Transcript Document

Final Canadian National Delphi Consensus Results What Are The Appropriate National Clinical
Pharmacy Key Performance Indicators (cpKPI) For
Canadian Hospital Pharmacists?
Olavo Fernandes BScPhm, ACPR, PharmD, FCSHP
Director of Pharmacy- Clinical, University Health Network, Toronto ON
Assistant Professor (Status)- Leslie Dan Faculty of Pharmacy
Sean K. Gorman, BSc(Pharm), ACPR, PharmD
Regional Coordinator - Clinical Quality and Research, Pharmacotherapeutic Specialist – Critical Care
Interior Health Authority, Clinical Associate Professor – Faculty of Pharmaceutical Sciences, UBC
Kent Toombs BSc(Pharm), ACPR
Clinical Pharmacy Manager, Capital District Health Authority, Halifax, NS
Canadian Hospital Pharmacy Leadership Conference , June 8, 2013
Objectives
To outline the key elements of the national consensus process in
developing clinical pharmacy key performance indicators (cpKPI)
for hospital pharmacists
including consensus definition, selection criteria for cpKPI, critical topic/
activity foci and pre-Delphi candidate cpKPI)
To report the final results of the recent national Delphi consensus
phase to establish a final suite of cpKPI
To summarize the next phases and communication plans in the
national cpKPI process :
1.
2.
3.
4.
5.
exploring interprofessional/ external stakeholder feedback,
national information capture/ measurement systems,
cpKPI knowledge translation kit
practical definition and measurement questions
pan-Canadian communication/ Manuscript publications / posters
2
Overall Goal of the National cpKPI Collaborative /
National Consensus Process
To develop a core set of national clinical
pharmacy KPI for hospital pharmacists via a
systematic national evidence-informed
consensus process
3
Key Performance Indicators (KPI)
What is it?
“Quantifiable measures that reflect the
critical success factors of an organization”
Quantitative measures of quality
1
Why is it important?
Elevate professional accountability &
transparency
Serve to improve quality of care
1. Doucette D, Millen B. Should Key Performance Indicators for Clinical Pharmacy Services Be Mandatory,
4
Can J Hosp Pharm 2011; 64(1):55-57.
Rationale for clinical pharmacy KPI (cpKPI)
GAP: currently NO established national or
international consensus on what constitutes a
KPI for clinical pharmacy services
Rationale: To advance practice toward desired
evidence-informed patient outcomes
cpKPI will serve to better define minimum
standards and permit benchmark comparisons
within and between organizations
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National cpKPI Collaborative
Definition of cpKPI
Five pillars/ characteristics of cpKPI:
1.
2.
3.
4.
5.
Reflect a desired quality practice and
A metric with a link to direct patient care and
Link to evidence of impact on meaningful patient
outcomes and
A pharmacy/ pharmacist sensitive metric
Feasible to measure
• Clinical metric would have to fulfill all 5 pillars to
qualify as a candidate cpKPI
Hierarchy of Study Outcomes (AHRQ)
Level 1: Clinical and QoL outcomes
• Morbidity, mortality, adverse events
Level 2 : Surrogate outcomes
• I.e. blood glucose, blood pressure, cholesterol
Level 3: Measureable variables with an indirect or
unestablished connection to target outcome
• I.e. medication disease state knowledge
Level 4: Indirect variables
• I.e. patient satisfaction, “potential adverse events”
Should Align with Local Consensus or Guidelines for
Prioritization of Hospital Pharmacist Activities
6 Domains
1. Pharmaceutical care patient care process
2. Operational patient care supporting activities
3. Drug information
4. Teaching/Education/Learning
5. Research
6. Service (clinical and pharmacy committees)
*Extracted from UHN Pharmacist Pyramid-Prioritization of Pharmacist Activities Draft
Information Gathering - Prior to
Consensus Building
Front-line
Staff/Leaders
Literature:
1.Evidence
2.Process
CSHP 2015/
CPhA Blueprint
Optimal
National
cpKPI
Peer Hospital
Best Practices
Pharmacy
Leadership
Proposed Timeline
Pre-Delphi
Delphi
Post-Delphi
KPIWG formed
May 2011
Information
Gathering
Delphi
Process
Dec’12Mar’13
Aug 2011
CSHP
endorsed
concept
We are here
Feb 2013
Survey
Development
Consensus
Meeting
Key National Process Milestones
National consensus definition – cpKPI (Aug 2011)
National Crude Inventory of candidate cpKPI / metrics (started Jan
2012)
National Information-gathering Process: Workshops/ Information
sessions-Front line feedback (Feb 2012- Nov 2012)
Outcome and Process Debates/ Finalized Evidence summary tables
(June-July 2012)
A priori consensus cpKPI selection criteria (ideal attributes)– “Slavik
11” (Finalized July 2012)
Key cpKPI Critical Activity / Topic Areas – “Doucette 8” (Finalized
August 2012)
Final Pre-Delphi Candidate cpKPI list (October 2012)
Selection of National Delphi Panel members (November 2012)
Delphi Panel Process – Round 1-3 (Dec 21, 2013- Mar 8 2013)
1.
