New Book Release: Resource on "Quality and Safety in Pharmacy Practice"

David Nau, PhD, RPh, CPHQ, Senior Director, Research & Performance Measurement for PQA and Terri L. Warholak, PhD, RPh, Assistant Professor, Department of Pharmacy Practice and Science at the University of Arizona College of Pharmacy have developed a compressive study of the principles of quality improvement for pharmacy.

This important reference published by McGraw-Hill and entitled "Quality and Safety in Pharmacy Practice" provides the reader with a thorough review of the principles of quality improvement and their application to present and future pharmacy practice. The book is divided into five parts, covering:

• The current and future landscape of health care quality and the business case for quality improvement and value-driven health care
• Quality improvement concepts and tools, including statistical process control
• Quality and safety measurement, including mechanisms for gathering consumer feedback
• Incentives and other drivers of quality improvement
• Application of the principles of quality improvement to pharmacy practice - complete with case examples

The book is a perfect companion to the Educating Pharmacy Students and Pharmacists to Improve Quality (EPIQ) program offered by PQA to help educate pharmacists and pharmacy students on the importance of quality measurement to improve medication use. Information on EPIQ is available on the PQA website at www.PQAalliance.org

The book by Nau and Warholak is available for purchase via the following link.
http://www.disruptingclass.mhprofessional.com/product.php?cat=116&isbn=0071603859&cat=116   Back to Top

Record Breaking Attendance at the PQA 5th Annual Meeting

A jam packed agenda, coupled with senior officials from several agencies, including CMS, the FDA and AHRQ, led a most successful PQA Annual Meeting on June 2-3 in Crystal City, VA. The record setting and enthusiastic audience was treated to timely and informative presentations including content regarding the implementation of the newly approved US Health Care reform bill H.R. 3590; the Patient Protection and Affordable Care Act.

PQA was pleased to have Board Member, Dr. Jeffrey Kelman, Chief Medical Officer for CMS, lead off the day’s event with a discussion on quality, value and measurement as it relates to pharmacy. He emphasized the critical importance of these factors in relationship to the $2.5 trillion health market of which over $300 billion goes to pharmacy and noted access is the first step to ensuring quality and value. Without access to healthcare, there is no quality and value. With enrollments into the healthcare system expected to increase by up to 36 million people over the next several years, pharmacies and pharmacists must be prepared to deliver that value to the beneficiaries we serve.

Dr. Karen Weiss, Associate Medical Director for the FDA, and point person on FDA’s Safe Use Initiative was also on hand to provide an overview of this important project. She challenged PQA to join forces with the FDA to define initiatives where direct collaboration could produce measurable reductions in preventable harm. PQA was fortunate to have Dr. Weiss join the PQA Board in March of this year and look forward to working with her and the staff at FDA to define several tangible initiatives to pursue later this year.

Dr. Karen Adams with the National Priorities Partnership spoke on the six national priorities and commended PQA for its actions to parallel the work of its own committees to align with the priorities. Dr. Adams spoke in depth on one of the six priorities, namely Population Health, and also on the role of the pharmacist in two critical areas: the impact pharmacists can have on the overprescribing of antibiotics, and also in the role of delivering immunizations within the communities in which they serve. Dr. Adams challenged pharmacy to look at the key drivers around consumer engagement and infrastructure capacity, payment incentives and performance measurement, and she asked PQA to help the National Priorities Partnership make these key drivers "real".

The final keynote speaker of PQA’s first day of programming was Dr. Carolyn Clancy, Director for the Agency for Health Care Quality and Research. Dr. Clancy spoke on the opportunities and challenges facing the healthcare stakeholders and their patients. With over $1.1 billion allocated to support CER (comparative effectiveness research) it is clear this is a priority issue. It is also notable that the policy implications are of great concern to many people, with key issues around how this information will be used and what the unintended consequences of CER might be. Dr. Clancy shared that, at all times, the role of AHRQ is to assure that the research is descriptive, rather than prescriptive. She also emphasized that efforts to improve quality and safety are really important when engaged, articulate and activated consumers are involved, stating that "activated consumers are a total game changer" and it changes the conversation among providers dramatically. Pharmacists play a very key role in medication management services. "I think the challenge for all of you is going to be to figure out what is the unique contribution, the value add of pharmacists, in the bigger challenges of implementing healthcare reform…figure out where pharmacists have a shared role and opportunity and responsibility versus focusing on the portions that are uniquely pharmacy-related."

The second day of the meeting began with the breakout sessions for PQA’s 11 unique workgroups. The sessions brought together members of the various workgroups to brainstorm for 90 minutes on their major objectives for the year. The groups ran out of time before they ran out of ideas and initiatives for PQA to pursue, which reflects the energy and knowledge inherent to PQA members.

