"This is a carefully considered approach to process change that allows us to test our assumptions about safety and risk and make adaptations to mitigate risk," says Jeremy Boal, MD, senior vice president and CMO of North Shore-LIJ Health System. "After implementation, we continue to audit it for adverse events by asking patients to log their experiences and by meeting frequently with the staff to see if they've identified new risks."
Six months after it was established, the team met its first two goals of reducing the length of time patients had to wait for the delivery of the medications for which they were admitted—to two hours (from 15 or more) for the first breathing treatment and four hours (from 18) for IV antibiotics. Beginning with a proactive risk assessment, the team had mapped the current system of care delivery and tested assumptions about its safety as well as the safety of new ideas. It also generated an order set that coordinates the workflow of all caregivers and, according to Jaffrey, "honors the actual way the work is done in the hospital."
The program went live in March 2010, with patients who opt to self-administer receiving special locked boxes containing all of their medications. Patients keep a log of what they take and when; nurses review the log to determine if medications are being taken correctly. The nurses also work with the hospital's pharmacists to keep the box replenished.
"The process gives the nurses oversight so we can still manage the documentation," says Margaret Murphy, RN, senior administrative director of patient care services. "It all seems so simple in retrospect, but at the time it required a lot of coordination and education. It offers a tremendous amount of efficiency while ensuring that the patients who know their medications are administering them correctly."