2.
3.
4.
5.
6.
7.
8.
9.
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cpKPI Live Meeting (February 5, 2013)
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Slavik -11- Consensus Criteria – Ideal Attributes
Based on high quality literature evidence
(e.g. Observational data vs. RCT vs. systematic review)
Relevant impact on clinically important outcomes
(e.g. Surrogate versus clinical endpoints, effect size of intervention)
Best-suited to pharmacist’s role
(e.g. Identifies pharmacist-specific clinical role vs. GP vs. RN)
Attributable to direct patient care
(e.g. Marker of clinical intervention, not distribution)
Specific to pharmaceutical care process
(e.g. Related to generally-accepted PC processes)
Aligned with professional goals, objectives, practices
(e.g. Accreditation Canada ROPs, standards, CSHP Vision 2015, etc.)
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Slavik -11- Consensus Criteria – Ideal Attributes
Accepted disease-based quality indicator
(e.g. ACEI or BB for HF, VTE prophylaxis in hospitalized patients)
Feasible to measure
(e.g. Reliable measurement systems can/could be put in place)
Efficient to measure
(E.g. Acceptable time commitment, useable)
Valuable quality measure
(E.g. Prevalent, impactful problem with practical, proven interventions)
Generalizability
(E.g. Versatile enough to be applied in large, academic and small community
sites)
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Delphi panelist priority ranking of consensus
cpKPI selection criteria- Final – Mar 2013
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Bringing the evidence all together with extrapolation………
Bond et. al. (2007) Observational
Study
Clinical Pharmacy & Mortality
1. admission drug histories
2. medical rounds participation
3. CPR team participation
Kaboli PJ et al. (2006) Systematic Review
1. attendance on patient care
rounds
2. patient interviews and
assessments
3. medication reconciliation
4. discharge “counselling”
RCT Outcome Findings
Gillespie U et al. 2009- RCT
Integrated Intervention pharmaceutical
care Integrated Intervention
1. post-discharge hospital visits (ED +
readmissions)
2. emergency department visits
3. drug related readmissions
Makowsky MJ et al. 2009- RCT
1. “overall quality score”
2. 3 and 6 month all-cause readmission
(hospital or ED visit after index
hospital admission)
(patient medication education)
5. follow-up after discharge
Chisholm-Burns MA et al 2010,
systematic review w/ focussed
meta-analyses
HbA1c , LDL Cholesterol, Blood
Pressure
Adverse Drug Events
Evidence Summary Tables
Discussion: specific group suggestions to modify or
concur with the follow sections
•
•
•
Strengths and Limitations
Application/Synthesis: How does this study inform the cpKPI
selection process (methods, cpKPI selection criteria, and
candidate cpKPI)?
What are the patterns (similarities and differences) compared
to other key papers?
Purpose: August- used to refresh and focus outcome
evidence for streamlining ; Nov- Used by Delphi
panelists to support ranking and decision making
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Levels of Evidence
1. Observational Studies
2. Systematic Reviews
3. Randomized Controlled Trials
PRACTICE QUESTION
Does pharmacist-led comprehensive pharmaceutical
care reduce morbidity (& other meaningful patient
outcomes) for elderly hospitalized patients?
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A Comprehensive Pharmacist Intervention to
Reduce Morbidity in Patients 80 years or Older
Gillespie U et al. Arch Intern Med 2009; 169(9):894-900.
Objectives:
assess the effectiveness of interventions performed by ward-based
pharmacists on morbidity and overall use of (secondary) hospital care
Design:
prospective, single centre, unblinded, randomized control trial
patient- unit of randomization, central centre
Setting: 2 acute internal medicine wards (university teaching
hospital) in Uppsala, Sweden
Duration: Oct 2005-June 2006
Patients:
Patients 80 years or older admitted to 2 acute care internal medicine
wards
Written informed consent
Sample size calculation : 400 patients
A Comprehensive Pharmacist Intervention to
Reduce Morbidity in Patients 80 years or Older
Gillespie U et al. Arch Intern Med 2009; 169(9):894-900.
Patients randomized to:
intervention (comprehensive care by hospital pharmacist)
• Ward based clinical pharmacists
1. comprehensive patient interview, BPMH, admission medication
reconciliation,
2. pharmaceutical care drug review (Cipolle method) to identify and
resolve DTPs, physician interventions on drug selection,
dosages, monitoring….
