Written By: Abier Hamami. RPH.CPHQ.
- Designing a Pharmacy Quality Indicators System.
- The ASHP Pharmaceutical Care Quality Indicators.
- The Joint Commission Medication Use Indicators.
Measures/Indicators are quantitative tools expressed as, rate, ratio, or percentage that evaluate actual performance, and compare it with a target or standard. These measures/indicators can provide continuous data over time that could be aggregated, analyzed and displaced as essential information for decision- making, and improvement- planning.
Effective measures should be:
· Valid to provide appropriate data for the purpose measured.
· Reliable to provide consistent and constant data over time.
· Relevant to the pharmacy scope and mission.
· Comprehensive to encompass a wide range of the process being examined.
· Simple and easy to use.
· Cost effective.
There are 2 types of Measures/Indicators:
Measure the degree of occurrence of an event either in a same population (same denominators) or different population (different denominators).
1.# Asthmatic patients educated on the use of inhalers/ Total number of asthmatic patients.
2.# Missing Medications/ Total number of Pharmacists.
· Sentinel Event:
Measure all serious events that require further analysis and investigation in an occurrence.
Example: Death as a result of a medication error.
Measures /Indicators are further classified into:
· Structure Indicators:
Measure the capability of the system to provide care, could focus on resources, qualifications, equipments, or space.
Examples: %Licensed Pharmacists, Hours of operation, Ratio of pharmacists to technicians.
· Process Indicators:
Measure the steps of a providing care procedure, could be clinical, supportive, or administrative.
Examples: Interpretation &Transcription of medication order, First Dose dispensed agree with order, Prepackaging of Bulk Medications into Unit of Use.
· Outcome Indicators:
Measure the result or product of a process of care, could be clinical, functional, and perceived.
Example: Patient's Satisfaction, Patients receiving vancomycin infusion over a period of less than 45min who experience red-necsyndrome.
Designing a Pharmacy Quality Indicators System:
A team should be formed representing different services and sections of the pharmacy department, and is usually coordinated by the pharmacy quality improvement coordinator.
The team is charged to:
1. Identify medication use functions related to the scope and mission of pharmacy department.
2. Identify related processes and prioritize them based on the following criteria:
· High Volume.
· High Risk.
· High Cost.
· Problem Prone.
3. Develop measures/Indicators to assess these processes.
4. Develop indicator's information set or matrix including:
· Indicator definition/statement.
· Focus of measure.
· Type of indicator (rate based or sentinel).
· Numerator and Denominator.
· Indicator type if process or outcome.
5. Define the data collection process in regards to:
· Sample size.
· Frequency of data collection.
· Duration for data collection.
· Responsibility of data collection.
· Source of data.
· Data collection tool.
· Pilot and test the tool for consistency and accuracy.
6. Define the data analysis process in regards to:
· Frequency of analysis.
· Methodology according to type of data.
· Triggers or benchmarks for further intensive analysis.
7. Determine the reporting process (to whom, and how frequent?).
The ASHP Pharmaceutical Care Quality Indicators.
The American Society of Health System Pharmacists (ASHP) developed quality indicators in terms of patient Care and processes, taking in consideration that pharmaceutical care is the framework in which these indicators are developed.
Patient Care Indicators
Are divided into 8 categories based on the medication-related problems that pharmaceutical care should identify, resolve, and prevent:
· Adverse drug reaction.
The patient has a medical problem that is a result of an ADR.
E.G. Patients receiving vancomycin infusion over a period of less than 45min who experience red-neck syndrome.
· Drug use without indication.
The patient receives a drug for no medically valid reason.
E.G. Patient who receive doses of drugs for which there was no order.
· Drug interactions.
The patient has a medical problem that is a result of a drug-drug, drug-food, and drug-laboratory test interaction.
E.G. Patients who experience bleeding due to interaction of warfarin and other drug.
· Failure to receive a drug.
The patient has a medical problem that is the result of not receiving a drug.
E.G. Patients who fail to receive antiemetics prior to receive emetogenic antineoplastic agent.
· Untreated indication.
The patient has a medical problem that requires drug therapy but does not receive a drug for that indication.
E.G. Patients with major depression for whom antidepressant drug therapy is not prescribed.
· Improper drug selection.
The patient has a drug indication but receives the wrong drug.
E.G. Patients with known drug allergies who receive the same drug or chemically related drug.
· Over dosage.
The patient has a medical problem that is treated with too much of the correct drug.
E.G. Patients receiving insulin or oral antidiabetic agents who experience episodes of hypoglycemia.
· Sub therapeutic dosage.
The patient has a medical problem that is treated too little of the correct drug.
E.G. Patients with uncontrolled atrial fibrillation who receive digoxin in a steady state serum drug concentration of less than 0.9 ng/ml.
Are divided into 22 categories to cover all processes or operations in the pharmacy related to medication- use.
· Formulary System
E.G. Frequency of admission of new drugs to the formulary without specific guidelines for their use.
