Download Improving efficiencies in the self-medication

Improving efficiencies in the self-medication program at
Bridgepoint Hospital
Chen Chen
Alexandra Heeney
Taylor Martin
Prepared for:
Janice Takata-Shewchuk – Pharmacy Director
Dr. Tammy Sieminowski – Attending Physician
MIE561
Professor Michael Carter
March 23, 2010
EXECUTIVE SUMMARY
The Bridgepoint Hospital (BH) Self-Medication Program (SMP) in the neurorehabilitation wing was
established to i) help chronic care patients become more self-sufficient in managing their medications
through education and ii) better anticipate patient outcomes post-discharge. Currently, the SMP is unable
to accept and adequately maintain all eligible patients for the program due to an unsustainably high
workload for pharmacists and the need to maintain the same nurse workload. The following is a list of
the challenges to overcome to achieve these workload objectives and to improve program performance,
and the recommendations on how to do so:
1. The current SMP information systems are inadequate for assessing patients and measuring SMP
processes. Information is not adequately stored to allow for easy data analysis, and information is
not adequately shared between departments leading to delays and redundant work.
Recommendations:
 Standardize metrics for measuring patient knowledge and consistency and timeliness of taking
medications; and
 Acquire new Meditech modules to allow for increased and improved electronic data entry which
can be remotely accessed.
2. The current SMP processes for making requests to start patients on the SMP, initiating patients
on the SMP, and maintaining patients on the SMP are inefficient, causing high pharmacy
workload.
Recommendations:
 Delegate pharmacy tasks for initiation to team members with more appropriate expertise;
 Decrease setup time for pharmacy to fill prescriptions by increasing flexibility in the procedure
and making it as modular as possible; and
 Establish standard practices for initiating and tracking patients on the SMP.
3. The current SMP does not provide patients with adequate medication management support to
help remind patients when and why to take their medications and to help patients learn to take
their medications.
Recommendations:
 Use best practices for pedagogical methods, habit formation, and educating people with
disabilities to better tailor patient education; and
 Provide low-tech systems to help patients track and remember to take their medications.
Table of Contents
Introduction ................................................................................................................................................. 1
1. Problem Definition.............................................................................................................................. 2
1.1. Inadequate program information systems .................................................................................... 2
1.1.1. Inadequate metrics for measuring program and patient performance................................... 2
1.1.2. Inadequate means of recording and storing information ...................................................... 2
1.1.3. Inadequate means of sharing, and retrieving information .................................................... 2
1.2. Inefficient process flow ................................................................................................................ 3
1.2.1. Inefficient request and initiation process .............................................................................. 3
1.2.2. Inefficient medication maintenance process ......................................................................... 3
1.3. Inadequate patient medication management systems (MMSs) .................................................... 3
2. Recommendations ............................................................................................................................... 4
2.1. Improving program information systems ..................................................................................... 4
2.1.1. Improving metrics for measuring program and patient performance ................................... 4
2.1.2. Improving means of recording and storing information ....................................................... 4
2.1.3. Improving means of sharing and retrieving information ...................................................... 5
2.2. Improving process flow ................................................................................................................ 5
2.2.1. Improving the request process .............................................................................................. 5
2.2.2. Improving efficiency of medication maintenance process ................................................... 6
2.3. Improving medication management systems (MMSs) for patients ............................................. 7
3. Evaluation of Recommendations ........................................................................................................ 7
4. Conclusions ......................................................................................................................................... 8
5. Future Work ........................................................................................................................................ 8
5.1. Measure outcomes post-discharge ............................................................................................... 8
5.2. Investigate electronic MMSs to support patients ......................................................................... 9
5.3. Make on-site visit to Bridgepoint Hospital .................................................................................. 9
Demonstration Report
Team AME
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Introduction
Bridgepoint Hospital (BH), a hospital specializing in complex chronic care and rehabilitation for people
with chronic diseases, has implemented a self-medication program (SMP) to teach patients to manage
their medications on their own [1]. This programme also helps patients better understand what
medications they are taking to prevent taking the wrong medication. This case study examines the SMP
in the neurorehabilitation ward where 60%, or approximately 19, of the 32 patients participate.
