|Citation: Dannan, H. E., & Ellahham, S. (2020). Improving Transfer Medication Reconciliation in an Emirati Tertiary Hospital Utilizing the Irish Health Service Executive Model. American Journal of Medical Quality, 1062860620920712.|
Transfer is a vulnerable setting that increases the risk of medication errors. Medication reconciliation (MedRec) ensures accurate medication transfer at interfaces of care. It is addressed as a key performance indicator (KPI) in a tertiary hospital. The issue was failure to meet the KPI of more than 75%; the objective was to improve compliance with transfer MedRec. A quality improvement project was conducted utilizing physician active education, leadership support, and the Irish Health Service Executive (HSE) change model. Compliance with the KPI did not improve with monthly monitoring and physician education. Following leadership support, compliance increased from 56% to 72% but was not sustained. Adoption of the change model yielded a sustainable improvement from 65% to 81% within 1 year of the intervention and a reduction in medication errors. Improvement in the MedRec process requires a culture of accountability to change. HSE expedited stakeholders’ engagement and implementation of the planned interventions.
Medication reconciliation (MedRec) is a key topic at every quality forum because of its direct correlation with patient and medication safety.1 It is identified as a key strategy to improve medication safety.1-3 MedRec is reinstated as a National Patient Safety Goal (NPSG.03.06.01) for 2019 by The Joint Commission.3 Similarly, the World Health Organization High 5s medication reconciliation project4 and many other health care agencies presented a framework for MedRec implementation in recognition of its impact on patient and medication safety. MedRec in a hospital setting is the formal process of comparing a patient’s home medications with the medication ordered or modified during every transition of care—admission, internal transfer, and discharge2—to avoid omission, duplication, wrong dosing, and interactions.3 Indeed, there is solid evidence of the positive correlation between an accurate MedRec process and reduction in medication discrepancies.5
MedRec is crucial during internal hospital transfer.4-6 Transfer of care is a critical process and error prone. The transfer is an interface of care as patients move from one unit or level of care to another. It is a vulnerable time during which risk for medication errors and discrepancies is significantly increased.7 Transfer of patients from critical care units to the wards reflects an improvement in patients’ clinical status. Therefore, the aim of transfer MedRec (TMR) is to ensure that patients continue to receive their home medication (BPMH), newly ordered medication since admission (MAR), and the adjusted medications post transfer.8,9
In the study organization, TMR in the pediatric department was not fully implemented. Hence, it was identified as an area for improvement. The hospital is one of the main tertiary care pediatric public hospitals in Abu Dhabi, with more than 586 beds. It was founded in 2005 with a vision to lead integrated high-quality safe health care services. It has a large, busy, academic pediatric department with a well-established residency program. It involves 1 surgical and 2 medical wards with more than 86 beds. It has a high bed-turnover rate with an average of 93 patient transfers from critical care units to the pediatric wards per month. The hospital culture is transforming toward a culture of safety and delivery of high-quality health care services.
Rationale, Aim, and Objectives
An electronic MedRec project began in 2013 and, as a result of continuous education, pilots, and monitoring, the hospital recently met the outpatient, admission, and discharge key performance indicators (KPIs), which are more than 90%. However, TMR (KPI), which is more than 75%, was not achieved.
TMR is a dual responsibility; the sending unit will ensure that MAR is consistent with the patient BPMH and then the receiving unit will reconcile and adjust the transfer orders according to patient clinical status.10 TMR requires active participation of an interdisciplinary task force1,2,7-10 (ie, physicians, nurses, pharmacists) to ensure that every patient transferred from critical care units to the wards has TMR orders done. The research team conducted a brief survey in one of the pediatric wards to investigate nurses’ knowledge about TMR. Forty-one pediatric nurses responded, and it was revealed that 97.5% of the nurses are aware of TMR, but only 87.5% know how to determine if it is completed in the system. Moreover, only 75% of the nurses ask physicians to complete TMR orders, which represented another area for improvement.
Based on these drivers, a quality improvement project was implemented by the pediatric quality/change team in the department to optimize the TMR process for all cases transferred from critical care units to the pediatric wards. In addition, the team planned to investigate MedRec impact as a key strategy for addressing medication discrepancies and supporting patient safety during an internal transition of care.
This prospective study consisted of 3 major phases in terms of the key interventions utilized.
In phase 1 (January 2018 to March 2018), the research team monitored physicians’ TMR compliance rates. Compliance ranged from 46% to 57%. This result was shared with the physicians and focused on active physician education. The team provided individualized feedback about compliance and the importance of compliance with the KPI.
