QUALITY IMPROVEMENT: MEDICATION RECONCILIATION 1

Quality Improvement: Improving Medication Reconciliation at Discharge

Heather Schaff, Maeghan Priest, Madison Tomlin, Brianna Miller, Nicole McIntyre

College of Nursing, University of South Florida

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Quality Improvement: Improving Medication Reconciliation at Discharge

Barriers to medication reconciliation at discharge have become a prevalent issue in

regards to patient health literacy, medication adherence, and safety. Improving the process of

medication reconciliation at discharge will aid in patient care quality improvement and is a great

aid for patients continuing their care at home. A plan is necessary to carry out the following

changes and revolutionize a system. The goal is that 90% of discharges at Tampa General

Hospital will include medication reconciliation at discharge within one year of implementation

of interventions. Details of a plan including resources, budgeting, management, change

theory,and the evaluation plan will be discussed further in this paper.

Stakeholders and Change Theory

Stakeholders

According to Concannon and colleagues (2019), stakeholders include any individual or

party that is involved in or affected by healthcare decisions, especially those that relate to change

in the healthcare setting. Thus, the stakeholders in our quality improvement plan would be

patients, employees (e.g., providers, nurses, pharmacy, etc.), top management and unit

management, and technology companies (for EMR-related processes and concerns). Patients

play a role as stakeholders because of the valuable insight they possess as a result of being

consumers of healthcare services and the manner in which they are affected by changes to their

healthcare. In this particular quality improvement project, patients experience the medication

reconciliation process ideally upon admission and at discharge. This process is meant to ensure

that the patient is taking the medications that they need to. Thus, improvements in the medication

reconciliation process impact patients by streamlining their care and promoting continuity of

care. Due to this impact, it is imperative that patients have a say in quality improvement for
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medication reconciliation. Employees also act as stakeholders due to their inside knowledge of

healthcare processes, including medication reconciliation. Employees including providers,

nurses, lab technicians, and pharmacists are also customers of the healthcare system since they

deal with various services each time they work. In this quality improvement project, employees

are exposed to the process for reconciling medications; consequently, they are affected by

changes to the system and can determine if it is conducive to providing safe and efficient patient

care. Employees can also offer their thoughts regarding improvements. Furthermore,

management at various levels can assist in the facilitation of new decisions and changes to the

medication reconciliation process. They are investing as well and hope to see a return in

investment - that is, an increase in the number of patients receiving medication reconciliation.

Lastly, technological companies’ role as stakeholders include facilitating changes in the

medication reconciliation process, hopefully making them more simplified. These companies can

improve the interface of electronic medical record (EMR) systems and make it easier for

employees to utilize them and complete medication reconciliation thoroughly and correctly. As

with the facility management, technological companies are also investing in these changes,

which is a risk to them and may present benefits as well as consequences as it relates to profit

and value.

Management structure and process issues

The management structure for a quality improvement project may consist of many

personnel, with the chief executive officer of the facility as well as other members of the top

management team at the apex of the management pyramid. Directors of the respective

departments and managers would then follow. Next on the management ladder would be

physicians, providers, nursing staff, and pharmacists. Lastly, ancillary staff would be at the base
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of the management structure. Some process issues that may be encountered include stakeholder

resistance, hesitancy to buy-in to the quality improvement project, or decrease in stamina and

loss of the vision among stakeholders. Changes are often met with resistance, which is normal as

it is not easy to change human behavior. It can be especially difficult when the resistance

originates from top management. In that case, the quality improvement team should identify

what is contributing to the unease and reluctance so that it can be further explored and addressed.

Moreover, stakeholders should be continuously rewarded for contributing to the project and

reminded of the shared vision and the potential benefits of the quality improvement plan to

prevent mental exhaustion. Other issues that may arise include financial concerns, where there is

not enough funding to execute the project or unforeseen circumstances that unexpectedly

increase costs. However, the former may be avoided through careful planning and consideration

of the resources needed to conduct the project.

Utilization of a change theory

Various change theories can be utilized to implement change in the healthcare sector.