Participation in the SMP can improve post-discharge patient outcomes at home, while failure to
successfully self-medicate may lead to discharge to a long-term care facility. The goals of the SMP are:
 Education: empower patients by educating them on what medications they are taking, how and
when to take them, the reasons for taking them and possible side effects.
 Diagnostic: better evaluate patient performance and anticipate outcomes post-discharge.
 Independence/autonomy: Promote patient ability to self-medicate to increase the number of
patients discharged back to their homes.
BH aims to increase the capacity of the SMP so that all eligible patients may participate. A patient is
authorized for the program when the physician issues the order to start after consultation with the
multidisciplinary team, which includes among others, physiotherapists, occupational therapists, nurses,
the attending physician, and a pharmacist, if possible. Next, the pharmacist makes the decision to initiate
a patient on the program based on perceived priority. The pharmacy is the most constrained resource.
In the medication administration process, pharmacy first transcribes paper prescriptions into the
computer system. Next, pharmacists prepare the patient-specific dosettes and packages the patient’s
medication based on his or her physical capabilities. Prescriptions are filled by pharmacy technicians
and are double-checked by the pharmacist. Medications are then distributed to patients by the ward
nurses, who must be present at the time of administration and who are involved in the patient education
process and in determining the degree of patient success on the program.
This case study analyses the information systems in the SMP, the process flow of both initiating patients
and managing patients on the SMP, as well as the support systems in place to help patients on the SMP.
Recommendations are provided to help meet the interconnected objectives outlined in Figure 1, in
particular, increasing patient capacity on the SMP while decreasing pharmacy workload, and
maintaining nursing workload. These recommendations will be evaluated based on cost and time for
implementation and resources required for maintenance.
Figure 1: How the case study goals and program goals are linked and required changes to meet the goals.
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1. Problem Definition
1.1. Inadequate program information systems
1.1.1. Inadequate metrics for measuring program and patient performance
It is difficult to produce measurable and sustained improvements to the SMP processes and patient
outcomes because of inadequate metrics and a lack of standardized processes. Very little is known
about the timing of the SMP process as only a few milestone times are recorded in the patient selfmedication process: the patient arrival, request for self-medication, and time of discharge. Although the
Medication Administration Record (MAR) indicates the time of receipt and delivery of medication,
these are recorded on paper and attached to each patient's chart; aggregate statistics would be hard to
extract. Similarly, determining SMP patient progress and self-sufficiency is difficult as nurses conduct
these subjective assessments and patient outcomes after discharge are unknown. Hence, it is unknown
whether the current program accurately assesses a patient's ability to take medications properly, and to
understand what is being taken and why.
1.1.2. Inadequate means of recording and storing information
Information is inadequately recorded and stored. This leads to inadequate data collection and difficulties
in accessing and analysing existing data.
The current MARs filled out by nurses, and in some cases patients, are not designed to easily record the
necessary metrics regarding patient performance in a time-efficient manner. This hampers the ability to
obtain data that are accurate and complete, as there is no monitoring of data recording.
The mix of paper and electronic records used to document patients leads to delays in communication
between hospital departments, particularly between the ward and the pharmacy. Paper documentation
includes drug prescriptions and nurses’ records of drug administration by patients. The paper
prescriptions are manually transferred to the pharmacy, where the pharmacist will input them into the
computer and carefully examine each drug order. This transcription practice is redundant and introduces
an extra opportunity for transcription errors, which may result in further delays if the pharmacist must
contact the doctor for clarification of a prescription.
There is no central system for data uploading, preventing analysis and identification of trends in the
overall performance of the program and up-to-date analysis of patient progress on the program.
1.1.3. Inadequate means of sharing, and retrieving information
Poor information sharing between staff in different departments and between staff and patients results in
an increased workload, primarily for pharmacy and nurses, who may be doing redundant work as a
result. For example, pharmacists may have to redo the time-intensive preparation of a patient’s
medication regimen for the week because a medication change did not reach them in a timely manner.
