This is the third day of the week long exploration of care transitions and medication errors. Knowing the importance and vulnerability surrounding care transitions I will present findings from the literature regarding medication reconciliation and safety culture/teamwork that will illuminate their “true” impact in reducing medication errors. For another look at how Hope Street Group conceives to improve the quality and cost of transitions between acute and other types of care, click here: http://www.hopestreetgroup.org/docs/DOC-2479 .

Medication Reconciliation

Medication reconciliation is a comparison of the patient’s current medication regimen against the admission, transfer and/or discharge orders for the purpose of identifying and fixing discrepancies (Northwest Memorial Hospital, 2011). Medication reconciliation is needed during every transition of care in order to clearly identify what medication changes are permanent, temporary and that duplicate or conflicting medications are not being prescribed. AHRQ projects that 14%

of patients upon being discharged from the hospital have some sort of medication inconsistency due to a lack of medication reconciliation (Agency for Healthcare Research and Qulaity).  Regardless, to date, evidenced based methods for medication reconciliation are lacking

despite the need for it to occur. As a result, the Joint Commission

announced in 2009 that they would no longer score medication reconciliation during on-site accreditation surveys, thereby reversing their 2005 stance (Agency for Healthcare Research and Qulaity).

Safety Culture/Teamwork

The concept of safety culture came from high reliability organizations. Agencies or groups such as air traffic control systems

that operate in hazardous conditions but have few adverse events were evaluated for common traits. Common features of high reliability organizations include

(Agency for Healthcare Research and Quality):

• “Preoccupation with failure—the acknowledgment of the high-risk, error-prone nature of an organization’s activities and the determination to achieve consistently safe operations.
• Commitment to resilience—the development of capacities to detect unexpected threats and contain them before they cause harm, or bounce back when they do.
• Sensitivity to operations—an attentiveness to the issues facing workers at the frontline. This feature comes into play when conducting analyses of specific events (e.g., frontline workers play a crucial role in root cause analyses by bringing up unrecognized latent threats in current operating procedures), but also in connection with organizational decision making, which is somewhat decentralized. Management units at the frontline are given some autonomy in identifying and responding to threats, rather than adopting a rigid top-down approach.
• A culture of safety, in which individuals feel comfortable drawing attention to potential hazards or actual failures without fear of censure from management.”

Even though safety can be defined and measured by survey and providers at all levels, creating sustainable cultures of safety has proven difficult

(Agency for Healthcare Research and Quality, 2011). Poor perceived safety culture has been linked to increased error rates (Agency for Healthcare Research and Quality, 2011).  Team training is a proven intervention to improve an organization culture regarding safety by raising situational awareness (Agency for Healthcare Research and Quality, 2011). Teamwork training also emphasizes the role of human factors such as fatigue, management styles, organizational cultures and perceptual errors such as mishearing instructions. This can be addressed using simulations or classroom/lecture style sessions.

Tomorrow, I’ll cover shovel ready interventions such as TeamSTEPPS and provide a research-based comparison of each intervention discussed this week in a handy chart for you to use.

I know there are dedicated supporters of each intervention. Let us hear what you have to say! Log in and share below.

Agency for Healthcare Research and Quality. (2011 February). Nursing Home Survey on Patient Safety Culture. Retrieved 2011 10-August from Agency for Healthcare Research and Qulaity: http://www.ahrq.org.gov/qual/patientsafetyculture/nhsurvindex.htm

Agency for Healthcare Research and Qulaity. (n.d.). PSNET, Patient Safety Primer, Medication Reconciliation. Retrieved 2011 10-August from Agency for Healthcare Research and Qulaity: http://psnet.ahrq.gov/primer.aspx?primerID=1

Agency for Healthcare Research and Quality. (n.d.). PSNet, Glossary, High Reliabiltiy Organizations. Retrieved 2011 10-August from Agency for Healthcare Research and Quality: http://psnet.ahrq.gov/popup_glossary.aspx?name=highreliabilityorganizations

National Priorities Partnership. (2011 10 August). National Quality Forum, Overuse. Retrieved 2011 10-August from National Quality Forum: http://www.qualityforum.org/Topics/Overuse.aspx

Northwest Memorial Hospital. (2011). MATCH Medicatin Reconciliation Toolkit. Retrieved 2011 14-March from Northwest Memorial Hospital: http://www.nmh.org/nm/making+the++case

Where does the healthcare continuum really begin?

With prevention?

In the home?

With the Primary Care Provider?

In the Emergency Department?

Although an argument can certainly be made for any of the four choices above, I’d like to challenge your opinion and perspective with a different answer…the continuum for many begins with Emergency Medical Services (EMS).

This past year I had the privilege to be included in two standard setting and forward thinking discussion forums-- AHRQ’s 2010 Annual Conference and HCIE Innovators Event as well as Hope Street Group’s Policy 2.0: Using Open Innovation to Reinvent Primary Care Project. Both of these events offered diverse perspectives from diverse participants in academia, corporations and all levels of government and localities who gathered to discuss and make recommendations to improve the health care system. Interestingly, the first responder perspective of EMS was only a footnote in these discussions. I believe that policy makers and leaders within healthcare all too often fail to look outside their sphere of influence and familiarity for answers or more importantly the critical questions. That said, I know this minimalization was not intended or planned, but a result of historical processes and comfort levels.

