There's no 'I' in Med Rec

Molly Rowe, for HealthLeaders Media, June 20, 2008

CEOs, while they care about patient safety, aren't always involved in the in-the-trenches work that goes on with different patient-safety initiatives. Oh sure, occasionally I'll hear a CEO say he worries about hand-washing and infection control, but usually patient safety is left to the various departments—until something goes wrong.

Except with medication reconciliation.

Med rec is one of the few patient-safety topics that senior leaders mention all the time. At a conference I attended recently, one CEO presenter started his presentation (on an unrelated topic) by asking the room of senior leaders who of them had mastered medication reconciliation. Not one hand went up.

Organizations have struggled to implement a process for reconciling patient medications since The Joint Commission began requiring it in 2004. Four years later, most hospitals have a process in place but few have consistent compliance.

As I've researched and learned about this initiative, I've found that, while every organization approaches med rec differently, there are usually a few commonalities:
1) There's some sort of med rec form used to document the reconciliation.
2) There's a med rec leader who oversees the process.
3) There's a lot of finger-pointing when it comes to noncompliance.

Although medication reconciliation is a hospitalwide initiative at almost every hospital, most organizations isolate oversight and responsibility for the process to one department: nursing, pharmacy, or, occasionally, the medical staff. This sounds good in theory because it makes one person/discipline the medication reconciliation gatekeeper. However, it can also foster blame and reduce accountability. Why, for example, should nursing be responsible for a process that relies on physicians and pharmacists to succeed? How can pharmacy really make sure that the entire nursing staff is properly trained in the med rec process?

Northwestern Memorial Hospital knows the challenges of medication reconciliation first-hand. In 2006, the organization's quality team had done all the recommended steps to meet The Joint Commission's medication reconciliation requirement but their compliance hovered around 40%. That's when they changed their process.

They created a medication reconciliation leadership team that included hospital leaders from all departments (the chief medical officer; the chief of surgery; the chief informatics director; the directors of nursing, pharmacy, and quality; and the president of Northwestern's outpatient areas).

And they restructured their staff training process from one that was done in the "train the trainer" format, separated by discipline, to a multidisciplinary training that included every applicable staff person (nurses, physicians, and pharmacists) all in one room. This ensured that every discipline involved in Northwestern's medication reconciliation process got the exact same message and eliminated the usual blame game that goes along with med rec.

Once leaders were on board, the staff was retrained, and the process was up and running, they took the multidisciplinary approach a step further by looking at compliance data by discipline. This way, Northwestern's quality team can track how groups of nurses, pharmacists, and physicians are doing in terms of compliance, and they can identify any weaknesses without a lot of the unjustified finger-pointing that goes on in a lot of hospitals.

"When we say hospitalwide priority, we don't mean hospitalwide priority for this one physician, we mean hospitalwide priority for physicians, nurses, and pharmacy divisions," said Kristine Gleason, RPh, Northwestern's Clinical Quality Leader, whom I talked with last week.

Today, Northwestern's medication reconciliation compliance ranks above 90%, and the goal for 2008 is to stay above 95%.

If you're one of those senior leaders who is still desperately trying to figure out why your organization can't fully grasp medication reconciliation, you may want to consider a multidisciplinary model like the one at Northwestern. Because, while it's nice to have one med rec leader, it's better to have a whole lot of them.

Molly Rowe is leadership editor with HealthLeaders magazine. She can be reached at
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