Paper documentation prevents remote access to patient information, which is available through existing
electronic information systems; delays occur in transferring paper documentation between departments.
This transfer forces multiple staff to interact in information exchanges, be it face to face or over the
telephone. In addition, data are not consolidated into easy-to-read reports for quick reference.
Communication breakdowns between departments are further exacerbated by the lack of a
comprehensive electronic health record system. For instance, nurses’ records are typically kept in the
patient’s file. While this allows continuity from shift to shift, this leads to a buildup of obsolete data.
Also, the system does not allow for posting of long-term or priority messages. Meditech software is used
in some tasks, but is not configured to facilitate integration of all of the patient’s information. For
instance, the Pharmacy module (PHA) is only accessed by pharmacists. This introduces the extra burden
of prescription input for the pharmacists.
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1.2. Inefficient process flow
1.2.1. Inefficient request and initiation process
Incorporating zero to four new requests for SMP each week, while pharmacists are still managing six to
eight patients long-term, the request process augments the high pharmacy workload for two reasons.
First, initiating patients on the SMP is labour- and time-intensive for pharmacists, taking an average of
three hours per patient [1]. Pharmacists are responsible for cleaning up the list of medications to provide
more standardized medication administration. For instance, making all drugs administered every eight
hours as opposed to every six and every eight hours). They must visit patients to determine the best
method for accessibly packaging the medication, even though this is not an area of pharmacist expertise,
as well as be the first contact for initially educating patients on their medication. Second, there is no
standard for when a patient should begin the SMP. The time between a request and the first delivery of
medication is not recorded, so anecdotal data is used to estimate this setup time. Because pharmacy has
been perceived to be taking longer to process requests, requests for SMP initiation have been placed
earlier to ensure that patients can receive timely treatment. However, this practice could be increasing
the average length of time a patient is on the SMP.
1.2.2. Inefficient medication maintenance process
The SMP process for medication maintenance is inefficient due to the uncertain timing of medication
changes for pharmacy and the uncertainty in patient calls to nurses. Self-medications are usually
prepared one week in advance with a manual process that involves both pharmacists and technicians. If
a physician determines that a patient's medication must be changed, then the previously prepared
medications must be recalled and new medications must be prepared. Pharmacists must update the
patient medication information sheets, which is also especially time-consuming because of standard
practice to tape individual pill samples to the information sheets for viewing by patients. This is
problematic as changes are hard for pharmacy to predict and information regarding the new changes is
not immediately transferred to pharmacy; medication orders are written on paper, resulting in redundant
work in medication preparation (also see section 1.1.3).
The SMP can be disruptive to nurses and nurse workflow. Patients call for a nurse to deliver their
medications. However, a patient will be reminded if the nurse realizes that the patient failed to call on
time. Since nurses will have competing duties, these calls can interrupt their regular work flow,
especially if the calls are not made in a timely, predictable manner.
1.3. Inadequate patient medication management systems (MMSs)
The Bridgepoint Hospital SMP does not provide adequate patient medication management systems
(MMSs) such as reminder systems to help patients remember to take their pills or easy-to-use
educational manuals. This lack of MMSs results in longer timelines for patients to reach independent
self-medication. Consequently, patients could be on the SMP longer than necessary, using up valuable
staff resources: pharmacy’s workload is increased due to managing more patients and the nurses’
workload will ultimately be increased which could become a source of additional bottlenecks. The lack
of MMSs also means that it may take longer for clinicians to be confident that patients can self-medicate
adequately for discharge.
WHO studies have identified a 50% non-compliance rate among chronic disease patients [3] and
indicate that this rate can be reduced through various MMSs [3]. As the neurorehabilitation unit
rehabilitates patients with additional cognitive problems, which inhibit their ability to successfully selfmedicate, MMSs are particularly important to ensure program success.
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2. Recommendations
2.1. Improving program information systems
2.1.1. Improving metrics for measuring program and patient performance
The SMP should establish metrics for both its patients and its internal processes to determine the
effectiveness of initiatives for improving the program.
Assessing patients
The main goal of the SMP is to ensure that the patient can manage his or her own medication by
discharge. The client named three aspects of this goal: consistency of intake, timeliness of intake, and
understanding of medication.