The two-day Annual Meeting was capped off by a thorough discussion and a firsthand look at the Phase II Demonstration Projects taking place in Tennessee, Pennsylvania and Illinois with members of each collaborative research team represented. The projects will focus on testing interventions to improve medication use quality and will also build actuarial models around pay-for-performance models for pharmacy services.

The final keynote speaker was Will Shrank, MD, MSHS from Harvard Medical School who presented "Medication Adherence: Can Pharmacists Make a Difference?"  His very detailed and insightful presentation was followed by a lively question and answer session around this critical topic and key opportunity for pharmacists to improve care for patients. Back to Top

Senators Hagan and Franken Introduce Bill to Help Seniors Manage Medications:
Act Calls for the Inclusion of Measures Established by the Pharmacy Quality Alliance

On June 29th, U.S. Senators Kay Hagan (D-NC) and Al Franken (D-MN) introduced a bill to help more seniors manage their prescriptions and reduce health care costs. The Medication Therapy Management Expanded Benefits Act would expand MTM eligibility to seniors with any chronic condition that accounts for high spending in the healthcare system as well as any other patient that a "pharmacist or other qualified provider determines may benefit from medication therapy management services." In her remarks, Senator Hagan noted that "Currently, only 12.9% of Part D beneficiaries are eligible under the MTM criteria for multiple chronic conditions."

PQA is encouraged by the provisions of this bill that require an evaluation of performance of these services. In particular, the bill includes a provision that requires the Secretary of HHS to establish measures and standards for data collection by prescription drug plan (PDP) sponsors to evaluate the performance of pharmacies and other entities in furnishing medication therapy management services. Inclusion of certain measures for pharmacists who furnish medication therapy management services shall include measures developed by the Pharmacy Quality Alliance. The Act calls for measures designed to help assess and improve the overall quality of care, including a reduction in adverse medication reactions and improvements in adherence and persistence in chronic medication use.

PQA has developed numerous measures of pharmacy performance and some of these measures may be very appropriate for ongoing performance improvement activities of MTM providers. Additionally, PQA has drafted several new measures that are specifically designed for evaluation of MTM services and will begin the pilot-testing of these measures in July. The vendor working with PQA will access MTM program data as well as prescription claims data to test the four draft measures, and will deliver a report on the pilot-tests before the end of 2010. Back to Top

PQA Receives the APhA Foundation Pinnacle Award:
Board, Staff and Active PQA Members Join the Recognition Award Ceremony

PQA received the 13th Annual Pinnacle Award in the nonprofit organization category on June 28th at an even hosted by the American Pharmacists Association Foundation and supported by Pfizer, Inc. The Pinnacle Awards recognize contributions to healthcare quality through the medication use process, and was established in 1998.  These awards recognize an individual, a group of individuals and a healthcare organization for significant contributions and/or exemplary leadership in the improvement of quality in the medication use process and the delivery of pharmaceutical care. Performance in medication use is an issue that cuts across disciplines including physicians, nurses and pharmacists.....but the most important stakeholder in this dialogue is the patient.  A systematic approach using modern quality improvement science can help us optimize our performance in medication use.

Hot Off the Press – A National Strategy to Put Accountable Care Into Practice

Health care reform legislation has heightened our attention to new payment models including Accountable Care Organizations (ACOs). While ACOs have received much discussion, there is still uncertainty as to what constitutes an ACO and how they should be implemented. Scholars from the Brookings Institution and Dartmouth University are collaborating on definitions and models for ACOs and a national strategy for their implementation. The key elements of this strategy are presented in the June edition of Health Affairs.

McClellan and colleagues suggest that ACOs should be built on three core principles: 1) provider-led organizations with a strong base of primary care that are collectively responsible for quality and total per capita costs across the full continuum of care for a population of patients; 2) payments linked to quality improvements that also reduce overall costs; and 3) reliable and progressively more sophisticated performance measurement to support improvement and provide confidence that savings are achieved through improvements in care. There is room for flexibility in the structure and participants within the ACO; however, all participants should share in the accountability for quality and healthcare costs, as well as sharing in the rewards for improvements in quality.
 

The authors recognize the numerous barriers to successful implementation of ACOs across the U.S. They suggest several strategies to overcome these barriers. These include: 1) national leadership from the public and private sectors; 2) consistent specifications for performance measurement and evaluation methods across the growing number of pilot programs for ACOs; 3) technical support for advanced performance measurement as well as new actuarial and payment systems; and 4) support for clinical transformation which includes identification of best practices for high-quality care and better coordination of care across team members in the ACO.

