In the first year of a new quality improvement project, residents at Maimonides Medical Center in Brooklyn, NY have significantly improved medication reconciliation, showing improvement of up to 44 percent in some departments. The results of the resident-driven quality improvement project will be published this spring in the American Journal of Medical Quality.
The medication reconciliation project was the first QI initiative undertaken after CIR and Maimonides negotiated a collective bargaining agreement in November 2010 that established a QI incentive program for housestaff.
“As residents we felt it was very important we tie in the benefits we were getting in our contract with the care we were providing to our patients; we wanted to connect those two in some way,” said Dr. Michael Kantrowitz, Chief Resident in Internal Medicine, in a presentation at the Partnership for Quality Care (PQC) conference in Washington, DC this past fall.
“We decided there were three core elements,” Dr. Kantrowitz explained. “It had to be patient focused. We didn’t want this to be something that happened on paper, we wanted to see results in our patients’ care. We really wanted a process that we could own and improve. And finally, we really wanted to be able to measure it.”
Both residents and administrators saw an opportunity with the rollout of a new Electronic Medical Record system, which gave them a window to examine how medications are managed during transitions of care. When they reviewed the data, they saw problems with dosage changes not being communicated.
“A patient would be on one dose of a medication in the hospital and be discharged on a different dose without any clear reasoning as to why,” Dr. Kantrowitz said.
“So we saw these problems, and it scared us as residents and scared the hospital administration and that made medication reconciliation even more important to us.”
Residents from all departments worked with the organizational performance staff and Maimonides Vice Chair of Medicine Dr. David Cohen to develop and refine a chart auditing process. The EMR, handwritten progress notes, and the list of medications patients were given on their way home were compared to assess the safety of the discharge process.
“Since residents do the bulk of that work, it was really important that we have the input into redesigning the process,” Dr. Kantrowitz said. “We needed to ensure that it was conducive to our current work flows, including our rounding process and our overall discharge process, so that was really the context of when medication reconciliation was done.”
After a year of work that included intensive peer education and faculty support, Orthopedic Surgery, Psychiatry, and Internal Medicine showed increases in quality of 21 to 44 percent. Other departments continued to analyze their results and strive for improvement. Residents who met their target received bonuses according to the CIR contract. But Dr. Kantrowitz said improving patient care and resident ownership over the project ultimately drove its success.
“We didn’t have the higher ups in the hospital telling us what to do, we told them what we needed to fix and how we were going to fix it, and they gave us the institutional support to do it.”
To see a video of Dr. Kantrowitz’s presentation on the Maimonides Medication Reconciliation project, visitwww.cirseiu.org/medrec.
Share Your QI
CIR will be launching a new website devoted to quality and patient safety. You’ll be able to share your QI work and get useful feedback from other residents, check out residents’ projects, pick up essential QI and patient safety tools, and find out what’s going on in patient safety and quality at your hospital. To submit a quick abstract of your ongoing or completed project, please email firstname.lastname@example.org for the project template.