on. The benefits of measuring on a run chart using improvement methodology is that results are consistently measured and the run chart annotated if this changes - and improvements for the individual Trust clearly demonstrated. Definitions are more important when results from different Trusts are being compared through benchmarking, as the data may not be comparable. NBT methods ensure robust auditable data with appropriate sample sizes and reduction of bias in patient selection and consistency in measurement. Medicines Management Technicians (MMTs) randomly audit 5 patients per ward per week.

Medicines Reconciliation ensures that medicines prescribed on patient admissions correspond to those taken before admissions. This process involves discussion with patients/carers and using primary care records (NICE/NPSA 2007). Medication errors cause harm to patients, lead to increased morbidity/mortality and inflate healthcare costs. The importance of Medicines Reconciliation is well documented:
- Globally: (2006) the 'High 5's programme' (World Health Organisation) and the '100K Lives campaign' [Institute of Healthcare Improvement (IHI)] both targeted Medicines Reconciliation.
- Nationally: (2007-2009) the 'Safer Patients Initiative' (SPI) (IHI/Health Foundation) was introduced.
- The key national driver is: 'Technical patient safety solutions for medicines reconciliation on admission of adults to hospital' (NICE/NPSA 2007).
- Medicines Optimisation dashboard (2014) links information from the Medication Safety Thermometer with Safety information from NHS England. - North Bristol NHS Trust (NBT) and SPI2.
NBT is a large acute NHS Trust in England with approximately 1000 beds. Our work affects 70,000 patients annually via elective and emergency admissions. NBT was selected for 'SPI2' (2007-2009) followed by the Southwest Quality and Patient Safety Improvement Programme (SWQPSI). Medicines Reconciliation was set as a target.

SPI2 and NICE guidance:
Before we started, we thought that Medicines Reconciliation occurred but could not prove. Our first task was to introduce processes to enable us to collect data to measure. When we started to measure, baseline assessments were our first results from 1 ward. We assumed most admissions would occur on our admissions wards, but found approximately 80% occurred on 30 different wards. In order to ensure consistency across NBT, we focussed on wards with the greatest number of admissions (>2%). Patients were involved in the work as in carrying out medicines reconciliation, patients and their carers were of paramount importance in finding out what drugs had been prescribed prior to admission and more particularly in finding out what medication they were actually taking and how. NICE guidance was the first key national driver to support and justify our actions. The benefits detailed in our results below ensured that medicines reconciliation was carried out as soon as possible after admission ensuring the patient was prescribed the correct medication reducing harm from medication errors.

SPI2 and SWQPSI use the Model for Improvement and 'Plan, Do, Study, Act' (PDSA) cycles; 'Tests of change'/'spread' and 'working in collaboration/couplets'. Our work involved spread through various phases:

Phase 1: Feb 2007-July 2008: SPI (1-8 wards) We liaised with Medical Staff to introduce a Medicines Admissions Proforma that included drugs on admission/sources of information. Pharmacists audited Medical staff and we involved frontline ward staff in PDSA cycles. We publicised work using 'Toilet Top Tips' (captive education!!)
Phase 2: Aug 2008-Jul 2009 (8-11 wards) We consolidated practices and involved more staff to continue spread. We designed a DVD for training medical students/doctors.
Phase 3: Aug 2009-Feb 2011: (11-30 wards) A new Pharmacist post enabled increased spread and service to a high risk area.
Phase 4: Feb 2011-Feb 2013: (31-20 wards) Target achieved We re-analysed admissions to ensure appropriate data collection and audited Sunday admissions to ensure weekend admission did not adversely affect results.
Phase 5: Feb 2013 -now: (20-15 wards) Target achieved

We are publicising our work to spread good practice. We extended clinical services to the emergency zone at weekends, benefitting from piloting 'Connecting Care'. New junior medical staff shadow the Admissions Pharmacist.

In 2008, we submitted a Business case for funding using the NICE/NPSA toolkit but this was not successful. We did not discontinue any services in implementing but redesigned our clinical services to ensure that we used more experienced Pharmacists to prioritise and carry out the medicines reconciliation as soon as possible after admission. These Pharmacists carry out Medicines Reconciliation more effectively than more junior pharmacists. The more junior Pharmacists could then focus on queries arising after transfer from the admissions ward knowing the patient had come to them having been prescribed the correct medication.