The numbers…

EMS contributes 15% or 17.25 million patients to the nations 123.8 million annual Emergency Department (ED) visits (CDC, 2008), yet Fire, EMS or Law Enforcement respond to over 240 million 911 calls per year (NENA, 2009). It’s difficult to accurately breakdown the national percentages of 911 call types, but upwards of 60% of EMS calls are generally considered low-acuity or non-emergent. To put this into a local perspective, the City of Tucson AZ with a population of approximately 530,000 (2005) generates approx. 79,000 Fire and EMS 911 calls per year, 84% or ~67,000 of these are medical in nature and 60% of those, ~46,000 require only Basic Life Support (BLS) care (TFD, 2009).

So what does that really mean? It means that the 911 system provides a substantial safety net for the Nation’s healthcare system. While this should come as no surprise, the volume of patients utilizing EMS, Emergency Departments and the 911 system continues to grow. Over 15 years ago, the National Highway Traffic Safety Administration and the Health Resources and Services Administration joined with leaders from the EMS community to put forth an EMS plan that would require significant collaboration with acute care, primary care and public health. This provided one of the earliest, nationwide, use of the scale-up-and spread model and was published as the1996 EMS Agenda for the Future (NHTSA, 1996).

The past…

To implement that vision and professional template, EMS has continued to grow it’s service provision model from one that was historically created for stabilization and transport of the acutely ill and injured; one that was set-up to intervene only when patients needed emergent support; one that operated in relative isolation from other health care and community resources; one that was not involved in the business of ensuring social service follow-up and one that did not have a working knowledge of community health care providers and regional health care organizations (NHTSA, 1996).

The present…

Today, EMS is integrated with other health care providers, public health and public safety agencies to provide community-based healthcare and management. EMS agencies and providers are involved in activities related to prevention education, illness and injury risk, acute illness and injury care, follow-up, treatment of chronic conditions and community health monitoring. This vision is also shared by the Injury Response Division of the National Center for Injury Prevention and Control/Centers for Disease Control and Prevention (NCIPC/CDC) and the American College of Emergency Physicians (ACEP) who have called for a better understanding of roles and collaboration between Public Health and EMS through their Appleseed Project initiative (CDC, 2004).

The reality …

As you can see, EMS has developed into more than a group of fire departments, rescue services and ambulance companies. While providing these additional and collaborative services, EMS remains the public’s emergency medical safety net.  Looking back to those 240 million 911 calls and the 17.25 million EMS-to-ED admissions, it’s clear that a significant amount of health assessment, care and triage occurs outside the hospital walls. In fact, there are no other healthcare providers that see patients in their own home or living environment quite like EMS. The “scene assessment” which is a fundamental EMS skill reveals more information about a person, their living conditions, their health, their support system and their coping mechanisms than any other assessment tool.  How many Primary Care providers, case managers or health plan administrators have this perspective into their own patient’s lives?

From where I sit with over 30 years of experience as an RN in Maternal-Child Health and EMS, I see several important questions that need further discussion and clarification before we can begin to understand how to move forward in improving the healthcare of our Nation.

• How can we better educate individuals to utilize the 911 system for acuity appropriate reasons?
  
• How do we encourage the use of Primary Care practitioners for non-emergent and urgent medical and injury complaints instead of defaulting to the approach of “if this is a medical emergency, please hang up and dial 911?
  
• How do we share the burden of after-hours and weekend low-acuity patient needs?
  
• How do we facilitate better communication and collaboration between EMS, public health, acute and chronic care case management, behavioral health and community services?
  
• How do we move patients calling 911 for non-emergent or non-healthcare reasons into a public or human services system that will better meet their needs?
  

Communication, collaboration, connectivity, consistency and caring are all functions of healthcare, yet as the patient numbers and range of patient complaints increase, we all need to utilize each others skills, knowledge and expertise to meet the needs of our patient population. Reaching out to our colleagues may be the first step toward improvement, integration and understanding of our healthcare system.

http://www.911dispatch.com/info/fact_figures.html

http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdf

http://cms3.tucsonaz.gov/sites/default/files/imported/data/demographic/eecpop00_05.pdf

http://www.nena.org/911-statistics

http://www.cdc.gov/injury/publications/index.html

http://www.nremt.org/nremt/about/emsAgendaFuture.asp

http://www.tucsonaz.gov/fire/AnnualReport.pdf

As Hope Street Group builds momentum on “Policy 2.0: Using Open Innovation to Reinvent Primary Care” we knew we could not miss out on the launch of the new issue of Health Affairs entitled “Reinventing Primary Care”.  Not only does the title mirror the focus of our open collaboration, the new issue also proved to contain a wealth of scholarly discussion and practical policy prescriptions for the future of primary care.

Kathleen Sebelius (Health and Human Services Secretary) kicked off the launch with a keynote address setting out the Administration’s funding provisions impacting on primary care, both through the Recovery Act and the Patient Protection and Affordable Care Act.  She also acknowledged the tremendous challenges ahead in implementing the legislation, including the many places where it says, “The Secretary shall…”

The launch provided an overview of new models of primary care delivery, focusing in particular on patient centered medical homes and retail clinics.  It also highlighted the importance of interprofessional teams in primary care, looking at the way teams work (or don’t work) in primary care settings, and the roles of nurse practitioners, physician assistants and pharmacists in primary care practice teams.  The event concluded with a series of practice profiles, covering: Greenhouse Internists, the Group Health Cooperative, QuadMed, the implementation of electronic referrals to specialists, and the role of Medical Assistants in chronic disease management.

I attended the event with Monique Nadeau (Executive Director, Hope Street Group) and was impressed by the quality and breadth of the information covered and the interesting dialogue that occurred between panel members and the audience.  I would be interested in the reactions of anyone else who attended or who has had an opportunity to look at the new Health Affairs issue.