In phase 2 (April 2018 to June 2018), leadership support and calls for improvement by senior management resulted in increased compliance from 56% to 72% but was not sustained.
In phase 3 (July 2018 to August 2019), the Irish Health Service Executive (HSE) 2018 change model (Figure 1) was fully adopted to undertake this organizational development project because it focuses mainly on cultural change and staff engagement.11 During this phase, compliance with the KPI increased from 56% to 81% and was sustainable.
In view of the value of this change model in engaging stakeholders, creating positive changes in the culture, and steering the change project, this article elaborates on the HSE model and how it was implemented in the study hospital.
Figure 1. Health Service Executive 2018 model.ª
Creating a People and Culture Change Platform
This represents the foundation of this change model.11 Collective leadership was practiced, which motivated stakeholders to strive to accomplish the same goal by creating excellence throughout the pediatric department. The research team focused on engaging and empowering nurses in addition to physicians as the key stakeholders. This process required a lot of face-to-face and electronic communication. Engaging people early in the change process reduced resistance and increased their readiness for change.
Nurses were trained and educated to partner with physicians, aiming to improve the reconciliation process. Nurses were equipped with the required knowledge to act as effective collaborative leaders. A culture of responsibility taking was fostered to improve engagement.
People’s Needs Defining Change
The aim of this stage is to outline the main activities for defining, designing, and delivering the change.11,12 Early in the change process, an Influence-Interest Mapping Grid was designed to define key stakeholders. It identified physicians, nurses and their managers, and clinical pharmacists as key stakeholders.
The research team employed physicians’ champions and nurses’ managers to educate stakeholders. Leaders supported the project as it progressed and intervened as needed. The mapping of some stakeholders, such as the heads of departments, was changing from low to high interest as the project evolved. Indeed, stakeholder analysis is a valuable dynamic tool that includes representatives from multiple disciplines, taking into consideration their level of motivation and power in influencing the process.13
Cycles of Define, Design, and Deliver
This stage is similar to the well-known Plan-Do-Study- Act framework. It is cyclical and intertwined. Yet it is guided by the strategic vision of the project that was generated based on PESTEL (political, economic, social, technological, environmental, and legal) and SWOT (strengths, weaknesses, opportunities, and threats) analysis conducted early in the project as proven development and strategic planning tools.14 Framework for implementation and action plan for communication was designed based on the recommendations from the Canadian Institute for Safe Medication Practices10 and the Agency for Healthcare Research and Quality MATCH (Medications at Transitions and Clinical Handoffs) toolkit1 for MedRec. Furthermore, the team employed lessons learned from previous experiences15 while implementing admission and discharge MedRec in the hospital.
Weekly educational reminders in physician meetings were communicated by physician champions. Physicians were receiving individualized feedback on their performance. Those identified to have poor compliance underwent focused group discussions to understand their struggles and engage them in the change process. The team scaled up education and training for those who had poor compliance. The change team was available to champion improvement in TMR and to support frontline specialist physicians and residents. The latter managed their workloads and engaged properly in the improvement because of the collective leadership practiced by the change team. At the same time, nurses’ education and empowerment with knowledge on how to trace TMR orders was ongoing and led by nurses’ managers. Availability of the flowchart prompts nurses to act for the change and to assist physicians to comply with TMR. Gap analysis identified poor compliance in the pediatric cardiology subspecialty. The cardiology chairperson was contacted who, in return, reinforced the importance of improving compliance among his staff. This is in addition to group discussions and the educational program that was provided to the team.
A monthly measurement was communicated to staff. In December 2018, the pediatric team celebrated success. Leaders stressed the importance of the achievement and the need for sustainability. As the compliance rate continued to be constantly greater than 75%, less urgency was sensed because the staff had adopted the new practice. Despite that, the change team continued to be available and visible.
On the other hand, a pre- and post-implementation audit of medication discrepancies was conducted to test the quality of TMR performed. Results revealed a significant reduction in the percentage of discrepancies— mainly duplications and the addition of unnecessary medications. The audit will be discussed further in the Results and Discussion sections.
A clear sustainability plan was stated in the form of continuous monitoring of physicians’ compliance rates and communication of results at every quarter of 2019. Sustainability of this project emerged from its invaluable correlation with international patient and medication safety goals. The project empowered nurses and physicians to be more accountable for safety and quality improvement. It contributed to the overall improvement in hospital MedRec measures.
