AOPXXX10.1177/1060028013503128Annals of PharmacotherapyRoss


Quality Improvement in Health Care: Opportunities and Responsibilities for Pharmacists

Annals of Pharmacotherapy 47(9) 1206­–1209 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1060028013503128 aop.sagepub.com

Leigh Ann Ross, PharmD, BCPS, DPNAP, FCCP, FASHP1

Abstract Quality in health care has never been more important than today. As health care providers, pharmacists have an obligation to serve as leaders and visionaries and actively demonstrate and document the advances that patient-centered pharmacy services can provide. Many agencies and organizations have developed initiatives to advance patient care through quality improvement measures and patient safety programs. Pharmacists, both individually and collectively, must actively engage in quality improvement and patient safety programs that elevate care and support the evidence base for clinical pharmacy services. Keywords quality, patient safety, engagement, patient-centered pharmacy services, leadership

Chronic illness affects more than 133 million Americans. Over 90% of prescriptions are for the management of a chronic condition, more than 1.5 million individuals experience medication-related harm, and the estimated cost associated with uncoordinated care is over $240 billion per year.1-5 Although quality has been a topic of discussion in the corporate arena for the last 40 years, only recently has quality moved to the forefront of health care initiatives and policy in the US.6,7 From the Institute of Medicine (IOM) report To Err is Human: Building a Safer Health System,1 which focused on the prevention of medical errors, to the more recent IOM report calling for a fundamental redesign of our delivery systems to address gaps in the quality of health care,8 attention has centered on patient safety and quality of care. A focus on quality and safety was evident in the discussions surrounding the passage and implementation of the Patient Protection and Affordable Care Act.9 This legislation calls for a National Strategy for Quality Improvement in Health Care.10 This strategy is intended to promote quality while decreasing the administrative burdens and barriers to collaboration within health care systems. Quality is a consistent theme in these strategies, which include ensuring safe care, engaging patients, facilitating effective communication and coordination of care, promoting effective treatment and prevention initiatives, supporting best practices that enable healthy living, and making quality care affordable by developing and fostering the adoption of new health care delivery models.10 The safe and appropriate use of medications is

clearly a critical component of these strategies. Pharmacy has long been engaged in initiatives to address safety and quality. However, new opportunities exist and our profession has the chance to make meaningful contributions to these important initiatives. This commentary reviews existing work in the area of quality and outlines the opportunities available for pharmacist engagement.

Quality and Safety in Health Care Many organizations and agencies focus on the quality and safety of medication use (Table 1). They provide access to information and resources for the nation’s pharmacists to be involved in quality improvement projects and initiatives.

Agency for Healthcare Research and Quality The Agency for Healthcare Research and Quality (AHRQ) is the federal agency that has quality and evidence-based health care at the forefront of its mission. The agency is 1

University of Mississippi, Jackson

Corresponding Author: Leigh Ann Ross, PharmD, BCPS, DPNAP, FCCP, FASHP, Associate Dean for Clinical Affairs, Chair and Associate Professor, Department of Pharmacy Practice, School of Pharmacy, University of Mississippi, Jackson, MS, USA. Email: [email protected]

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Ross Table 1.  Quality Organizations and Resources. Resources


AHRQ AHRQ Quality Indicator Tools AHRQ Quality Measures Tools and Resources CMMI Partnership for Patients Medicaid Quality Measures PQA HRSA PSPC Change Package

http://www.ahrq.gov/ http://www.ahrq.gov/professionals/systems/hospital/qitoolkit/index.html http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/index.html http://innovation.cms.gov http://innovation.cms.gov/initiatives/Partnership-for-Patients/ http://www.gpo.gov/fdsys/pkg/FR-2012-01-04/pdf/2011-33756.pdf http://www.pqaalliance.org/ http://www.hrsa.gov/publichealth/clinical/patientsafety/index.html http://www.healthcarecommunities.org/showcontent.aspx?id=4294968497

AHRQ = Agency for Healthcare Research and Quality; CMMI = Center for Medicare and Medicaid Innovation; HRSA = Health Resources and Services Administration; PQA = Pharmacy Quality Alliance; PSPC = Patient Safety and Clinical Pharmacy Services Collaborative.

committed to improving care, safety, and quality by developing successful partnerships and generating the knowledge and tools required for long-term improvement. The agency’s goal is to foster measurable improvements in health care in the US, gauged in terms of improved quality of life and patient outcomes, lives saved, and value gained for the resources expended.11 The AHRQ provides resources and patient safety tools for providers and patients from information garnered through consumer surveys, studies to standardize performance measures, online databases to evaluate health care quality, inpatient quality indicator toolkits, and research programs. The agency also engages pharmacists and other health care professionals to showcase practice innovations and tools that improve quality and reduce health care disparities. The agency administers numerous funding opportunities for projects that measure the quality of various modes of health care delivery. The AHRQ serves as a resource for pharmacists in all practice settings to plan, assess, and report outcomes of innovations in the patient care services they have developed.12

