Expert provides guide to pharmacy 'high performance'
Rate improvements to pick low-hanging fruit
Pharmacy leaders across the United States have created a model that makes it easier for hospital pharmacies to create a high-performance pharmacy practice within their own institutions.
Several years ago a panel of pharmacy leaders identified the qualities of a high-performance pharmacy.1
These dimensions were turned into a framework, consisting of evidence-based standards and practices, says Lee C. Vermeulen, BSPharm, MSPharm, FCCP, director of the Center for Drug Policy at the University of Wisconsin Hospital and Clinics in Madison, WI. Vermeulen is a co-author of a paper detailing the panel's work in creating the high-performance pharmacy practice framework.
McKesson Corp. provided educational grants to support program development. (Find more at: www.highperformancepharmacy.com.)
"We started with an exhaustive search of pharmacological literature to identify evidence-based standards and practices," Vermeulen says. "Then we drafted a series of elemental statements that appear in a journal article in the American Journal of Health-System Pharmacy."
One goal was to create formal metrics for the model, Vermeulen says.
"We wanted to be able to say that if you achieved this element to this degree then you should get this kind of score," he explains. "And we initially hoped the score would create a foundation for self-assessment, much like ISMP has with safety assessment."
But as the team worked through the process, it found that the level of evidence supporting many of the elements was shallow, he adds.
"There are some where there is great evidence to support the importance of a particular element, but in many cases that's not true," Vermeulen says. "So we used a more subjective, although empirically driven assessment scale that is broken into three different categories of feasibility, financial return, and quality/safety return."
Each of the three categories are given a rating according to a particular health care organization's assessment of nearly 80 performance elements within eight dimensions.
The dimensions include the following:
- Leadership;
- Medication preparation and delivery;
- Patient care services;
- Medication safety;
- Medication-use policy;
- Financial performance;
- Human resources; and
- Education.
Within each dimension is a list of elements that are rated according to their feasibility, financial return, and quality and safety return. The ratings are made with symbols, such as a checkmark, a dollar sign, and a star sign. There can be from zero to four symbols for each qualitative score.1
The feasibility column applies to financial expenses, staffing changes, and program changes necessary to make a change. If a particular element is deemed to be very feasible, then it will have only one checkmark; if it will be costly and require a great deal of changes, then it might warrant four checkmarks, Vermeulen says.
The financial return of change is rated according to no dollar signs (if there's no expected return on investment) to four dollar signs (if there's expected to be a 100% return on investment).
There is more subjectivity in determining the quality/safety return on investment, Vermeulen says.
"This is the most opinion-driven of the three," he says. "We had pretty decent evidence on feasibility and arguably very good evidence on the financial return from many elements, but from a quality/safety perspective we had to use the expert opinion of panel members to help us with that rating."
The self-assessment tool is easy to follow and it explains how ratings might be applied, given an organization's existing qualities and needs.
For instance, a hospital might find that having pharmacist-performed medication histories is a project that would be challenging to implement, but its financial return would recoup all investment in the change, and it would reap huge benefits in quality and safety. So for one particular hospital, this might be an example of a low-hanging fruit, just waiting to be picked.
Vermeulen stresses while that it's always important to come up with good ideas for improvement, it is less helpful to use external benchmarking as a thermometer.
"Say a hospital is at the 75th percentile in a measure, and the hospital's leadership want the hospital to be at the 90th percentile by the next quarter," he explains. "But for the most part these metrics are not outcomes-oriented."
For instance, a hospital that ranks lower than peers on a cost-savings scale still might have far superior outcomes which make the investment worthwhile, Vermeulen adds.
"This model presents in one consolidated document an exhaustive list of things we believe, based on our feedback from around the country, represents high performance for hospital pharmacy practice," Vermeulen says. "There are hundreds of references of why a hospital should do it and how to do it."(See table, for examples of the elements, left.)
"Each element has a description of what we mean by that and a list of supported evidence that shows why it's important," Vermeulen says. "Also, there's a list of standards that recommend it."
The idea is that organizations will not only be high-performance, but also will meet performance standards that professional organizations have promoted, he says.
"So if you desire to become high-performing in a particular area, then you have a roadmap to guide you through that process," Vermeulen says. "If you need to argue with your hospital administrator about putting resources into a particular element, then you have the professional standards showing why you should make this change."
Reference
- Vermeulen LC, Rough SS, Thielke TS, et al. Strategic approach for improving the medication-use process in health systems: The high-performance pharmacy practice framework. Am J Health-Syst Pharm 2007;64:1699-1710.
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