One that has proven to be especially successful is The Change Theory of Nursing by Kurt Lewin,

which is represented by Lewin’s Model of Change. There are three phases discussed in this

model: unfreezing, change, and refreezing. The unfreezing stage is essentially introducing the

change to a group of people and helping them to accept and implement the change. The change

stage is when people begin to accept and implement that change and become more willing to

participate in change efforts. The refreezing stage involves ensuring that the change is set and

that people refrain from returning to the old way of doing things (Hussain et al., 2018).

According to a study conducted by Harrison and colleagues (2021), this model of change can

result in many improvements for stakeholders in the healthcare setting including significant
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reductions in admission rates and hospital stays; increased teamwork; increased patient

involvement, safety, satisfaction; and improved quality of care, meaning greater patient-centered

care. In this particular quality improvement project, the unfreezing stage would include assessing

stakeholders thoughts on changes to the medication reconciliation process and presenting data on

rates of patients who receive medication reconciliation throughout the hospital to increase buy-

in. It would also involve informing stakeholders on the importance of medication reconciliation

and the consequences of failing to complete medication reconciliation as well as the benefits of

ensuring that medication reconciliation is done for each patient. The change stage would entail

managers of different units in addition to top management educating their staff and introducing

policies throughout the hospital and on the respective units in order to facilitate change. Lastly,

the refreezing stage would include empowering employees and offering incentives such as

making staff that are following the changes “superusers” and providing additional training and

support for staff overall.

Resources Needed to Implement Plan

Resources needed

To effectively implement the plan that has been created, additional resources are going to

be needed so that it can be efficiently executed. The first resource that is going to be needed is

the information technology (IT) team as they are going to be the ones that can add new additions

to the software so that the nurses can adequately be reminded to document as part of the plan.

The IT staff will also aid in adding the task of medication reconciliation to the task list in the

EMR so that at admission and discharge a task will appear reminding the nurse to complete this

duty. The next part of the plan is patient education on medication reconciliation which will allow

the patient to feel more confident in what they are taking and can help in the avoidance of drug
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errors and interactions while empowering them to speak up about their care. Through the help of

IT, a place for documentation of these crucial steps in the plan can be created. For the last piece

of the plan, the staff needs to be able to see how many medication reconciliations have been

completed by the nurse and are awaiting doctor approval. To do this, a new software is going to

have to be created that allows for someone such as the charge nurse to be able to monitor this.

The charge nurse will then be able to advocate for their nurses when doctors are not completing

these medication reconciliations in a timely fashion.

Recommendations for needed resources

For this specific plan, many resources are available however have not been created as of

yet. For example, the new software that shows the data on if doctors have completed medication

reconciliations. This can be created by an IT team which is why it is also included in the section

above however it also may need an outside team to come in and add this if the IT team feels they

do not have the proper resources to achieve this. The need to bring in an outside team to update

the current software would need to be included in the budget as the hospital may have to pay for

their time, travels and more. Other than this, the rest of the parts of the plan can be achieved

through resources that the hospital already supplies.

Budgetary needs to implement plan

The addition of new resources consequently creates the need for allocation of more

money to certain budgets so that these resources can be paid for. As mentioned previously, if an

outside team is needed to update the hospital’s current software then a budget would need to be

allocated to their services. Some of the costs that may be encountered could include the travel

costs if the team is in another state, the cost of their time and work and cost of their stay. In some

cases the company may cover these costs but if not then it would need to be included in the cost
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of the plan. Another cost that may be confronted is the cost of overtime. When adding to both the

nurse and doctors daily list of tasks that need to be completed, it also adds to how much time

they spend in the hospital. Having to educate the patient and complete additional documentation

can add to how long the nurses stay and may end up with them working overtime. These two

costs would need to be added into the plan to make sure that they can be accommodated for so

that the plan can be implemented as efficiently as possible until further necessary change may be

assessed and implemented.