Fairman KA, Curtiss FR. Clinical Quality Indicators and Provider Financial Incentives: Does Money Matter? J Manag Care Pharm. 2010;16:360-65. Back to Top

Nau Selected to Participate in Key NQF Panels

Dr. David Nau, PQA Senior Director of Research and Performance Measurement, has been selected to participate in the National Quality Forum in a variety of capacities. First, Nau will serve on the Measure Use Evaluation Advisory Panel, which will evaluate the current state of NQF-endorsed performance measure use in the field. The panel will investigate uses such as public reporting, quality improvement, performance-based payment, and accreditation and certification. The panel will gather feedback on how performance measures are enabling systems that support accountability, continuous quality improvement, and improved population health. Barriers to performance measure uptake will also be explored. Based on the findings, recommendations for future development of the performance measurement system will be generated.
 

Dr. Nau has also been selected to be a member of the Steering Committee for the NQF’s National Voluntary Consensus Standards for Patient Safety project. The Patient Safety Measures Steering Committee will oversee the development of a draft consensus report, including recommendation of which measures should be endorsed as consensus standards for patient safety. NQF has endorsed 34 safe practices in the 2009 update of the Safe Practices for Better Healthcare and 28 Serious Reportable Events (SREs). The SREs, Safe Practices, and NQF-endorsed patient safety measures are important tools for tracking and improving patient safety performance in American health care. Significant gaps remain in the measurement of patient safety and there is a recognized need to expand available patient safety measures beyond the hospital setting and harmonize safety measures across sites and settings of care. In order to fill these gaps and to develop a more robust set of safety measures, NQF will be soliciting patient safety measures that address condition-specific and environment-specific issues with the highest potential to drive improvement.
 

Dr. Nau has received the extra distinction of being appointed as chairperson of the Technical Advisory Panel (TAP) focusing on medication safety, which will report to the Patient Safety Committee. According to Laura Cranston, Executive Director of PQA, "The formation of this panel is an acknowledgment of the importance of measuring the safe and appropriate use of medications in the healthcare system and the selection of Dr. Nau as chairperson is well-deserved recognition of his leadership in this area." In his role as chairperson, Nau will facilitate the TAP’s discussions towards a recommendation that will be included in the Patient Safety Measure committee report.
 

PQA congratulates David on his new appointments! Back to Top

Experts Highlight "Human Factors" in Advancing Pharmacy Practice
PQA Lecture Series Review

Human factors scientists study the relationships among humans, the tools they use, and the environments in which they work. As pharmacists are asked to utilize more technology and to expand their practice roles, it is important to understand what can be changed in pharmacists' work environments to help them improve medication use safety, provide Medication Therapy Management (MTM) services and collaborate with other health care professionals. On May 27th, PQA members were provided insight into human factors during the PQA Quality Forum Lecture Series, led by two national experts on the topic.
 

Dr. Michelle A. Chui, PharmD, PhD and Ben-Tzion (Bentzi) Karsh, PhD - both based out of the University of Wisconsin in Madison - are collaborating on research to improve the safe dispensing of medications. Dr. Chui is an Assistant Professor in the School of Pharmacy and Dr. Karsh is an Associate Professor in the College of Engineering. Their combined expertise in pharmacy services and "human factors engineering" (HFE) provide a unique combination of perspectives on the topic of pharmacy safety, quality and efficiency.
 

Dr. Chui emphasized the need for research in the area of community pharmacy practice and spotlighted barriers to improving practice that commonly exists in these settings such as heavy or excessive workloads, the fast pace of work, pharmacy layout and workflow patterns, financial pressures and even pharmacists’ training. Dr. Chui noted that "previous studies around MTM have explored pharmacist’s skills and training necessary to deliver MTM and the resulting clinical and economic outcomes. However, what has not been published is the process by which these pharmacists overcame workflow designs, personnel management, and other barriers in order to successfully implement time-consuming interventions." Dr. Chui noted that the 2000 IOM report "To Err is Human…" stimulated human factors engineering research in hospitals, but these efforts were not immediately transferred to non-hospital settings. The bottom-line is, if your technology is bad, your workflows don’t work, or the physical space doesn’t work for you, your performance will be bad. If your performance is bad, your patients suffer.
 

