The Royal is a specialized mental health centre that provides services to people with complex and serious mental illness across eastern Ontario.
With the introduction of Accreditation Standards for medication reconciliation (MedRec) and required organizational practices (ROPs) in community care, medication safety became a top priority for The Royal.
Health Quality Ontario had a chance to catch up with Anita Bloemen, RN, CPMHN (c), Manager of Patient Care Services, and Trudy Kelly, RN, BScN, CPMHN (c), Local Step Down Clozapine Coordinator, from The Royal’s Community Mental Health Program to find out how the team reviewed and improved their MedRec process among their community mental health teams.
What steps did you take to review your current MedRec process?
First, we wanted to get a sense of the number of clients who required MedRecs across all the community health teams. We estimated that there were approximately 300 clients across our teams including intensive case management, ACT and dual diagnosis teams.
In our assessment, we found that each team was collecting information about medications in different ways and there were several different Medication Administration Records (MARs) and non-standardized order formats being used. The psychiatrists were each doing a Best Possible Medication History (BPMH) prior to re-ordering medications, but this wasn’t being captured in the medical record.
We recognized the positives too! Psychiatrists were calling community pharmacies whenever they would re-order a client’s medications. This was an informal BPMH and a way to check for any changes to the Ontario Disability Support Program (ODSP) drug profile. The psychiatrists had a system of doing this for a portion of clients every month, so that every client would have a BPMH completed at least twice a year; aligning well with the re-ordering of mental health medications. We knew we needed to build from this point.
How did you work to standardize your MedRec process?
We developed two phases. The first phase was to complete an initial MedRec for every client and add it to their medical record. The second phase was to maintain this work and ensure MedRecs were being updated according to ROPs.
Phase 1: Completing initial MedRecs for every client
Since the psychiatrists had an established workflow of calling community pharmacies, we decided that this was an opportunity for more interdisciplinary team members to do this piece. We divided up the clients amongst the team so that about 20 clients’ pharmacies were called by a team member every month, until all of our clients’ charts were updated. The information was then flagged for the psychiatrist to reorder medication as needed.
The team’s two nurses conducted BPMHs with each of the hundreds of clients during community visits and ensured medication information for the MedRec was captured in the medical record using the new standardized form (see an example of the form here).
All the medications prescribed and/or taken by our clients were captured, even those from primary care providers. This was really the first time we had one form that contained multiple sources of medications, including medications the client was taking over-the-counter.
Everyone pitched in to do the first MedRecs, which took approximately one year. We ensured there was protected time to complete the work and education was provided when needed. Each team member realized they had a role to play in reducing risks associated with medication errors.
We developed and utilized a tally sheet and an auditing process to verify the completion of MedRecs for all clients.
Phase 2: Updating MedRecs on an ongoing basis
Any medications that were re-ordered triggered a new workflow for the nurse, whereby the nurse would meet with the client during a community visit and get an updated BPMH for the MedRec.
How was the new workflow maintained and sustained?
A guide-book of medication-related care tasks was created for team members. We also created a form for the client’s medical record and new order sheets, which required collaboration with the Records Department to ensure that the forms met the organization’s standards.
The introduction of a new electronic medical record allowed us to capture BPMHs and completing full MedRecs became a “hard-coded” change in how we provide care.
What were your results?
The dedication of the nurses was recognized with an organizational Laurie Strano Quality Award.
The efforts taken to improve the medication profile of clients received a lot of praise from community primary care providers. We decided to ensure a copy went to the client’s providers outside of the hospital.
Physicians would call us and give verbal appreciation since it was the first time they were able to know exactly what medication their clients were prescribed. Physicians also recognized that many of the clients were now able to articulate what medications they were taking.
We have seen more comfort among staff to talk to clients about medications, regardless of professional designation. With the MedRec available in the system, the entire team will now participate in discussions with clients. For example, we had a team discussion about gastrointestinal slowing, constipation and potential for intestine rupture that can occur with clozapine. Our social workers and occupational therapists now have a conversation with clients to assess their bowel functioning, and that didn’t happen before.
What challenges did you face?
Our biggest challenge was finding ways to make medication safety a shared responsibility. It meant that our interdisciplinary staff had to reconceptualize their roles and expand the view from being responsible to one’s assigned caseload to using one’s professional scope across the entire team for client safety.
Once people started to see the results, which was a drop in medication errors, staff really took on their part in the BPMHs to provide high quality care.
What advice would you give to other organizations looking to make similar improvements?
When the team gets involved from the beginning to identify issues and come up with solutions, they are more likely to invest in the work.
Once you have people thinking about what is going well, ask if they think the proposed changes would fit with what is already happening. Figure out the culture strengths and then capitalize on those; if others really don’t think there’s a good fit, then it won’t work. You need to have the positive reinforcements in the culture already.
Leaders will find that by taking this approach, the buy-in to change workflow follows because there is a realized value connection. It is empowering to the nursing role to see the impact to clients.
Be prepared to see that workload is an issue in the beginning. Get a little creative and have nurses oversee other staff and help where they can. It would also help to liaise with community pharmacies and set up collaborative conversations about BPMH with pharmacists, nurses and the client.