Consistency and timeliness of medication taking
Although there are many methods for measuring
patient adherence to medication, direct observation the most accurate measure of adherence, as
compared to an indirect method such as counting number of pills taken [4][5].
The patient assessment should be modified to include information about what kinds of medications and
with what frequency they are being taken. The current metrics, such as how often and what time
patients call for medications, do not account for the type of medication being taken. Certain medications
may require high adherence rates to ensure effectiveness, while others may be more forgiving about
missed intake [6]. Poor adherence might also be the result of a medication schedule that requires many
doses per day [5]. These metrics will likely emphasize the importance of providing simple and forgiving
medications for older patients; studies have reported adherence rates of the elderly that range from 26%
to 59% [7]. Furthermore, research on habit formation suggests that forgetting some occasions will not
significantly affect the otherwise consistent repetition [8].
Patient knowledge A patient’s knowledge of his or her medications is not only important for patientcentred care, but also can affect the patient’s adherence to medication [5]. Thus patients should be
regularly assessed for their knowledge of what medications they are taking and why. Although there is
an existing process to keep track of this, we recommend also keeping track of the number of medications
that the patient has to remember, and the number of prescription changes that occurred. Keeping track
of six or more prescribed drugs is a considerable task for many older patients even without cognitive
disabilities [4].
Measuring Processes
Recording start and finish times for processes in the hospital should be incorporated into each of the
SMP’s processes. This may be more convenient with electronic records. Requests, for example, could
be sent to pharmacy by updating a shared spreadsheet, with a date-and-time field to log this information,
and the confirmation of the request could be logged. Time studies should be conducted on processes
that are labour-intensive or that are bottlenecks, such as the pharmacy process of weekly refilling
medications. Each and every subtask of a process should be timed, such as moving a pill from a pile into
a bottle. Such detailed timekeeping would make it easier to identify problems in the workflow design
and to track the improvement of the SMP’s processes over time.
2.1.2. Improving means of recording and storing information
To improve communication and lessen workload for pharmacists and nurses, electronic recordkeeping
and messaging software use should be increased. Integration of the whole staff team into the existing
electronic record system, Meditech, would reduce redundancy in the communication process. In
particular, transcription delays, as well as errors, would be reduced by allowing the attending physicians
to electronically enter prescriptions and medication changes into the PHA module. Pharmacists would
remain responsible for double-checking for adverse medication interactions. However, potential
interactions may be avoided in the first place by providing doctors with access to the complete and up to
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date medication profile of each patient at the time of writing prescriptions.
Other Meditech modules could also improve the SMP with little added work and maintenance by the
hospital’s IT department. Meditech’s Data Repository module could support the program staff by
consolidating data and generating reports in a timely manner [9]. The repository could also be mined for
data when evaluating the SMP process. The electronic system would also allow for more frequent
evaluations.
The use of electronic MARs would help reduce redundant data taking and improve consistency in
nurses’ records. Electronic forms also have the advantage of data checking capability, which ensures
that all required data are recorded in every case. It may be possible to create MARs such that only
changes in patient data are recorded, carrying forward the pre-existing information. MARs should be
designed to be as task-specific as possible to minimize time and effort required for good record-keeping.
For example, MARs could contain a list of the medications for each patients, with a time-log created
when each medication is indicated to be taken (ticking a check-box), and with a special check-box to
indicate whether or not the patient remembered to call for medication (or some metric to determine how
well the patient remembered), and a place to easily enter score for patient’s memory of what the
medication is for. This should make nurse record-keeping less time consuming and be more conducive
to ensuring good, consistent record-keeping. Data entry should be standardized to allow for easy
comparisons between administration of medications for individual patients and also for comparisons
between patients.
2.1.3. Improving means of sharing and retrieving information
Electronic records and communication systems should be used to improve information sharing and will
increase access to information for each department. Meditech’s Order Entry module should be obtained
as it allows remote access to patient information for doctors, nurses, and pharmacists [9]. Test results
may also be shared under this system, providing data autonomy to departments by eliminating
dependencies. Access to the centralised system is immediate and reduces the amount of non-medical
work done by staff.
