Table 2 Implementation categories, associated strategies, and examples of operationalization

ERIC implementation strategies

Examples of strategy operationalization (tactics)

Revise professional roles

Included in the role of non-physician professionals the ability to document medication-related changes in the EHR.

Pharmacy technicians documented in the EHR and took a BPMH. Dedicated pharmacist time to do MedRec instead of nurses and physicians. Decentralized pharmacy services. Moved the responsibility for training pharmacy technicians from physicians to pharmacists and pharmacy technicians. Used nurse practitioners in certain areas to correct medication lists.

Change records systems

Adopted electronic processes to support MedRec such as tracking boards and use of icons; processes to show flow and completion of MedRec stages; keyboard shortcuts to facilitate documentation.

Transitioned from paper process to electronic processes to support MedRec. Adapted EHR systems to accommodate documentation of MedRec in the EHR.

Created a progress note template in the EHR. Adapted EHR to be clear to show which patients had a BPMH done and who still required one. Used bed boards to identify patients who might still need medication history (high-risk patients).

 Facilitate relay of clinical data to inter-professional teams

Used the EHR and existing technology to aid inter-professional information exchange such as using keyboard shortcuts for common phrases related to MedRec and icons on tracking boards.

Used the EHR to share when pharmacist or pharmacy technician has reviewed medication lists.

Standardized documentation in one repository to communicate the admission list was completed.

Used progress notes in the EHR to relay information.

 Change workflow systems

Restructured work or responsibilities to allow pharmacists dedicated time for MedRec.

Adapted existing technology such as adding progress notes or board systems to follow patient flow.

Used algorithms to flag high priority patients for pharmacy technicians to see.

Connected to external pharmacy, care centers, and physician office EHRs for patient medication list.

Integrated discharge orders with standardized and pre-selected boxes.

ERIC implementation Strategies

Examples of strategy operationalization (tactics)

Use advisory boards and workgroups

Determined board membership; Built a multi-professional team and focused on including professions “touched” by the improvement activities (e.g., clinical, operational, patient experience, physicians).

Advisory board provided support to hospitals’ participation in collaborative.

Audit and provide feedback

Audited various aspects of MedRec: specific processes such as BPMH appropriateness and accuracy of medication lists; individuals doing MedRec; physician’s completeness of medication information.

Observed staff conducting MedRec to evaluate, monitor, and provide feedback. Conducted daily discussions and use of data.

Purposefully re-examine implementation

Examined new structures (e.g., documentation and notes in EHR) with involvement of frontline staff and determine best practices.

Re-evaluated best ways to use pharmacy technicians.

Use a quality improvement/implementation advisor

Identified and used a mentor internal to organization and include QI department staff or process improvement person from the beginning of the project.

Made use of external mentors for discussions about challenges like time and resource limitations and for troubleshooting.

Develop tools for quality monitoring

Used Excel spreadsheet to track number of patients seen each day by pharmacy technicians.

Built a note template into EHR with a screening element to monitor type and time used for doing interventions.

Modified medication list status choices in EHR to reflect the workflow (pharmacy team initiated or in process, pharmacy technician history completed but pending pharmacist review, pharmacist review completed)

Obtain and use patient/consumer and family feedback

Shared ideas and findings, and changes staff wanted implemented.

Provided feedback of efficacy of MedRec notes to ensure physicians used correct processes as desired by pharmacists.

Improved EHR processes by using MD feedback.

Used staff (pharmacy services, nursing, hospitalist, physician) feedback on what should be improved and how.

 Determine project-related goals for individual performance measures

Created a scorecard of activities that pharmacy technicians completed.

Monitored the number of medication histories completed within a week.

Recognized units when 100% of their patients have completed MedRec. Monitored individual providers’ discrepancy rates.

Expected pharmacy technicians to use two-source verification when conducting medication history.

 Determine ownership and hold individuals accountable.

Assigned ownership of the project and held people accountable for their performance.

