Accreditation: Pharmacy’s role is between the lines
But new JCAHO requirements are coming
Current accreditation standards do not include specific pharmacy oversight or reporting in their increasingly outcomes-based reviews, but that is posed to change.
Neither the ORYX self-report card system by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), set to begin in 1998, nor the National Committee for Quality Assurance (NCQA) HEDIS 3.0 system requires specific health indicators from the pharmacy.
The closest elements to a specific pharmacy requirement in JCAHO’s accreditation system are the oversight of formulary development and the management of drug use and adverse drug reactions contained in more broad standards like continuum of care or health promotion and disease prevention. Other pharmacist roles, like serving on the pharmacy and therapeutics committee or conducting drug-use evaluations, are not included in JCAHO’s related standards.
And while JCAHO pushes for a health system’s overall performance improvement, any such improvement programs for the pharmacy itself are not spelled out. (Last year the Joint Commission developed a long-term care accreditation program that does focus elements of the process on the pharmacy.)
NCQA’s accreditation requires raw numbers from the pharmacy (total prescription costs, average costs over a time line, total prescriptions ordered, and then average prescriptions per member per month,) and some pharmacy claims data are included in scoring, but again, direct evaluation of the pharmacy is not required.
Nevertheless, pharmacists say their niche and roles in accreditation are being defined from within, though it’s often up to them to get involved, even when accreditation may not be the overriding reason.
"Many pharmacy organizations are not under any specific accreditation. We do it because it’s good business and in the patient’s best interest to potentially create standards we can adhere to," offers Gordon Vanscoy, PharmD, MBA, a vice chairman at the University of Pittsburgh’s School of Pharmacy and vice president of the Managed Clinical Care Division of Stadtlanders Pharmacy Services in Pittsburgh.
"The Joint Commission is important, but so is your hospital administrator. Once you find out who you’re reporting to you can begin to ask what outcomes are of interest," adds David Holdford, PhD, assistant professor of pharmacy administration at Virginia Commonwealth University in Richmond.
Vanscoy and Holdford, though, advise pharmacists not to steer too far from accreditation, especially now that both JCAHO and NCQA have moved to a more outcomes-based accreditation model simply by switching the focus from department-specific oversight to a systemwide approach.
When NCQA solicited ideas from the industry toward the formation of HEDIS 3.0 in 1995, organizations such as the American Society of Health-System Pharmacists (ASHP) submitted criteria for adverse drug reactions and patient counseling in a largely failed attempt to specify pharmacy roles in the NCQA accreditation.
In 1994, JCAHO moved from its department-based standards to a systemwide model. "Organizations were not finding it easy to get the pharmacy into the rest of care. This accreditation change moved it that way. The Joint Commission identified the importance of the interdisciplinary care, and when they changed the standards, they weren’t focusing on the pharmacy as a department but on medication use, so the interdisciplinary approach has that focus," says Burt Finkelstein, PharmD, director of pharmacy and management services at Johns Hopkins Bayview Medical Center in Baltimore.
"Historically, pharmacy has not been a major player in the Joint Commission and accreditation," says Darryl Rich, PharmD, MBA, associate director of JCAHO’s Division of Accreditation Opera-tions. And while Rich says outcomes will grow within the Joint Commission’s system, "We tend to use performance measures more than outcomes as measuring the performance of a system. The problem we see with outcomes is what one person views as a good outcome, another may not. A system should be designed to yield an outcome, but you need to measure the system. Measuring just outcomes will not give you a good view of how systems are working. You need a good combination of measures."
But like most other segments of the industry, JCAHO is getting on board. "The fact is, reporting outcomes or performance measures is not unique to us. HMOs and third-party payers and the government are getting into the act very shortly, and it’s important for our [accrediting] organizations to get up on it ahead of time," Rich says.