The Meditech Physician Desktop should also be acquired as it has clinical messaging capability that
would greatly improve communication between departments [9]. For instance, non-urgent questions
from pharmacy about prescriptions or medication changes could be logged for the attending physician to
address at the end of his/her shift. This would replace the practice of asking questions over the phone.
Electronic nurses’ communications on patient files could be flagged for others based on urgency. Notes
containing data relevant only to the short-term could be scheduled for automatic deletion or filing.
2.2. Improving process flow
2.2.1. Improving the request process
The request process can be improved by eliminating unnecessary work and by establishing a standard,
well-documented procedure for preparing patients for self-medication.
Eliminating unnecessary work
The initial patient interaction and education should be delegated by pharmacy to the nurses, who would
be the main point of patient contact thereafter, reducing pharmacy workload. Pharmacists would
prepare the nurses to educate their patients about the medications the patients will be taking. Although
this delegating would increase the initial responsibility of nurses, it would improve the nurses’ judgment
about their patients’ medication knowledge and may speed up patient success on the SMP, ultimately
reducing nursing workload. Further, because nurses frequently interact with patients, they would be in a
better position than pharmacists to document the outcomes of their education program. The task of
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determining what form of packaging to use for the weekly medications should be delegated to the staff
OTs: they have more appropriate expertise for assessing patient capabilities and have more direct patient
contact. This will help reduce pharmacy workload.
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Team AME
Establishing standard practice
A standard procedure for determining when to place a request will prevent patients from being placed on
the program too early. Unfortunately, the lack of convincing evidence regarding self-administration
programs means that there are no definitive standards for the Bridgepoint SMP to rely on
[10]. However, we can provide suggestions for determining the time to place a patient on SMP.
Before placing a patient on SMP, it would be useful to gauge the patient’s capability of adhering to a
regular schedule. Following the practice of the study by Hayes for testing pill dispensing machines,
Bridgepoint should place patients on a vitamin C regimen - or if this is considered too risky, a placebo
pill regimen - as soon as possible low-risk way to estimate how well patients would be able to learn from
the SMP [11]. Unlike most medications, vitamin C or placebos can be left at the patient’s bedside,
reducing the burden of delivering medicine by the nurses.
Counting remaining pills at regular intervals would provide an objective measure of how well the patient
was able to implement regular pill intake. Tracking poor performers separately from other performers
throughout the SMP would provide useful statistics. For example, if patients who fail the SMP were all
poor performers at the vitamin/placebo regime, these patients may require certain interventions such as
medications whose efficacy will not be affected by delayed or missed doses [5].
Bridgepoint should try to avoid placing patients in the SMP if their medications are likely to change. If
throughout the SMP the patient experiences multiple medication changes and substitutions, this could
increase patient anxiety and confusion [12]. Additionally, the most important part of habit formation
occurs in the first few weeks of constant repetition of the habit; if medications change too often, patients
may have to unlearn old habits while also learning new habits, which could be difficult [8].
Consequently, delaying certain requests for SMP in order to avoid medication changes might improve
the patient’s habit formation. In the meantime, the patient could be placed on a vitamin/placebo regimen
so that he or she can become accustomed to taking pills at regular intervals.
2.2.2. Improving efficiency of medication maintenance process
The medication maintenance process can be improved by increasing flexibility in pharmacy, and by
redesigning the nurses’ work. Pharmacy is producing self-medication packages in weekly batches to
reduce their workload by spreading out their setup time over many patients’ medications. We
recommend instead that pharmacy reduce the setup time for refilling prescriptions by redesigning their
tasks. For example, pharmacy generates a list for all patients’ medications. A modular information
sheet, which was used to keep separate records for each patient, would be more flexible and would save
time to fill out. With sufficiently short setup times, it will become feasible to reduce batch sizes and thus
increase pharmacy’s flexibility to changes in prescriptions. For example, if medications are prepared
three days ahead instead of seven and prescription changes occur on random days, there would be two
fewer days of medication wasted per change. By attempting to reduce batch sizes, pharmacy will be
more likely to find ways to reduce setup time.
