In 2011, the Institute of Medicine (IOM) identified workflow problems with certain electronic health record (EHR) systems. In the report, Health IT and Patient Safety, examples of “design-workflow mismatches” are cited, such as providing medication information in alphabetical lists instead of grouping medications by type, indication, or regimen.1 To save patients from accidental injury, the IOM has called for “processes that identify, evaluate and minimize hazards.”2 Current medication use processes result in too many medication errors, injuring patients and increasing the cost of healthcare.2
Medication use process improvement efforts aren't new. For example, in 2005, The Joint Commission established implementation of medication reconciliation as a National Patient Safety Goal to minimize adverse drug events from confusion at transitions of care. However, achieving effective medication reconciliation has been more difficult than anticipated. In many cases, nurses, pharmacists, and physicians developed new, linear processes with steps conducted in isolation that were simply unworkable in fast-paced, dynamic healthcare work environments. Instead, there's a compelling need to develop collaborative, resilient medication use processes based on a common understanding of shared responsibilities and an expectation of consistent teamwork.
Nurses, pharmacists, and physicians must work to transform hazardous medication use processes into safer ones by incorporating new techniques and technologies that foster team-level awareness and coordination of activities.3 Healthcare leaders generally agree that medication errors result from problems with processes and systems. Consequently, leaders must also appreciate how only consistent teamwork by those providing care will lead to needed safety and quality improvements.
Patients encounter predictable hazards during transitions of care between care settings, some resulting in readmission.4 Among these hazards are mishaps from failures to collect complete information about medication use and reconcile that information to ongoing patient-care plans and discharge instructions.5,6 Previous attempts to share responsibility for medication reconciliation have divided this collaborative work into an ineffective series of discrete tasks.7
In a typical medication reconciliation process, nurses list current medications, physicians prescribe while referencing the list, and pharmacists periodically evaluate overall medication use. It isn't uncommon for one or more of these discrete tasks to be left incomplete or unintentionally duplicated. In either case, medication reconciliation workflow confuses patients, families, and caregivers, potentially causing more medication errors.5 Medication reconciliation hinges on collaboration; the development, implementation, and operation of such a transformed process can only be accomplished through teamwork.
Support for transformed processes
The challenges of fractionalized workflow, exemplified by the difficulties with medication reconciliation, are part of a larger problem with the “complex and nontransparent” workflows found in healthcare.7–9 Even successful health information technology (IT) endeavors often have workflows hampered by: interruptions; inadequately defined roles and responsibilities; poorly kept and managed schedules; and sparse documentation of steps, expectations, and outcomes.9 Experts recommended a focus on identifying, prioritizing, and managing workflow changes to achieve measurable clinical performance gains.9 But how will this “focus” be achieved?
An effective, learning health system, one that constantly analyzes operational data as the basis for improving its processes, requires nurses and pharmacists who consistently collaborate to optimize benefits for patients and families by adopting evidence-based best practices for the direct patient care they provide.10 In the risky domain of medication use, previously isolated work processes must be transformed using new ways of coordinating, communicating, and reminding users about what's truly collaborative work. Fortunately, this kind of care process transformation has the support of healthcare's professional disciplines.
Organizations such as the IOM emphasize the vital role nurses play in transforming healthcare in our country.11 Nurse leaders have successfully leveraged health IT as a tool to support care process innovation. Now the profession of nursing must lead transformative quality and safety initiatives, bringing evidence for decision making to the point of care, and empowering patients and families to be involved partners in transformed care processes.12 Meanwhile, the American Society of Health-System Pharmacists intends pharmacy practice to be transformed into a patient-centric practice. Two recommendations from its ongoing Pharmacy Practice Model Initiative are transformative: first, that “drug therapy management should be provided by a pharmacist for each hospital inpatient,” and second, that “all drug distribution functions that do not require clinical judgment should be delegated to pharmacy technicians.”13,14 Nurses accustomed to having pharmacists attend directly to a select group of patients will now see pharmacists establish lasting patient-care relationships with all inpatients.
Organizing new teams
There are several recommendations to organize the work of medication use process transformation. These include:
1. Establish medication use process improvement committees.
Healthcare leaders must create the right circumstances that allow nurse-pharmacist teamwork to achieve new workflows characterized by meaningful collaboration between nurses and pharmacists. The work of developing new and better medication use processes is unending. Project-based approaches won't suffice. Healthcare executives should charter medication use process improvement committees with co-chairpersons from pharmacy and nursing, and thoughtfully invite a cross-section of other stakeholders to participate and offer support. Executive sponsors must make their committee co-chairpersons aware of the most pressing organizational needs, and set specific performance targets and clear expectations for transformational results.
2. Determine ground rules and objectives.
Medication use process committees should begin their work by establishing ground rules, goals, and objectives. Beyond ground rules for ethical and professional behavior, committee members must commit to evaluate and apply lessons from the available body of scientific research on health IT and healthcare processes. A good starting point is to collectively acknowledge that “imposing simple standards on complex processes will never yield simplicity.”15 Prepare the committee to respect the complexity that pertains to healthcare processes by seeking flexible, adaptive, supportive, feasible, and testable workflow improvements. It's also critical that process improvement committees aren't cast in the role of technology project steering committees; the role of a continuous process improvement committee is different: to define and demonstrate the effectiveness of transformed, collaborative work processes using available means.
3. Prioritize efforts.
Medication use process committees must carefully prioritize their efforts. For example, it's necessary to give preference to those medication use process improvement needs for which consistent measurements can be taken and used as metrics to assess progress.
Medication reconciliation: First focus
Medication reconciliation at transitions of care may be one high-priority medication use process that's both subject to measurement and in need of transformation to make the process collaborative. Although complex, medication reconciliation at transitions of care is manageable, and several of its qualitative and quantitative outcomes can be assessed.
Collectively, we're all still seeking an ideal set of medication reconciliation processes. Imagine a roomful of nurses, pharmacists, and physicians brainstorming possible ways to define efficient, flexible, synchronous, well-coordinated, and assigned work processes supporting the need for caregivers to collaboratively evaluate patient medication histories and medication use plans. More effective work methods will result. Old, ineffective processes, once considered mandatory, will be discarded.
When performance targets are exceeded, meaningful collaboration will be evident. Technology will continue to be a fundamental enabler of future care delivery models, but transformation demands more teamwork than ever before to create the new, more resilient workflows that technology enables. As transformative agents and leaders, teams of nurses and pharmacists can establish new times and places for collaborative care to be provided, and safer, enhanced methods of utilizing and integrating technology to support their collaborative work on behalf of patients.
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