Evaluation Plan

Monitoring the Outcomes

The status of completion and efficacy of the quality improvement plan must be monitored

in order to reevaluate the plan to determine the need for changes. In order to monitor the

outcomes of our plan, we will monitor the percentage of completed medication reconciliation as

a concurrent process audit. In other words, we will analyze the communication and timely

completion of the intervention by monitoring the documentation and sign off of the medication

reconciliation task list assignment in the patient’s electronic medical record (EMR) at the time of

discharge. The percentage will be calculated by reviewing the number of completed medication

reconciliations per shift over the number of patients currently admitted, yielding a daily

percentage of completed medication reconciliations for patients ready for discharge. The

timeliness of medication reconciliation sign off by the physician on the case will also be

monitored as it ensures surveillance of variables contributing to timely discharge including

possible delays in sign off of medication reconciliation. This measure will be monitored by

comparing the number of medication reconciliations completed by the nurse and ready for
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approval to the number of patients ready for discharge, yielding a percentage indicating

timeliness of medication reconciliation at discharge.

An important factor to assist in monitoring this quality improvement plan is the advocacy

of the healthcare team - the charge nurse, nurse, patient, pharmacy, and physician - in ensuring

that all members of the team complete their part in completing medication reconciliation so that

results may be evaluated by the end of the shift. Through ensuring patient education, patients can

contribute to this advocacy if they understand the importance of medication reconciliation and

can thus share control in their care. According to an article in 2019, providing care in an

autonomy-supportive environment is an optimal way to provide patient-centered care and can

lead to improved patient outcomes (Tonelli, 2019). Therefore, it will be documented if teaching

about medication reconciliation was administered at the beginning of their admission to ensure

the patient’s ability to practice autonomy in the healthcare setting and advocate for medication

reconciliation completion leading up to their discharge (measured by number of medication

reconciliation education documented over number of patient admissions).

Reassessment Strategy

For the reassessment strategy of the quality improvement project, the charge nurse will

not only review the completed medication reconciliations at the end of each shift, but will also

store those numbers to compile an average at the end of each month to have an ongoing and clear

evaluation strategy to see if the intervention has reached the overall goal. The optimal goal of the

project is to achieve a minimum of 80% of patients receiving medication reconciliation at

discharge. Every month this percentage will be tracked for a total of twelve months and will be

plotted on a run chart with the x-axis being the number of months of the project implementation

and the y-axis being the range of medication reconciliation completion from 0% to 100%.
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Utilizing a run chart will allow the quality improvement team/stakeholders to evaluate if the

quality improvement project reached their goal. Additionally, reassessment of the variables

contributing to medication reconciliation at discharge including physician sign-off timeliness as

well as documented patient education on the importance of advocating for medication

reconciliation will be critical aspects of determining progress on the goal.

The Nursing Leadership Theory and Reevaluation Plan

The reevaluation phase is essential in understanding whether or not the outcomes were

successful at reaching the goal of the quality improvement plan. This part of the process is

categorized in Lewin’s refreeze theory, where the improvement in the medication reconciliation

process is accepted and being conducted routinely. The reevaluation phase involves

implementing feedback processes from stakeholders in order to ensure there is no resistance

involving the new process. The reevaluation plan will involve meeting with nurses, doctors, and

administrators to identify any barriers involved in the newly implemented process as well as any

feedback that would help the adjustment of this process in becoming the new norm of medication

reconciliation in nursing practice. Patients will also be asked to provide feedback about the

education they receive regarding medication reconciliation. In order to evaluate the effectiveness

of this new process, the run chart would be evaluated. Ideally, the run chart would be trending

upwards closer to 80% at each quarterly audit.

Timeline for Reevaluation Plan

Reevaluation of the change theory would happen quarterly. Every three months, an audit

will be conducted to examine the data regarding the percentage of completed medication

reconciliations at discharge. After examining this data, stakeholders will be consulted about any

feedback regarding the medication reconciliation process in order to promote an easier transition.
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Adjustments may be made after evaluating feedback and data. The change theory will be

considered successful if at 12 months the percentage of completed medication reconciliations is

at 80% of all patients being discharged on the unit.

Conclusion

To conclude, the aim of this plan is to improve the incidence of medication reconciliation

at discharge starting with a goal of 90% of discharged patients having the reconciliation

included at Tampa General Hospital by 2024. The Change Theory of Nursing by Kurt Lewin will

serve as a foundation for beginning to implement change. With resources including an IT team,

educational sessions, and added documentation software, an improvement in the amount of times

medication reconciliation is provided at discharge may be seen. Other interventions like chart

auditing supports the refreeze stage of the change model. In addition a proper budgeting plan put

in place to support these changes is necessary with the two biggest factors being potential

overtime pay, and payments regarding the IT team. With evaluation and reassessment being the

last pieces to the puzzle, any necessary alterations can be made in the event the goal is not being

met based on the outcomes and feedback of the stakeholders.