Compliance with TMR improved after adoption of a comprehensive change model. Table 1 describes the number of transfer cases on a monthly basis from January 2018 to August 2019. Figure 2 reflects the success of the project as compliance rates with TMR exceeded the target KPI after July 2018. Proper staff education and coaching by quality champions, leadership support, interprofessional collaboration, and collective leadership proved to be effective in streamlining the MedRec process.16-20 However, a gap analysis conducted on a monthly basis revealed variable compliance percentage among different physician groups. First, it showed that most of the transfer cases from critical care to the pediatric wards were under the care of general pediatrics followed by the pediatric cardiology subspecialty service.
Table 1. Number of Transfer Medication Reconciliations Before and After the Change.
Pediatric transfer cases
Transfer MedRec completed
Table 1 Cont. Number of Transfer Medication Reconciliations Before and After the Change.
Pediatric transfer cases
Transfer MedRec completed
Table 1 Cont. Number of Transfer Medication Reconciliations Before and After the Change.
Pediatric transfer cases
Transfer MedRec completed
Figure 2. The percentage of transfer medication reconciliations before and after the change.
Abbreviation: KPI, key performance indicator.
Second, the general pediatricians’ compliance percentage was higher than for cardiologists. As shown in Figure 2, cardiologists initially failed to sustain their target compliance percentage. Leadership involvement was the main intervention that enforced the change. Subsequently, a decline in compliance was recorded after December 2018, in contrast to general pediatric physicians who continued to sustain their compliance with the KPI. This could be explained by the large difference in the number of physicians covering each of these services. The cardiology service is covered by only 8 physicians, whereas the general pediatric service is covered by at least 60 physicians and residents.
Examining the compliance percentage run chart (Figure 2), a peak in compliance was noted in May 2018 followed by a drop to below the KPI level. Another peak in cardiologist performance was observed in November and December 2018, followed by another drop (Figure 2). These peaks were directly related to the leadership intervention. It could be explained that physicians perceived the intervention as an act of imposing compliance. Thus, success was not sustained because of the lack of commitment to change. According to Bass and Avolio,21 transformational leaders build trust and develop a sense of purpose to benefit the organization and people. Moreover, Bass22 explored the types of leadership and their impact on employees; it was evident that a transactional leadership style usually has a negative effect on organizational outcomes.
Utilization of the HSE change model expedited engagement of stakeholders and implementation of the planned interventions. The literature review conducted by Barry et al12 underpins the value of engaging frontline employees to promote and manage positive changes. It emphasizes the empowerment and engagement of stakeholders in charge of the change to consolidate the bottom-up approach.11,12 It highlights factors that can result in meaningful changes, utilizing up-to-date resources and focusing on communication and appreciation of public value. Moreover, it identified context, people and power, culture and social interaction, leadership, and learning as key factors for success or failure of any improvement project.11,12 Although the HSE 2018 model was created for the Irish health care sector, it is easily applicable everywhere. It provides detailed guidance on planning, execution, and implementation of a project with the tools required to deliver it.11 It is a soft change model that acknowledges emergent changes that can occur in the change process. Moreover, it acknowledges the complexity of health care. Furthermore, nurses’ empowerment and collaborative leadership resulted in an increased level of awareness and knowledge about TMR. Nurses’ collaboration was evident in reporting unreconciled cases and keeping the pace of project progress. Unit managers were keen to ensure proper nurse education and contribution to the project. This integrated approach demonstrated an environment of greater accountability to clinical quality, which is described by Scally and Donaldson23 as the foundation for good clinical governance at continuously improving organizations. In relation to nurses’ shared leadership in this project, a systematic review that examined leadership practices of nurses revealed that organizations that embraced transformational and shared leadership resulted in improved quality measures such as patient satisfaction, outcomes, and fewer medical errors.24 The intent of this study is to improve the compliance rate and reliability of TMR. An “all-or-none” measurement approach is used to ensure accurate reporting of compliance rates, which reflects the interests and likely the desire of patients, especially when process components are interdependent, such as during TMR. This method translated the comprehensiveness of study interventions in creating the desired change. Additionally, all-or-none measurement fosters concern with the design of the whole sequence of care, not merely parts, but also offers a more precise scale for assessing improvements by uncovering defects in specific groups. Thus, this provides ample room for improvement and may stimulate more motivation to make changes. Indeed, adopting an all-or-none measurement approach encouraged physicians to improve their performance and to better comply with the KPI.25 The pediatric compliance percentage was based on the all-or-none measurement approach. Decrease in total compliance rate was related to low compliance of the cardiologist.