By demonstrating an improved service we were supported by funding for a new Pharmacist (2009) for Medicines Reconciliation in a new seated assessment area and an increased number of specialist posts who contributed to this work as well as specialty work. These included Pre op Surgical Admissions Pharmacists. Apart from data collection (as under definitions), motivation was significant as we had not anticipated the timescale to reach our target, spread and embed. Involving more staff was crucial.

Our unique results exceeded expectations (see supporting information). Our run chart demonstrates clear and measurable outcomes that benefit our patients:
- 2007: 60% reconciled on 1 ward
- 2011: achieved/maintained/improved: 95% target on 30 wards
- Quality, Innovation, Productivity and Prevention (QIPP) benchmarking shows NBT is the best performing Trust in England/Wales with associated cost avoidance of £350k/yr.

Other outcomes include patients' satisfaction through increased opportunities to discuss medicines and admissions proformas/electronic data collection tools. Results are accessible to all staff with run charts displayed via the NBT Ward Quality Synopsis dashboard.

We have been finalists for the following awards:
- HSJ Award (2014)
- Lean Healthcare Academy Award (2014)
- HSJ National Patient Safety Awards (2013)
Presentations:
- European Association of Hospital Pharmacists (EAHP) Congress, Hamburg (2015)
- Pharmacy Management National Forum, London (2014; 2013)
Posters:
- Patient Safety Congress, Birmingham (2013)
- EAHP Congress, Paris (2013)
- Pharmacy Management National Forum, London (2012)
Publications:
- 'Improving Medicines Reconciliation on Admission': Hospital Pharmacy Europe (HPE) (v074 Summer 2014)
- 'Medicines Reconciliation on Admission: other issues': HPE (v075 Autumn 2014)
- Nationally: we are the best performing Trust as shown by 'QIPP' Benchmarking, with associated cost avoidance: £350k/yr.
- We achieved/maintained/improved our 95% target on up to 30 wards.
- We successfully carry out Medicines Reconciliation, providing a better quality service for our patients.

Globally: There is little data explicitly showing successful spread. Frank Federico: Executive Director: IHI: 'Your efforts inform us that, as difficult as medication reconciliation may be worldwide, it is possible to succeed'.

At the Patient Safety Congress (2013) we highlighted QIPP benchmarking demonstrates missed opportunities - our systems are transferrable. Clare Howard, Deputy Chief Pharmaceutical Officer, NHS England supported our work: "North Bristol Trust are to be congratulated on their impressive journey to improve medicines reconciliation rates". Extrapolating our NBT data (70,000 patients) to Dr Foster data shows Medicines Reconciliation should benefit 9 million patients in England with cost avoidance of £40 million.

Various factors that have contributed to our success that we would recommend:
- SPI2 was an invaluable arrangement with support from experts and peers to understand improvement methodology; 'learn from others'; 'Share success' and 'steal shamelessly!'
- NBT's successful approach for SPI2 provided strong executive support and each project has a named executive to support the work.
- Clinical audit support has also been invaluable and enabled us to have data portrayed in clear run charts, broken down to ward level and displayed on the Trust quality dashboard. We ensured data accurately reflected processes with accessible run chart results.
- We annually review patient admissions data to ensure our data is collected from appropriate wards. When wards achieve consistent results, we reduce but do not stop data collection.
- Continuous measurement is ESSENTIAL to know we are achieving results.
- SPI2 quoted W. Edwards Deming: 'In God we Trust -all others bring data!'
- The "buy-in" of staff is vital, starting with enthusiasts and leaving laggards who often change with peer pressure. It is tempting to spread too quickly, so important to plan and continue to embed as the project evolves. Increased staff involvement improves sustainability, embeds into routine work and lessens the main barrier of time.
- We used quality improvement techniques and segmented the patients to develop reliable processes to ensure that medication reconciliation is completed.
- By embedding our work through the Medicines Governance Group we have access to a wide range of staff and the group has also included patient panel representatives for nearly 5 years that add a more complete perspective.
- Improvement work never stops so we work in continuing phases. Tests of change have focussed on weekend data and the quality of the medicines reconciliation process. Future work is now linking in Medicines Reconciliation on discharge and primary care for the complete view.