Adverse outcome + process of care. Outline. Outline of a Medication Use System. Review. Performance Indicator Format. System Performance Information

Transcription

1 Outline Outline of a Medication Use System Part 2: A Medication Management System Review Performance Information System Structure FOCUS PDCA Review Pharmaceutical Care Within a Medication Management System ASSESS- MENT PROB- LEM IMPRE S-SION Pharmaceutical Care System Performance Indicators REFER DEFINE & RESOLVE PROBLEMS MONITOR PATIENT PROGRESS Drug Therapy Problems? IMPLEMENT THERAPEUTIC (DISPENSE & ADVISE ) IMPLEMENT THERAPEUTIC (ADMINISTER/ CONSUME) Done OUTPUTS - Performance Database Standards. Derived from Purpose? Assessment & Correction Indicators Guidelines System Performance Information Performance Indicator Format Performance Criteria (Guidelines) Performance Indicators Performance Database Performance Standards Adverse outcome + process of care process includes DTP that are recognizable correctable Charles D. Hepler 1

2 Examples of indicators #45, A patient was admitted to hospital or ED with code for CHF when he had a history of CHF and no record of ACE inhibitor #33. A patient was admitted to hospital or ED with code for CHF or heart block when history of CHF or heart block or bradycardia record of digoxin prescription & use Examples of indicators #39. Patient had gastritis or upper GI bleeding or Gastric ulcer or anemia and used 2 or more NSAIDs concurrently for 2 weeks or more #48. Status asthmaticus or (ED visit or hospitalization) for asthma and history of asthma use of bronchodialator no use of inhaled steroid Frequency by Indicator (Top 2) 2.% Top 5 = 57% (3.6 % prevalence) 18.% 16.% Top 1 = 8% (5% prevalence.) 14.% 12.% 1.% 8.% 6.% 4.% 2.%.% Large s in overall performance are possible by addressing selected problems Possible uses of medication performance indicators (2) Develop outcome-linked process indicators to manage the process to help identify possible problem patients Provide a basis for discussion and intervention. Provide evidence of performance Possible basis of payment Medications Use System = Pharmaceutical Care + Medications Management Ph.C. System Patient entering care Continue Therapeutic Purpose Assess Prescribe Dispense Advise OK? Adjust Clinical Indicators OUTPUTS DATABASE Performance Indicators Criteria & Stds. Assessment & Correction Derived from? Purpose Extraction of process indicators Indicator P:O #45 ED/H. CHF no ACE Inhibitor.75 #33 ED/H. CHF/Ht Block digoxin.95 #39 ED/H. GI Bleed w/ dupl. NSAID.12 #22 ED/H Hyperthyroid TRT, no T4/TSH.45 #48 ED/H Asthma BD but no inh steroid 1. Charles D. Hepler 2

3 Possible uses of medication performance indicators (2) Develop outcome-linked process indicators to manage the process to help identify possible problem patients Provide a basis for discussion and intervention. Provide evidence of performance Possible basis of payment How Could We Manage Quality in a System? THE HCA FOCUS- Find a process to improve Organize a team that knows the process Clarify your knowledge of the process Select the process FOCUS- (Asthma Example) FOCUS- (Asthma Example) We choose to improve asthma therapy Organize a team that knows the process Clarify your knowledge of the process Select the process We choose to improve asthma therapy The entire staff will work on this Clarify your knowledge of the process Select the process FOCUS- (Asthma Example) We choose to improve asthma therapy The entire staff will work on this Key outcome issues are drug therapy and talking to patients about s/s of disease control Select the process Understand the Causes of Variation Collect Data Nominal Group Exercise Brainstorming Ishikawa (Fishbone) Diagram Search for Root Causes General Ref: Charles D. Hepler 3

4 % of Total Refills Refill Times for Albuterol MDI (Baseline Data) n=175 About 25% of refills were too soon. Refill Times for Beclomethasone MDI (Baseline Data) % of Total Refills n=131 About 6% of refills were too late. (Actual data) >21 Days from Last Refill Very Early Early "On-Time" Late Very Late Time of Refill Understand the Causes of Variation Brainstorming and Affinity Diagram Collect Data Nominal Group Exercise Brainstorming Ishikawa (Fishbone) Diagram Search for Root Causes Clarify/Agree on Objectives e.g. to define root cause of poor asthma control Quick uncritical ideas from each group member, in turn, or pass. Recorded without comment After everyone passes -- discuss for agreement on meaning Sort similar ideas together Understand the Causes of Variation Collect Data Nominal Group Exercise Brainstorming Ishikawa (Fishbone) Diagram Search for Root Causes Ishikawa (Cause and Effect) Diagram Physical Environment Providers Patients workload crowded Patient advice Incentives uninformed Communications Management What factors or combinations of factors are at the root of uncontrolled asthma?? Uncontrolled Disease Charles D. Hepler 4

5 The Five Why s Tree Diagram:Causes by System Level The five why s are a method of finding the components of a big problem. Ask Why? five times to find the root causes, problems that must be solved. Cause Patient Professional Microsystem Management Environment FOCUS- (Asthma Example) We chose to improve asthma therapy The entire staff worked on this We recognized that a key is talking to patients about s/s of disease control. Over use of b-agonists & underuse of steroids are major causes of problems Select the process FOCUS- (Asthma) We chose to improve asthma therapy The entire staff worked on this We recognized that a key is talking to patients about signs/symptoms of disease control. Over-use of b-agonists & underuse of steroids are major causes of problems We will monitor meds & outcomes Plan the intervention () Planning the Improvement Pharmacists will -- review recent refill histories of inhaled b-agonists for asthmatics ask patient/caregiver four questions about asthma status recommend steroids when necessary document information and recommendations Charles D. Hepler 5

6 Implementing the Improvement Implement the Intervention (Improvement) Get technical advice as needed Write practice guidelines Develop new patient record In-service training Get computer DUE program to give refill histories Implement, supervise, correct as needed Check the results of intervention (what you did). Percent of all refillst Control Chart for Early MDI Refills Jan New Program Mar May July Sept Nov UCL LCL Indicator values are plotted by time period Percent Jan New Program Control Limits Mar May July Sept Nov A system is out of control when it shows special variation Special Variation UCL Random Variation LCL Special Variation % of Total Refills (Hypothetical data) Refill Times for Albuterol MDI (Three months Later) n=175 Early refills have been reduced by half >21 Days from Last Refill Charles D. Hepler 6

7 Hold the gain and continue the Continuous Improvement Of Quality (CQI) Definition of CQI: A customerfocused, data-driven, continuous [approach]... used to understand systems and processes aimed at optimizing outcomes. Years of successful experience in manufacturing Kaizen Kaizen is the practice of continuous small increments of change (quality ). A major is sometimes not possible or safe. Take opportunities to improve small things. In CQI philosophy, additional planned is always possible. Charles D. Hepler 7