And for JCAHO, that means its new ORYX clinical indicators reporting system. Hospitals under Joint Commission accreditation face a December 31, 1997, deadline to have a reporting software system chosen, and the initial voluntary indicators based on hospital population that will be detailed to JCAHO. The reasons are to gather data that can be benchmarked against comparable institutions, both for accreditation factors and to allow health care organizations to present the data or market them to payers.
The total number of indicators reported to JCAHO will grow over time, until the commission begins dictating back to hospitals exactly what indicators must be reported for accreditation.
"The best way for pharmacists to get involved is have the hospital pick a medication use indicator or a system that has medication use indicators in it," says Rich, meaning anything from ordering and dispensing to patient monitoring.
"It’s up to each pharmacy how to measure outcomes and how much to get involved in ORYX, but if I had to look into a crystal ball of the 10 indicators [that JCAHO eventually will require for reporting], I’d be willing to bet one will be a medication use indicator," Rich says. He bases his prediction on the growing concern over medication errors and, he says, by the simple fact that just about every patient is prescribed some kind of medication. "There’s been much more emphasis on medication use based on the number of errors being reported."
The Joint Commission this fall signed up with a host of organizations to form the National Patient Safety Partnership. Led by the American Medical Association and federal Department of Veteran’s Affairs, the organization’s goal is to reduce medical errors and injuries it says affect three million people a year at an estimated cost of $200 billion. The American Hospital Association, American Nurses Association, and Association of American Medical Colleges also are partners in the venture. And though just a part of the medical error focus, medication errors will be scrutinized, partnership officials say.
Pharmacist role in NCQA scoring
Having done her own analysis of pharmacist input in NCQA scoring, Colleen O’Malley, MS, director of ASHP’s Center on Managed Care Pharmacy, says the proactive pharmacist can have an effect on accreditation. "I hear people say there are no pharmacy outcomes in accreditation, but if you’re taking a systemwide approach, there are ways to get involved even though it doesn’t say pharmacy right at the top," she says.
The basic opportunity for pharmacists is through quality programs aimed at improving outcomes."There’s so many simple things a pharmacist can do to impact outcomes: [providing] simple education on how asthma patients can use an inhaler or by collecting data, which comes naturally and is something we’re trained to do," O’Malley says.
In terms of the specific measures included in HEDIS oversight, she points out three examples: one dealing with pediatric inner ear infection, another concerning myocardial infarction (MI) patients, and a third dealing with depression. The first measure looks at how often recommended antibiotics are not given to children with uncomplicated otitis media. O’Malley says a pharmacy intervention could improve the prescribing patterns and, therefore, a system’s score.
For MI patients, the HEDIS measure tracks how many patients were prescribed B-blockers when not showing evidence of an adverse effect. O’Malley says pharmacists could provide an earlier screening for B-blockers and could set up a compliance program. Also included in HEDIS 3.0 is a measure for ongoing treatment of depression, which O’Malley says includes an indication that more studies on the influence of patient compliance are needed to assess the rates of depression in a given plan. Here again, pharmacists can play a large role in how their facilities score.
[For more information, contact: Darryl Rich, PharmD, MBA, Associate Director, Division of Accreditation Services, JCAHO, 1 Lincoln Center, Oakbrook Terrace, IL 60181. Telephone: (630) 916-5600. The National Committee for Quality Assurance, 2000 L St. NW, Washington, DC 20036. Telephone: (202) 955-3500. Gordon Vanscoy, PharmD, MBA, Vice Chairman, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 1104 Salk Hall, Pittsburgh, PA 15261. Telephone: (412) 825-8331. Colleen O’Malley, MS, Director, ASHP Center on Managed Care Pharmacy, 7272 Wisconsin Ave., Bethesda, MD 20814. Telephone: (301) 657-3000. David Holdford, PhD, Assistant Professor of Pharmacy Administration at Virginia Commonwealth University, Medical College of Virginia, 410 North 12th St., Richmond, VA 23298. Telephone: (804) 828-6103. Burt Finkelstein, PharmD, Director of Pharmacy and Management Services, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224. Telephone: (410) 550-0100.]
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