Centers for Medicare and Medicaid Services In 2010, the Centers for Medicare and Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) was created to identify, validate, fund, and encourage adoption of new care models and to improvecare and reduce costs through continuous improvement for Medicare or Medicaid beneficiaries. Focus areas for this government agency include health care delivery and payment models, coordinated care across health care settings, and community and population health models.13 Pharmacists are actively involved in community and health-system care teams in the majority of grants and several were the primary investigators of those awarded by CMMI in 2012.14 In April 2011, CMS announced the Partnership for Patients initiative, which focuses on patient safety by

reducing preventable errors, hospital-acquired conditions, and hospital readmissions associated with care transitions.15 Pharmacists within the 3700 participating hospitals have opportunities to contribute to this national effort. In January 2012, the Department of Health and Human Services released the initial core set of quality measures for Medicaid beneficiaries, developed jointly by CMS and AHRQ, for voluntary use by states.16 To facilitate voluntary reporting by states, CMS is now implementing components of the Medicaid Quality Measurement Program, which will assist in the development, testing, and validation of evidence-based measures and the development of a standardized reporting format for this core set of adult quality measures.16

Pharmacy Quality Alliance The Pharmacy Quality Alliance (PQA) is a nongovernment organization established in 2006 with broad representation of pharmacy-related groups. PQA’s mission is to improve the quality of medication use and management by developing and implementing performance measures that could be used across health care settings. Alliance work-groups, whose focus and deliverables are aligned with other quality groups such as the National Quality Forum practitioner stakeholders and the National Priorities Partnership workgroups, have developed quality measures in many areas including medication safety, medication adherence, and appropriateness.17 The PQA provides information and resources to pharmacists interested in performance measurement and quality improvement.

Health Resources and Services Administration Patient Safety and Clinical Pharmacy Services Collaborative Initiatives developed by AHRQ, CMS, and PQA are just a few examples of the significant focus placed on quality and safety in our health care environment. The Health Resources

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Annals of Pharmacotherapy 47(9)

and Services Administration (HRSA) has long focused on improving care for underserved patients and has actively engaged pharmacists in these efforts. In 2008, HRSA sponsored the Patient Safety and Clinical Pharmacy Services Collaborative (PSPC) to improve the quality of health care across the US by integrating evidence-based clinical pharmacy services into the care and management of high-risk, high-cost, complex patients. The PSPC was intended as a disruptive innovation, with quality improvements designed to transform pharmacy practice and reform health care at the community level.18 PSPC adapted the Institute for Healthcare Improvement’s Breakthrough Series Collaborative Model,19 which involves learning sessions that alternate with action periods and results in rapid changes and significant outcomes. The model is centered on voluntarily formed community-based, multidisciplinary teams that deliver patient-centered services to improve medication safety and health outcomes. Participating organizations include safety net providers and hospitals; public health departments, schools, and colleges of pharmacy and medicine; primary care associations; and/ or Quality Improvement Organizations. Now in its fourth year, the PSPC is building upon the successes and lessons learned during the first 3 years and expanding the work to a greater national scale, with the goal of reaching 3000 communities by 2015. One of the foundations of the PSPC’s success is known as the Change Package, a collection of best practices, tools, and information gathered from site visits to more than 34 high-performing health care organizations to learn about their successful integration of clinical pharmacy services with patient care. The 5 main strategy areas within the Change Package include leadership commitment, measurable improvement, integrated care delivery, safe medication use systems, and patient-centered care.20 To provide a glimpse of the success of PSPC teams, results from the third year include a 35% average improvement in the health status marker for 39 teams focused on diabetes, a 40% average improvement in the health status marker for 12 teams focused on hypertension, a decrease from 0.7 to 0.5 adverse drug events per patient for all teams, and a decrease from 1.5 to 0.8 in the average number of potential errors per patient for all teams.21 Improved patient outcomes from PSPC teams’ work were recognized in 2011 with the prestigious American Pharmacists Association Foundation Pinnacle Award.22 Practice leaders throughout the country have used these concepts to begin the process of engaging in clinical pharmacy services, integrating these services into interprofessional teams, or enhancing or expanding existing services.20 The need is great among large segments of our population who suffer from disparities in care, are more susceptible to medication and adverse events, and are not engaged in a process of coordinated care.23 Through clinical pharmacy

services, we have a tremendous opportunity to provide the expanded access to care and the improvement in chronic health outcomes that are lacking in an estimated 15% of the population.21,24