The nurses’ workflow can be redesigned such that, when verifying patient medication knowledge, the
nurses need not ask patients to repeat all side effects and information each time. The level of needed
repetition could be decided by the nurse on a case by case basis depending on patient performance. This
could reduce the overall time required of a nurse in handling patient calls for medication. The
medication timing should be staggered appropriately; for example, patients could be asked to call at
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Team AME
certain scheduled times as part of the SMP. This would smooth out the demand for nurses.
2.3. Improving medication management systems (MMSs) for patients
The medications for patients should be administered in a manner that would simulate as closely as
possible how patients would take the medication after discharge. This includes how the patient
remembers (or is reminded) to take the medications, how the patient is asked to identify the medications,
and how the patient interacts with any provided informational material, such as the medication list. This
will be integral in helping patients to develop good habits [8]. Education on medications should be
enforced through engaging multiple learning styles to ensure that appropriate pedagogical methods are
used when teaching patients about their medications [13]. These could include auditory, sensory, visual,
and kinaesthetic. It may also be helpful to make use of existing research on helping people with
disabilities cope with medication management, such as how the blind manage medications, as many BH
patients are nearly blind [14].
Additionally, there should be systems to help remind patients of their medications, such as an alarm that
will ring at the appropriate times for medication. MARs should also be rolled out to all patients that can
use them to help each better track his or her medications. If these are inappropriate due to language
barriers or visual problems, other tracking systems should be put in place, such as a white board above
each patients’ bed with a list of all medications and times when medications should be taken. The board
could include a place to check off each medication as it is taken. These MMSs could easily be put into
practice at home. The information that patients should track is similar to that outlined in section 2.1.1.
3. Evaluation of Recommendations
Solution
1
New metrics for patient
assessment
Ease of Implementation
Cost: cost of implementing the tracking of metrics
Time to Implement: <1 month
Maintenance: None
2
Acquire new Meditech
Modules
Cost∫: Cost of Meditech software
Time to implement: 3-4 months, including training for staff
Maintenance: periodic maintenance and back-up by IT department
3
Transfer patient interaction
from pharmacy to nursing
4
Standard practice for SMP
requests
Cost: Initial increase in nurse workload but more than offset in long-term by
improved nurse knowledge, better assessment of patient performance, leading to
better patient outcomes and shorter times on SMP/patient,
Time to Implement: 1-2 months
Maintenance: Educational materials can be added to the program over time;
Time for nursing and pharmacy to communicate and monitor patients
Cost∫: time to design SMP request process and any technological support system
Time to Implement: <1 month
Maintenance: none
5
Preliminary trials with
vitamins to assess patients
6
Reduce setup times in
pharmacy and batch sizes
7
Reduce batch sizes in
pharmacy
8
Test patient knowledge at
different times from
medication calls and ensure
education methods are
optimal
Provide low-tech MMSs
9
Cost: Cost of vitamin pills (low)
Time to implement: 1-2 months
Maintenance: Pill counts and recordkeeping will be needed throughout
Cost: Cost of transporting medications more frequently and multiple setup times
Time to implement: <1 month
Maintenance: None
Cost: low
Time to Implement: <1 month
Maintenance: None
Cost: reduces cost of SMP/patient, cost of teaching nurses education methods
Time to Implement: <1 month
Maintenance: Nurses must track what knowledge has been tested and when to
ensure all knowledge is appropriately tested
Cost: low – cost of whiteboard or alarm clock, etc
Time to Implement: <1 month
Maintenance: Update tracking methods/alarm systems with medication changes
Implementation Decision
Implement immediately as
these will be necessary for
evaluating all other
recommendations
Implement as soon as possible
as this could cause significant
improvements, but may need to
wait to acquire funds
Implement immediately
Implement immediately as this
is needed to ensure overall
process improvements and is
low-cost
Wait until new metrics have
been established
Implement setup time reduction
immediately, and once
successful, reduce batch sizes.