ERIC implementation strategies

Examples of strategy operationalization (tactics)

 Conduct a local needs assessment

Used QI processes and surveys to identify areas for improvement and resources available.

Used Gantt charts, swim lanes, and gap analysis to identify areas of need. Identified all requests for MedRec and where the biggest needs for MedRec were. Identified resource needs to justify resource requests. Information from needs assessment would drive the impact of the pharmacy team doing Med histories.

 Assess for readiness and identify barriers

Determined project staffing, map existing processes and identify gaps that need addressing.

Called meetings with frontline staff and organizational leaders to identify barriers. Implementation team represented all disciplines involved in MedRec (physicians, pharm tech, ED, pharmacists) to understand existing processes.

 Identify resources

Specified who would be doing the work and collecting the data on these resources.

Leveraged and used the large pharmacy residency program at the hospital to assist with the project. Identified staff that could be reallocated to meet project demands (e.g., nurse on light duty was trained and used to perform MedRec tasks)

 Identify and prepare champions

Delineated job functions/ Expectations of persons serving as champion.

Identified those who were passionate about MedRec and recruited them to serve as champions. Some champions self-selected because they were motivated and identified MedRec improvement as an issue.

 Involve executive boards and/or sponsors

Used quality improvement board, quality improvement section of the pharmacy department, and chief of quality improvement committee to promote and support the program and to make staff available and set structures in place for data collection.

Executives promoted the program and encouraged applying to MARQUIS2; Obtained executives ‘permission to apply to MARQUIS program and to obtain resources to support implementation efforts.

Garnered executives’ support for the project by having them help with selection of units for participation and set program expectations.

 Recruit, designate, and train staff

Hired staff and trained new pharmacists.

Used observation to provide training on how to perform medication histories

Received hands-on training from another pharmacist.

Identified individuals on existing steering committees to lead the MARQUIS project.

 Conduct local consensus discussions

Set goals, expectations, and priorities during discussions.

Conducted formal meetings with discussions with pharmacists and nursing staff on how to make changes to the MedRec process.

Implementation teams held informal meetings and discussions with frontline pharmacists and pharmacy technicians to evaluate process and status of project.

Conducted formal meetings with stakeholders to discuss how processes could improve when implementation problems occurred.

 Marketing to stakeholders

Provided a bi-weekly tip sheets to physicians to raise awareness.

Conducted noon lectures to house staff.

 Tailor strategies to overcome barriers and honor preferences

Identified and discussed barriers, then strategies identified to overcome the barriers.

Redesigned forms, obtained frontline staff feedback and made changes, with group consensus, to forms based on feedback.

 Stage implementation scale up

Scaled up MedRec from when pharmacy technicians were available to also doing when they were off duty (nights/weekends). Achieved this by doing MedRec the next day when pharmacy technicians were available on those patients who were admitted overnight.

Conducted a pilot on three units before scaling it up to other units.

 Build a coalition

Developed a MedRec committee and a team of hospitalists to work closely with the implementation team and site leader.

Established a MedRec steering committee (MD lead, a MedRec pharmacist, regional pharmacy director, IT reps, QI specialist).

Partnership with MARQUIS2 provided a structure for MedRec processes and specific project goals.

 Partner with quality improvement experts external to the organization

Used QI staff to gather information, streamline processes, and identify high yield efforts.

 Develop interdisciplinary implementation teams

Interdisciplinary teams used for implementation, including clinical coordinator, director of pharmacy, pharmacy residents, hospitalists. Teams consisted of pharmacy director, pharmacy manager, pharmacy coordinator, medical director.

 Identify people and time necessary for data collection to support the project.

Determined persons responsible for data collection to support the project and identify resources needed to support data collection activities.

Developed specific tools for data collection, interpretation and sharing - custom Excel spreadsheet, dashboard to assess productivity, repurposing existing reports to track pharmacist performance.

ERIC implementation strategies

Examples of strategy operationalization (tactics)

 Develop effective educational materials

Used electronic modules to broaden reach to staff

Survey staff to identify learning needs. Created a “help” sheet for all the nursing units, inpatient-pharmacy, and hospitalists.

