Getting started

It is important to determine a realistic timeline prior to starting a Quality Improvement (QI) project. As a guide, it can take six to 18 months to initiate, test, implement and sustain an improvement.

Note: This timeline may be shorter if previous improvement efforts have been made; and may be longer if the change is complex and/or involves different services and departments.

Unintentional changes to patients’ medicines at transfers of care can result in considerable harm and have been linked to poorer health outcomes, increased hospital readmissions and mortality.^1,2

Continuity of medication management and medication reconciliation is included in the National Safety and Quality Health Service (NSQHS) Standards. All health services are required to meet these standards.

Medication reconciliation (Med Rec) is a formal process of obtaining, verifying and documenting an accurate list of a patient’s current medications on admission and comparing this list to the admission, transfer, and/or discharge medication orders to identify and resolve discrepancies. At the end of the episode of care the verified information is transferred to the patient and next care provider.³

By formalising the processes of Med Rec, medication errors and adverse drug events can be prevented.⁴

To undertake a QI project, there must be an issue or problem that you and others want to improve. For example:

• Poor documentation of best possible medication history
• Low completion rate of admission medication reconciliation
• Inaccurate transfer of medicines information to the next health care provider or patient

At this stage of the project, it is about identifying the problem you aim to improve NOT brainstorming solutions.

Change is not always welcomed or accepted by individuals or teams, even when it is improvement focused. Projects can often struggle to gain momentum if there is considerable resistance from those who will be impacted most by the change. Visit the CEC Safety Culture webpage for further information.

Use the Medication Reconciliation Readiness Assessment Tool to determine practical and realistic changes you can make in your services.

Local data will assist you to identify the problem and build the evidence base about why this is an important problem to focus on. Seek guidance from the local clinical governance unit or the CEC to identify appropriate sampling numbers and data sources.

Think about "What is the existing data for Med Rec?" and "How is Med Rec being captured"? and consider the following:

Existing local data: Examine your health service's Med Rec data via eMeds reports, incident data from your incident management system (ims+, IIMS etc), pharmacy intervention progress notes and other sources.

Baseline audit: If there is insufficient data or the data does not reflect your local Med Rec practice, you should consider conducting a baseline audit. You can design your own audit to capture specific data points.

There is no definitive rule on the amount of data you need to collect but it is always a good idea to collect data that is recent and from a continuous period of time. Frequent small samples have been shown to be more manageable and provide sufficient data to support ongoing quality improvement activities. For example, when reviewing medical records, it is recommended at least 20 randomly selected records (distributed evenly across the wards/units) to be included. However, the number and proportion of medical records audited will depend on the site and the purpose of the audit.

Refer to the Med Rec audit tool resources and user guide links within the top right navigation bar of this page.

Staff and patient stories: It is worthwhile collecting stories on how poor Med Rec processes have impacted patient care, hospital stays or continuity of care. This helps gain different perspectives of the Med Rec process, identify unintended consequences and sheds light on different areas for improvement.

Gap analysis: A gap analysis is designed to look specifically at each process task of Med Rec. It assists teams to identify where they would like to be and where they are now. Improvement strategies can then be tailored, commencing with one or two tasks, or targeting the areas of greatest need.

• Medication Reconciliation Gap Analysis

Literature search: Further information can be gathered by conducting a literature review.

You can also refer to the CEC Med Rec website for best practice processes. You will find a framework, local operating procedure and guide for determining roles and responsibilities for Med Rec.

When you want to initiate a change in your unit, your stakeholders will have questions about what you are trying to achieve and why, how you are  going to implement the case and what is required.

To create an Improvement Project Brief, you should include:

• why Med Rec is important (with evidence of best practice)
• what the problem is (with data)
• what recommendations or changes you want to make and the associated benefits
• how the project aligns with the organisational plan and priorities
• what support or resources are required
• a realistic timeline.

Use the Med Rec Improvement Project Brief template to build your case.

It is strongly recommended that you engage with your Clinical Governance Unit to seek support for and during your improvement project. Your Clinical Governance Unit will be able to link you with local quality improvement experts or groups with a vested interest in improving Med Rec.

Locally, you can also reach out to colleagues in your district or utilise available networks to find out how others approached their improvement work, as well as their successes and learnings. For example,

• Hospital executive (e.g., Director of Medical Services/Nursing)
• Medication Safety committee members
• Med Rec working group, or leads
• Quality Improvement advisors (Clinical Governance/Patient Safety Unit).

One of the most important tasks is to establish a project sponsor. This will involve presenting your case for change to your potential sponsor. A sponsor should provide support and guidance to the project team and has authority to make changes. They should also ensure appropriate resources are provided and help remove barriers when needed.

Ideally, your lead/sponsor is someone who does not work directly on the project but is in a senior position who believes the problem is worth solving. The team should communicate closely with the sponsor and provide regular updates.

Use the Med Rec Improvement Project Brief to approach your sponsor and project team.

Your project sponsor will be able to provide guidance on where the governance of the project will sit within your health service. This will ensure there is operational responsibility for the project and a channel to report back on how the project is progressing. For example:

• At unit/ward level: Integrate project reporting with existing Quality Use of Medicines (QUM) review meetings
• At health service/LHD/SHN level: Integrate project reporting with existing Drug and Therapeutics Committee (DTC) or Medication Safety Committee.

Note this is different from your project team structure. Your project team consists of members who carry out the project interventions.

* marks members that are strongly recommended

While a team leader's role is to steer the QI project, it is essential to assemble a dedicated team who are also committed to actively supporting the project. QI projects often fail when team members are unable to sustain interest or participation in the project, leaving team leaders to carry the project.

The role of the project team includes:

• evaluating current medication reconciliation processes
• identifying and enlisting clinical champions
• establishing general goals
• developing, implementing and evaluating improvement strategies
• disseminating results and findings.

Once the project team has been established, it is important to make sure everyone is aligned regarding the problem that the project is targeting and what is IN and OUT of its SCOPE. Without a well-defined scope, projects tend to grow beyond what is achievable, lose focus of the problem, and fail.

1. Cornish PL, Knowles SR et. al. (2005). Unintentional medication discrepancies at the time of hospital admission. Arch Intern Med 165: 424-429.

2. Gillespie, U., A. Alassaad, et al. (2009). A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: A randomized controlled trial. Archives of Internal Medicine 169(9): 894-900.

3. Australian Commission on Safety and Quality in Health Care. (2017). National Safety and Quality Health Service Standards Guide for Hospitals. Sydney: ACSQHC.

4. Mueller SK, Sponsler KC et al. (2012). Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med 172(14): 1057-1069.