HFE discovers and applies information about human behavior, abilities, limitations and other characteristics to the design of tools, machines, systems, tasks, jobs, and environments for productive, safe, comfortable and effective human use. In other words, HFE designs the fit between people and products, equipment, facilities, procedures and environments. The goal of HFE is to reduce errors, stress and fatigue and improve productivity, safety and quality. This is accomplished using an approach that takes the focus off the individual and examines system design. HFE approaches consider "workarounds and violations" in processes and protocols to be outcomes and not just causes that indicate system design issues. Dr. Karsh indicated that HFE could be of great benefit in most community pharmacy settings and noted that "most pharmacists know chaos when they see it" and know when their work system is not performing optimally. However, it was recognized that pharmacists are not always early adopters and tend to be averse to change unless innovation has been proven or there is a clear need. Dr. Karsh emphasized that for research to be completed in the community pharmacy practice setting, the researcher and the pharmacist have to agree on the process and that research needs to be done prior to major workflow or environmental changes such as implementation of MTM services or addition of new technology.
 

Drs. Chui and Karsh summarized that "We know that quality and safety emerge from the interaction between people and the systems in which they work. Human factors engineering helps you understand that interaction so that you can better design systems to improve quality and safety." Both presenters encouraged pharmacists to learn more about HFE. They added that "tools, standards, guidelines and principles for improving human performance, safety and productivity are now available; it is time for pharmacy to put them to use!" Back to Top

Julie Kuhle Joins PQA as a Consultant on Performance Measurement

PQA is pleased to announce that Julie Kuhle, RPh has joined PQA as a consultant on issues of performance measurement.

Julie’s primary role within PQA will be to work with several of the PQA Workgroups, and to play an integral role in the measure development and validation work that PQA is undertaking through two separate contracts for a second set of measures, including MTM measures. Julie’s initial responsibilities will be to serve as a liaison to four PQA Workgroups:

• Medication Therapy Management Services
• Population Health
• Measure Uptake and Implementation Strategies Workgroup for the State Payors
• The Role of Medication Management Programs in Care Transitions and the Patient Centered Medical Home Workgroup

Julie currently serves as the Pharmacy Manager at the Iowa Foundation for Medical Care (IFMC), the Quality Improvement Organization (QIO) for Iowa. She will continue working with IFMC and PQA will be contracting for her professional services through IFMC.

Julie’s longstanding relationship with PQA as a co-chair of several different workgroups, her experience in working with the Quality Measurement Expert Panel, and her involvement in previous PQA Phase I demonstration projects make her uniquely qualified to assist the PQA leadership in supporting the workgroups to ensure the efforts of these workgroups meet their 2010 strategic objectives.

Julie’s passion, skills and commitment related to improving quality, enhancing patient safety and appropriate medication use through pharmacists’ services are tremendous additions to PQA. Back to Top

PQA Welcomes New Members Express Scripts, Inc., IQware and NHIN

Express Scripts, Inc. is one of the largest pharmacy benefit management companies in North America, and covers millions of members through the provision of services to improve healthcare outcomes and lower costs by assisting in influencing their behavior. Headquartered in St. Louis, Express Scripts provides integrated PBM services including network-pharmacy claims processing, home delivery services, specialty benefit management, benefit-design consultation, drug-utilization review, formulary management, and medical and drug data analysis services. The company also distributes a full range of biopharmaceutical products and provides extensive cost-management and patient-care services.

IQware is a Health Care Information System (HCIS) that is designed to work cooperatively with existing health care IT systems. IQware helps all these systems work together and eliminates the need for error-prone, costly manual re-entry of critical health care and patient information. IQware can handle all common activities including admissions, EMR, pharmacy operations, tracking auditing and compliance verification.

National Health Information Network, Inc.: Asserting the role of pharmacy in healthcare is the mission of PDX-NHIN-Rx.com. A portable, interoperable electronic pharmacy record, an advanced, fast, easy-to-use pharmacy management system, partnerships with pharmaceutical manufacturers that generate revenue, fulfillment services, and a host of other technologies are integrated into a single solution no other company can provide. Over 10,000 pharmacies across the U.S. benefit from technologies and services provided by PDX and affiliates Rx.com and NHIN. PDX boast a 25+ year commitment to excellence in retail pharmacy and patient care. Back to Top

Mark Your Calendars: Warholak and Hines to Discuss Severe Drug-Drug Interactions for September PQA Lecture Series

Please mark your calendars for the next Quality Forum Lecture Series which will take place on September 9th, 2010. The topic will be "Preventing Drug Interactions for Quality Improvement" and the presenters will be Terri L. Warholak, PhD, RPh, Assistant Professor, Department of Pharmacy Practice and Science, College of Pharmacy and Lisa Hines, Pharm.D, Clinical Research Pharmacist Center for Health Outcomes & PharmacoEconomic Research, both with the University of Arizona. This very timely presentation will be followed by a question and answer session. The PowerPoint presentation will be sent on September 8th to those who register for the lecture.