E.G Frequency of failure to place orders despite cues that reordering was needed.
E.G. Frequency of the presence of expired or recalled drugs in drug inventories.
· Drug Preparation
E.G. Frequency of preparations that are incorrectly compounded, or reconstituted.
· Drug Distribution
E.G. Frequency of unordered drugs delivered to patient care areas.
· Billing and Reimbursement
E.G. Percentage of patients' bills for which the organization does not obtain 100% payment.
· Drug Information
E.G. Frequency of information requests rated as urgent and not given within specified time limit.
· Data Management
E.G. Frequency of detection of drug interactions and therapeutic duplications.
· Quality and Risk Management
E.G. Frequency of drug- related incident reports that do not adequately document the problem.
· Continuity of Pharmaceutical Care
E.G. Frequency of patient treated in emergency room and failing to return for scheduled clinic visits before depletion of dispensed drugs.
· Technology Assessment
E.G. Frequency of newly acquired technologies affecting the drug-use system for which there is no documentation of pharmacy input.
· Patient Education
E.G. Percentage of asthmatic patients discharged on metered-dose inhalers who receive documented instruction in the use of the devices.
E.G. Percentage of investigational drug study protocols on file in the pharmacy department.
E.G. Frequency of failure to document age, weight, allergies, ADR, and drug indications in patient’s records, per organizational procedures.
· Hazardous Waste Disposal
E.G. Frequency of bulk cytotoxic waste disposal via methods other than environmental protection agency-approved methods.
· Resource Utilization
E.G. Number of units of items prepared and packaged by the pharmacy department that are discarded.
· Automated Systems
E.G. Frequency of transportation of information by couriers or mechanical means, when an electronic transfer system is available.
· Emergency Medication System
E.G. Frequency of emergency medical events involving the administration of drugs in which there is no pharmacy department involvement.
· Facilities and Equipments
E.G. Frequency of temperature, light, moisture, airborne particles, or unsanitary conditions that threaten the health and safety of persons or the integrity of drug products and supplies.
· Therapeutic Drug Monitoring
E.G. Frequency of phlebotomy timed inappropriately with respect to the time of dug administration.
· Drugs stored outside the department of pharmacy
E.G. Frequency of the dispensing of institutional drugs stored outside the pharmacy department for outpatient use without appropriate labeling.
· Investigational Drugs
E.G. Frequency of drug investigations initiated within the organization for which drug supplies are stored outside the pharmacy.
The Joint Commission Medication Use Indicators.
The Indicator Measurement System (IMSystem) is a health care performance measurement system developed to meet the accreditation needs of the Joint Commission on Accreditation of Healthcare Organizations.
The Indicator Measurement System (IMSystem) was developed to cover several clinical functions as perioperative, obstetric, cardiovascular, oncology, trauma care, medication use, infection control, home infusion, and behavioral health.
33 indicators were developed, 8 of them cover the medication use function. The selected medication use indicators are expressed either as number or rate with numerators and denominators identified, and focus on the following:
· Individualizing dosage
Numerator: Inpatients 65 years of age or older in whom creatinine clearance has been estimated or measured.
Denominator: Inpatients 65 years of age
· Timing of medication administration
Patients with selected surgical procedures receiving intravenous prophylactic antibiotics: Timing of prophylactic antibiotic administration
· Informing the patient about the medication
Numerator: Inpatients with a discharge diagnosis of insulin –dependent diabetes mellitus who demonstrate self-blood-glucose monitoring and self administration of insulin before discharge or are referred for postdicharge follow-up for diabetes management.
Denominator: Inpatients with a discharge diagnosis of insulin-dependent diabetes mellitus
· Monitoring patient response
1- Numerator: Inpatients receiving digoxin who have no corresponding measured drug level or whose highest measured level exceeds a specific limit.
Denominator: Inpatients receiving digoxin
2- Numerator: Inpatients receiving theophyllin who have no corresponding measured drug level or whose highest measured level exceeds a specific limit
Denominator: Inpatients receiving theophyllin
3- Numerator: Inpatients receiving phenytoin who have no corresponding measured drug level or whose highest measured level exceeds a specific limit
Denominator: Inpatients receiving phenytoin
4- Numerator: Inpatients receiving lithium who have no corresponding measured drug level or whose highest measured level exceeds a specific limit
Denominator: Inpatients receiving lithium
· Reviewing drug regimen
Inpatients: Number of prescribed medications at discharge.
· Joint Commission Primer on Indicator Development and Application: Measuring Quality in Health Care.
· Janet A. Brown, The Healthcare Quality Handbook. A Professional Resource and Study Guide.2003/2004.
· Preliminary report of the ASHP Quality Assurance Indicators Development Group.
Am J Health Syst Pharm 1991 48: 1941-1947.
· Summary of the final report of the ASHP Quality Assurance Indicators Development Group. Am J Health Syst Pharm 1992 (49)9:2157-8.