 Provide ongoing consultation

Pharmacists were available to answer questions and to consult and troubleshoot with hospitalists and review with them quality reports. Implementation teams consulted with QI experts to streamline processes and address challenges to change behavior.

 Conduct educational meetings

Used existing clinical (e.g., hospitalist meetings) and business meetings (e.g., quality improvement meetings) to provide education. Used different modalities including the intranet, in person feedback in clinical units, use of data, and role-play.

 Make training dynamic

Used staff training in combination with shadowing pharmacy staff to verify accuracy of project-related processes; provided various modalities (pocket cards, online classes, and posters) available for self-paced learning.

 Conduct educational outreach visits

Visited other successful MARQUIS sites or have them visit the hospital to provide training to project staff. Participated in a learning collaborative organized by MARQUIS project staff.

 Conduct ongoing training

Conducted ongoing training through weekly emails and in person when needs presented.

 Distribute educational materials

Communication occurred through distribution of educational materials that included using the Internet, creating help sheets, and using project generated toolkits and pocket cards.

 Inform local opinion leaders

Provided key stakeholders (like unit managers, service line directors) with information about the project (e.g., PowerPoint presentation to leadership), outcomes data, and project progress

 Create or participate in a learning collaborative

Hospitals participated in a MARQUIS collaborative where sites presented their results and shared best practices with each other (online collaborative) and local one day workshops, where site leaders from several sites received in-person training. It also provided a chance for sites to meet leaders from other sites and to share their experiences.

 Use mass media

Use TV advertisements, newspaper articles, education in the community, and marketing using social media. Used posters to inform hospital staff.

 Individualized training sessions

Individual training sessions allowed for discussion of questions, answers, and immediate feedback; communicated performance on an individual basis; live training to allow trainees to ask questions. Train pharmacy technicians, shadowed them to ensure they were asking the right questions and putting the correct data into the charts, allowing them to work independently, and checking up to 20 records they completed to ensure history done correctly.

Finance

Various finance strategies leveraged to incentivize the use of the MARQUIS Toolkit and provided resources for training and ongoing support.

 Incentivize positive performance and training.

Incentivized engagement with project using gift cards and other rewards.

 Demonstrate value to justify program and gain ongoing support.

Used data to show the value of the program and its impacts on patients.

Used pilot study to demonstrate return on investment.

Policy context

Strategies that encouraged the adoption of the MARQUIS Toolkit through accrediting bodies, licensing boards, and legal systems.

ERIC implementation strategies

Examples of strategy operationalization (tactics)

Use accreditation bodies and organizational policies to direct change.

Accreditation bodies required MedRec implementation and helped to enhance adoption/implementation. Organizational policies changed to allow lower level providers to correct the medication list to enhance the workflow.

Integration (non-ERIC category)

Strategies that facilitated the integration of the new intervention(innovation) into existing structures and/or processes

 Adaptation of existing processes

Adapted existing MedRec program to fit new intervention or adapt existing technology to meet project needs including health electronic record systems and bed boards. Adapted existing high-risk patient criteria to what MARQUIS2 Toolkit provided. Adapted existing process of medication histories within 24 hours to focusing on patients who will be admitted from the ED.

 Alignment of the project with existing initiatives

Aligned project with the quality improvement infrastructure of the hospital and with existing infrastructures like committees (medication safety committee, patient safety committee) that are multidisciplinary in nature. Used existing pre-surgical phone call to obtain a medication history during surgery prep phone calls.

Attend to professional roles (non-ERIC category)

Strategies that promoted implementation of team members and professionals who used the MARQUIS Toolkit intervention feeling valued and having clarity about their roles in the implementation of the toolkit

 Professional roles and task responsibilities.

Specified team member roles and share with key stakeholders, clarify and specify the role of the implementation team in the context of the project within the organization. Frequency of team meetings and assignment of roles and responsibilities to each team member.