Call for Engagement There is a need for pharmacists to use the tools of AHRQ, PQA, and CMS as a foundation to foster engagement within communities and drive quality improvement initiatives. Many who are reading this commentary are practicing in a pharmacy site that would qualify to participate in the PSPC or could utilize other resources and tools referenced in this article. I challenge everyone to align within their local community by either enrolling in the PSPC campaign or providing support to others who have taken the initiative to enhance local care and services. To learn how to engage as a site with PSPC, please go to http://healthcarecommunities.org/ content.aspx?id=4294975049 and let pharmacy be the driver to help PSPC reach its goal of 3000 practices by 2015. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References 1. Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academies Press, 1999. 2. CDC National Center for Chronic Disease Prevention and Health Promotion: Chronic disease prevention. http://www .cdc.gov/nccdphp/overview.htm (accessed 2012 Aug 31). 3. American Heart Association. Heart disease and stroke statistics—2008 update. Dallas, TX: American Heart Association, 2008. http://www.americanheart.org (accessed 2012 Aug 31). 4. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2003;18:646-51. 5. Owens MK. The health care imperative: lowering costs and improving outcomes. The Institute of Medicine, Washington, DC: National Academies Press, 2010. 6. Management practices: US companies improve performance through quality. US General Accounting Office, Government Printing Office (GAO/NSIAD-91-190), May 1991. 7. President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Quality first: better health care for all Americans. March 30, 1998. http://www .hcqualitycommission.gov/final/ (accessed 2012 Apr 21). 8. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press, 2001.

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Ross 9. Patient Protection and Affordable Care Act, HR 3590, Public Law 111-148. March 23, 2010. http://www.gpo.gov/ fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf (accessed 2012 Mar 6). 10. US Department of Health and Human Services. Report to Congress: National strategy for quality improvement in health care. Washington, DC, March 2011. http://www.healthcare .gov/center/reports/quality03212011a.html (accessed 2012 Apr 21). 11. Agency for Healthcare Research and Quality. AHRQ at a glance. http://www.ahrq.gov/about/mission/glance/index.html (accessed 2013 Mar 12). 12. Agency for Healthcare Research and Quality. Effective healthcare program. http://www.effectivehealthcare.ahrq .gov/ (accessed 2012 Aug 31). 13. US Department of Health and Human Services Centers for Medicare and Medicaid Services. Innovation Center portfolio criteria. Baltimore, MD, March 2011. http://innovation.cms.gov/ About/Our-Portfolio-Criteria/index.html (accessed 2013 Mar 12). 14. American Pharmacist Association. Pharmacists in majority of latest round of Innovation Center grants. http://www.phar macist.com/pharmacists-majority-latest-round-innovationcenter-grants (accessed 2013 Mar 12). 15. US Department of Health and Human Services Centers for Medicare and Medicaid Services. Community-based Care Transition Program. Baltimore, MD, April 2011. http:// www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail. asp?itemID=CMS1239313 (accessed 2011 Apr 27). 16. US Department of Health and Human Services Centers for Medicare and Medicaid Services. Medicaid program: initial core set of health care quality measures for Medicaid-eligible adults. Federal Register 77(2); January 4, 2012. http://www .gpo.gov/fdsys/pkg/FR-2012-01-04/pdf/2011-33756.pdf (accessed 2012 Sep 30).

17. Pharmacy Quality Alliance. Workgroups information. http:// pqaalliance.org/workgroups/default.asp (accessed 2012 Aug 31). 18. Mitchell JR. Supporting the patient safety and clinical pharmacy services collaborative. Am J Health-Syst Pharm 2012;69:1246-50. 19. Health Resources and Services Administration. Patient Safety and Clinical Pharmacy Services Collaborative (PSPC). Healthcare communities. http://www.healthcarecommunities .org/MyCommunities.aspx (accessed 2013 Mar 10). 20. Health Resources and Services Administration. Patient Safety and Clinical Pharmacy Services Collaborative (PSPC) change package, October 2011. http://www.healthcarecommunities .org/showcontent.aspx?id=4294968497 (accessed 2012 Nov 12). 21. The Patient Safety and Clinical Pharmacy Services Collaborative National Performance Report PSPC 3: October 2010-September 2011. Communities organizing integrated delivery systems with clinical pharmacy services. http://www.medsmatter.org/default/assets/File/PSPC NationalPerformanceReport2011.pdf (accessed 2012 Sep 30). 22. American Pharmacists Association Foundation. APhA Foundation Pinnacle Awards. http://www.aphafoundation .org/AM/Template.cfm?Section=Pinnacle_Awards (accessed 2013 Mar 13). 23. US Department of Health and Human Resources. National healthcare disparities report. March 2012. http://www.ahrq .gov/research/findings/nhqrdr/nhdr11/nhdr11.pdf (accessed 2013 Apr 30). 24. US Public Health Service. Improving patient and health system outcomes through advanced pharmacy practice. http:// www.usphs.gov/corpslinks/pharmacy/documents/2011 AdvancedPharmacyPracticeReporttotheUSSG.

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Quality improvement in health care: opportunities and responsibilities for pharmacists.

Quality in health care has never been more important than today. As health care providers, pharmacists have an obligation to serve as leaders and visi...
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