How our findings may impact care outcomes

The impact on care has the potential to be tremendous for patients and their family

members. It is likely that with the improvement of medication reconciliation at discharge will

come lower rates of readmission due to exacerbations of chronic conditions potentially caused by

poor medication adherence. This change directly affects patient safety and health outcomes as it

concerns necessary medications. Furthermore, these changes support a more complete and

concise EHR for medical professionals and patients to refer to. Improving medication

reconciliation also helps prevent harm and complications that can be caused from potential
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interactions between drugs that may not have been caught without proper medication

reconciliation.

Lessons learning in Quality Improvement

Quality Improvement is a difficult and thorough process that takes time to get right.

Interventions are not always successful on the first try and budgeting/resources can also be hard

to come by. Change is not always openly embraced even when it is from good intentions.

Teamwork is necessary for things to run smoothly and quality improvement projects require

collaboration from all stakeholders with the main vision or goal always in the forefront. It is

imperative to consider all perspectives and insight from stakeholders in order to create a well-

rounded improvement plan that is meaningful and impactful to all those involved and affected by

changes brought about by the quality improvement plan. The quality improvement team may

encounter some resistance during implementation, but this is expected. The team should assess

reasons for resistance and consider how best to reevaluate the project and improve it to make the

project meaningful to those who are resistant.

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References

Concannon, T. W., Grant, S., Welch, V., Petkovic, J., Selby, J., Crowe, S., Synnot, A., Greer-

Smith, R., Mayo-Wilson, E., Tambor, E., Tugwell, P., & Multi Stakeholder Engagement

(MuSE) Consortium. (2019, March). Practical guidance for involving stakeholders in

health research. Journal of General Internal Medicine. Retrieved February 25, 2023,

from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6420667/

Harrison, R., Fischer, S., Walpola, R. L., Chauhan, A., Babalola, T., Mears, S., & Le-Dao, H.

(2021). Where do models for change management, improvement and implementation

meet? A systematic review of the applications of change management models in

healthcare. Journal of Healthcare Leadership. Retrieved February 25, 2023, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7966357/

Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2018). Kurt Lewin's

change model: A critical review of the role of leadership and employee involvement in

organizational change. Journal of Innovation & Knowledge. Retrieved February 25,

2023, from https://www.sciencedirect.com/science/article/pii/S2444569X16300087

Tonelli, M.R., & Sullivan, M.D. (2019). Person-centered shared decision making.

Journal of Evaluation in Clinical Practice, 25(6), 1057-1062.

https://www.doi.org/10.1111/jep.13260
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Appendix

AIM Outcome Measure Process Measure Balance Measure

(Where are we (Are we doing the right things (Are the changes
ultimately trying to to get there?) Resource introducing
go?) Resource problems?) Resource

By 2024, of Percentage of 1. Percentage of completed 1. Nurses rush to

all admitted patients that medication reconciliation on complete task list
patients receive medication task list. (# of med recs including med rec
being reconciliation by completed / # of pts admitted) which can cause
discharged at discharge (# of incorrect med rec
Tampa patients that Readmissions r/t medication increasing the
General receive med rec / # issues? potential for sentinel
Hospital , of patients events (# of incorrect
90% of admitted) med recs / # of total
patient completed med recs)
discharges
2. Percentage of documented 2. Nurses spend time
will include
patient education on the on patient education
medication
process of medication and do not have time
reconciliation
reconciliation - info to have for other priorities (#
.
them advocate about med rec of nurses staying
.Resource
on admission and discharge overtime/# of nurses
d/t new meds being rx working)
(# of documented med rec
education/# of patients
admitted)

Benefit of education at
discharge

3. Percentage of nurse 3. For awaiting

completed med recs awaiting doctor approval make
doctor approval sure that discharge
(# of med recs awaiting times are not
approval / # of patients ready prolonged (# of
for discharge) patients whose
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discharge was
Interprofessional delayed/ # of patients
communication discharged)