This session will provide an overview of the PQA drug-drug interaction measure. Methodology and rationale for selecting the drug interactions will be described, including a brief discussion of the potential clinical consequences and supporting evidence. Additional discussion will surround methods to improve health care provider performance through integration of educational, systems-based, and quality improvement strategies.

Please join us on Thursday, September 9th from 1 PM to 2 PM EDT. Early registration is highly recommended for this complimentary program. Please RSVP via email to Karen Peterson at kpeterson@PQAalliance.org

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Spreading the Word about PQA: Staff Activities for Summer, Fall 2010

A critical component of the PQA is to develop collaborative relationships with individuals, organizations and key stakeholders who play a role in improving quality in health care. To increase the awareness of PQA, its mission and current activities, Laura Cranston, RPh, PQA Executive Director and David Nau, PhD, RPh, CPHQ, Senior Director, Research & Performance Measurement, maintain a busy schedule, serving as speakers or panelists at numerous meetings and conferences. (See list below.) If you are aware of a speaking opportunity to promote PQA, whether it is an internal meeting to your own organization's associates, or externally through a national organization that you have been involved with, please contact Laura at Lcranston@PQAalliance.org for more information or scheduling questions.

Laura Cranston:

• Oregon State Pharmacy Association meeting: September 12
• Ohio Northern University: September 29

David Nau:

• American Medicaid Pharmacy Administrators Association (AMPAA), Colorado Springs, July 20
• NACDS Pharmacy & Technology Conference, San Diego, August 31
• NIQIE 2010: Mastering Performance Improvement, Chicago, September 13
• AMCP Educational Conference, St. Louis, October 14

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NQF Releases Medication Management Report

In 2008, the National Voluntary Consensus Standards for the Reporting of Therapeutic Drug Management Quality project recommended the development of a set of measures to address medication management. In response to this recommendation, the NQF Medication Management Steering Committee has endorsed 19 measures for assessing the quality of medication management. According to Janet M. Corrigan, PhD, MBA, President and Chief Executive Officer of NQF, "These measures focus on various important medications such as warfarin, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and antipsychotics used to treat medical conditions as varied as asthma, diabetes, and coronary artery disease. Appropriate medication management, particularly for patients with chronic illnesses, can help ensure proper medication use, reduce adverse medication events, and improve outcomes."

The report authors acknowledge that this set of endorsed measures does not "represent the full array of measures that are needed to fully assess medication management and to improve the quality of care in this area. " NQF and PQA recognize that significant work lay ahead in developing measures that address outcomes or that are closely linked to outcomes, that are patient-centered and provide consumers with meaningful information about care, and that address all of the priority areas of medication management and capture a broad spectrum of conditions, settings, and populations. There also is a need to develop measures across conditions that apply concepts and definitions in a consistent manner (e.g., use, adherence) and that enhance harmonization across measure sets. Back to Top

The report, which was released in May, presents 19 NQF-endorsed measures for assessing the quality of medication management. Each candidate consensus standard was evaluated for appropriateness as a voluntary consensus standard for accountability and public reporting through the NQF Consensus Development Process. These measures include:

• Proportion of days covered (PDC): 5 rates by therapeutic category
• Adherence to chronic medications
• Coronary artery disease and medication possession ratio for statin therapy
• Use and adherence to antipsychotics among members with schizophrenia
• Diabetes mellitus and medication possession ratio (MPR) for chronic medications
• Diabetes suboptimal treatment regimen (SUB)
• Diabetes and medication possession ratio for statin therapy
• Asthma Control—suboptimal asthma control (SAC) rate (rate 1) and asthma control—absence of controller therapy (ACT) rate (rate 2).
• Pharmacotherapy management of COPD exacerbation (PCE): two rates are reported
• Chronic kidney disease, diabetes mellitus, hypertension, and medication possession ratio for ACEI/ARB therapy
• ACE inhibitor/angiotensin receptor blocker use and persistence among members with coronary artery disease at high risk for coronary events
• HBIPS-4: patients discharged on multiple antipsychotic medications and HBIPS-5: patients discharged on multiple antipsychotic medications with appropriate justification (Paired Measures)
• Care for older adults—medication review (COA)
• Medication reconciliation post-discharge (MRP)
• Monthly INR monitoring for beneficiaries on warfarin
• INR for beneficiaries taking warfarin and interacting anti-infective medications
• HBIPS-6: post discharge continuing care plan created
• HBIPS-7: post discharge continuing care plan transmitted to next level of care provider upon discharge