Wait until initial attempts at
reducing setup times are
successful
Implement immediately
Implement immediately as this
may reduce bottlenecks and the
time patients must be on the
SMP
In order to determine exactly when to implement each of these recommendations and how useful each
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would be, a computer model should be developed to track how these methods would produce results.
For example, the model could track as inputs: number of patients on the SMP, number of medication
changes to SMP patients, time for pharmacy to process each change, cost of staff hours and of new
equipment/software. Estimates of these metrics could be used initially and updated as better information
tracking was implemented. The goal of the model would be to maximize number of patients on the
program, given constraints on pharmacy and nurse time and financial resources. Sensitivity analysis
could be performed to determine, for example, how much setup times need to be reduced to produce a
significant reduction in workload and increase in program capacity.
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4. Conclusions
This case study addressed three main problems that the BH SMP should address to increase patient
capacity while reducing pharmacy workload and maintaining nursing workload. First, there are
inadequate program information systems: good metrics have not been developed to adequately track
program and patient outcomes, electronic records and systems are underutilized limiting information
sharing between apartments, and data entry is largely done manually making it both time consuming and
difficult to determine program outcomes. This can be alleviated by developing appropriate metrics for
assessing patient progress, acquiring additional Meditech modules to improve electronic record-keeping
and information sharing, and making improvements to data entry [9].
Second, the processes for initiating and maintaining patients on the SMP were problematic. Because
they are labour and time-intensive, this led to an unsustainably high workload for pharmacists,
producing bottlenecks, which worsened the problem. Processes can be improved by standardizing
procedures, reducing setup times and using batches in pharmacy when filling prescriptions, and
delegating some of pharmacy’s tasks (such as assessing the patient for medication packaging) to team
members with more appropriate expertise and greater contact with the patients.
Finally, the SMP does not provide adequate support to patients to help manage their medications. Patient
education may not make use of best practices for pedagogical methods, educating people with
disabilities, and ensuring good habit formation. Best practices for engaging learning styles and ensuring
habit formation should be incorporated in the education process. Reminder systems such as an alarm and
a means to track when and what medications have been taken can support patients in a way that can be
continued after discharge, which will reduce their time on the SMP, and thus make better use of BH
resources.
5. Future Work
5.1. Measure outcomes post-discharge
Patient adherence to medication taking should be measured post discharge to obtain direct feedback
regarding the SMP’s main goal to ensure patient self-sufficiency in adherence, as studies indicate
adherence declines post-discharge within 30 days [5]. This means data gathered in the hospital may be
overly optimistic regarding long-term adherence. A representative sample of patients who represent
each possible outcome post-discharge should be tracked. The nature of this information will depend on
what the source can provide; for example, a pharmacy or nursing home may be able to provide the
frequency of refill, the time-of-day and frequency with which medication was administered, but
discharged patients likely could only provide a self-reported assessment of their adherence, for instance
on a scale of one to seven. Adherence will very likely decline upon discharge: studies have found a socalled “white-coat” effect, where patients have poorer adherence 30 days after an appointment with a
health care provider compared to the time period shortly before and after it. Patients could also be
provided with electronic or paper MARs to track their medication adherence and these forms could
either be mailed to the clinic if paper is used or, preferably, synced with the clinic’s database remotely.
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5.2. Investigate electronic MMSs to support patients
Although an electronic MMSs may not be feasible due to costs, electronic MMSs may be a long-term
solution for improving patient medication management to ensure that reminder systems will be in place
no matter where the patient is, which can be achieved through use of a portable device [11]. Many
electronic MMSs are currently on the market [6][11][15]. Examples include a SMS system which sends
a text message to the patient’s phone reminding what medication to take and why, a watch which has
programmable alarms for what medication to take at pre-determined times, and adherence packaging
which helps electronically remind patients and to take their medications and log adherence [16][17][18].
5.3. Make on-site visit to Bridgepoint Hospital
In order to better understand the BH SMP processes, where the bottlenecks are, and how best to alleviate
them, an on-site visit is recommended. The goals of the visit would be to determine the details of the
pharmacist processes and their timing, how education is currently carried out and appropriate data are
recorded, and determine if, and if so, how additional Meditech software could be employed.
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