The outcome of this project was its vital impact on the quality of the reconciliation process. The research team conducted a 2-month audit on the quality of reconciliation early in the project and 6 months later. A total of 60 charts were reviewed. Each month, the team studied 15 transfer pediatric cases for which TMR was completed. The team checked for the presence and types of medication discrepancies. Results were significant as the percentage of medication orders with discrepancies decreased from 8.98% to 3.9%. The most common type of discrepancies identified continued to be duplication of orders (50%), the addition of unnecessary medication (30%), and wrong doses (20%), but there was a significant reduction in the number of discrepancies (Figure 3). Consistent with the literature, the results of this audit revealed a reduction in the percentage of medication discrepancies as a result of the improved reconciliation rate.10,26,27 Yet the literature primarily discusses medication discrepancies in relation to reconciliation at admission, discharge, and the outpatient setting; few focused on discrepancies in the transfer setting.
Figure 3. Types of transfer medication discrepancies.
The pediatric department celebrated its success in achieving and even exceeding the target KPI for TMR. Thus, more energy was generated within the team. It represented a motivator for the team to maintain interest in sustaining success. The significant reduction in medication discrepancies reflecting an accurate high-quality TMR process was another win that warranted celebration. The project started to roll out to other departments. The cost of the project was minimal, which encourages adoption by other departments.
Overall improvement was well recognized by the governing body of the hospital who recently increased the target for TMR KPI from 75% to 80% and 85% for years 2019 and 2020, respectively. With the rise in the target, the pediatric department continues to perform well.
As the project evolved, the research team faced some challenges that warranted further investigations, consultations, and actions. The main one was setting up an audit to assess the quality of MedRec. No baseline data were available to get a sense of what types of discrepancies were common in the study hospital before the intervention.
In evaluating the results of the audit, first, it was evident that the reduction in duplication and the addition of unnecessary medications were significant. This can be simply explained by the outcome of successful education and improvement intervention. On the other hand, selection bias could be blamed. It is known that the new academic year for residents and interns starts by August and September; accordingly, the higher incidence of medication errors or discrepancies during that period was a result of the lower level of experience. Second, the audit was done retrospectively; thus, the auditors reviewed documentation in the charts to report discrepancies. But to minimize potential bias, different reviewers completed the audit every month, and it was done by selecting random charts on nonspecific days of the week.
The second major challenge was studying nurses’ level of knowledge and contribution to the MedRec process. A simple, short survey with a set of 3 open-ended questions was used. It can be criticized that this type of survey could not allow a complete assessment of the level of learning. Furthermore, upon repeating the survey in the post-implementation stage, the research team was challenged by limited participation in the survey. The number of responses was less compared to the initial survey. Also, the survey was done in one pediatric ward, which added to the sampling issue. Hence, a larger sample and utilizing structured quality evaluation models, such as Kirkpatrick’s evaluation, could have been more helpful, but that was not achievable in view of the limited project time line. However, the value of the survey was in its ability to reflect the level of knowledge and practice of the nurses in a simple and effective way.
The improvement in compliance with TMR was accomplished via implementing an organized educational plan, engaging stakeholders from different disciplines and investing in them, practicing collective leadership, and clear communication of goals, which is in keeping with the HSE 2018 model 9 key priorities for change.
The critical success factors of this project were effective communication, staff accountability toward change, physician champions, continuous monitoring, and the supportive management culture. Within the pediatric group, quality leader and project champion physicians with improvement expertise were the key facilitators for the change. Effective communication of short-term wins, impact on safety, challenges and addressing individualized feedback to physicians, continuous monitoring, and measurement of compliance rates were major accelerators of project success. These factors fostered the enthusiasm to change and promote excellence in physician performance and adherence to the KPI. Change is a journey that must be steered by various change models and approaches. Utilization of an evidence-based well-structured model to guide change prompted the change team to explore various quality tools, study the literature, and keep the pace of change and improvement throughout the journey. Furthermore, sustainability in every change is an important aspect to be dealt with. The sustained improvement in pediatric physicians’ compliance percentage was a success. However, cardiologist compliance status that demonstrated an initial rapid improvement followed by a drop represented a challenge to sustainability, which is attributed to the large difference in number of physicians covering each of these services. Leaders should consider an alternative tool to control the rate of improvement to achieve sustainability and avoid rebound.
We thank all members of the Pediatrics Department at Sheikh Khalifa Medical City for their great engagement and dedication. We especially acknowledge Dr Salah Eldin Hussein and Mohammed Saifuddin for their significant contribution to this project.
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