1. Addressed: indication, effectiveness, safety and adherence
2. DTPs discussed on ward rounds
3. Patients received education and discharge counselling/
reconciliation
4. pharmacist discharge letter communicated to primary care physicians by
pharmacists
5. Follow up telephone call 2 months after discharge
control: standard care without pharmacist involvement by
physicians and nurses
Results: Major Outcomes
Gillespie U et al. Arch Intern Med 2009; 169(9):894-900.
Patients Evaluated (n=368, 182 intervention / 186 control)
over a 12 month period
Post-Discharge Hospital Visits (ED + readmission)
↓ 16% intervention group
(quotient 1.88 vs. 2.24, 95% CI 0.72-0.99)
Emergency Department Visits:
↓ 47% intervention group
(quotient 0.35 vs. 0.66, 95% CI 0.37-0.75)
Drug Related Readmissions:
↓ 80% intervention group
(quotient 0.06 vs. 0.32, 95% CI 0.10-0.41)
Aside: Balancing Measures- Readmissions Alone and Mortality :
- No significant difference
Bringing the evidence all together with extrapolation………
Bond et. al. (2007) Observational
Study
Clinical Pharmacy & Mortality
1. admission drug histories
2. medical rounds participation
3. CPR team participation
Kaboli PJ et al. (2006) Systematic Review
1. attendance on patient care
rounds
2. patient interviews and
assessments
3. medication reconciliation
4. discharge “counselling”
RCT Outcome Findings
Gillespie U et al. 2009- RCT
Integrated Intervention pharmaceutical
care Integrated Intervention
1. post-discharge hospital visits (ED +
readmissions)
2. emergency department visits
3. drug related readmissions
Makowsky MJ et al. 2009- RCT
1. “overall quality score”
2. 3 and 6 month all-cause readmission
(hospital or ED visit after index
hospital admission)
(patient medication education)
5. follow-up after discharge
Chisholm-Burns MA et al 2010,
systematic review w/ focussed
meta-analyses
HbA1c , LDL Cholesterol, Blood
Pressure
Adverse Drug Events
Doucette 8- Consensus Critical Activity / Topic
Areas
1. Pharmaceutical Care – Integrated (DTP assessment/
care plan/ monitoring)
2. Medication Reconciliation- BPMH/Med History Taking
3. Medication Reconciliation- Admission Reconciliation
4. Medication Reconciliation- Discharge Reconciliation
5. Team (or Patient) Rounds
6. Discharge Patient Education / Counselling
7. Post Discharge Follow-Up
8. Disease or Drug Specific – Best Practice Quality
Indicators
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Doucette 8- Consensus Critical Activity / Topic
Areas
• Dot voting: 20 dots per person
• Assign proportionately
Question:
• Will measuring a cpKPI in this “critical
activity topic area” be useful to advance
clinical pharmacy practice to improve the
quality of patient care?
• Semchuk-26 Draft Candidate KPI list
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DEMOGRAPHICS OF cpKPI DELPHI PANEL
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What is your practice setting (check all that apply)?
69%
(18)
Other= Administration, Pharmacy Association,
Oversee multiple sites, Regional Health Authority,
Long Term Care and Rehabilitation Centre, District
health authority with tertiary and community practice.
35% (9)
27% (7)
27% (7)
23% (6)
12% (3)
Teaching
hospital
Community
hospital
Tertiary care
hospital
Academia
Other
Clinic
Do you work primarily with pediatrics or adults?
Adults
88% (23)
12% (3)
Pediatrics
How many years of experience do you have as a
licensed Pharmacist?
65%
(17)
19% (5)
8% (2)
8% (2)
0% (0)
0-5 years
6-10 years
11-15 years 16-20 years
20+ years
What is your educational background?
Other: MBA, BSc (Pharmacology), EXTRA
Fellowship (CFHI) Certified Health Executive (CHE),
MBA, Post PharmD Residency, Certified Geriatric
Pharmacist
100%
(26)
54% (14)
54% (14)
23% (6)
BScPhm
PharmD
Residency
(ACPR)
Other
19% (5)
Masters
Degree
DOUCETTE 8 – 20 Dot Voting
RESULTS
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Doucette 8- Consensus Critical Activity / Topic
Areas
1. Pharmaceutical Care – Integrated (DTP assessment/ care
plan/ monitoring)
2. Medication Reconciliation- BPMH/Med History Taking
3. Medication Reconciliation- Admission Reconciliation
4. Medication Reconciliation- Discharge Reconciliation
5. Interprofessional (team) patient care rounds
6. Discharge Patient Education / Counselling
7. Post Discharge Follow-Up
8. Disease or Drug Specific – Best Practice Quality Indicators
• Used to create “Semchuk 26” candidate cpKPI list
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Grape Analogy: BUNDLES AND
CRITICAL ELEMENTS
Modified Delphi Process Methodology
A Delphi technique is a structured process commonly used
to develop consensus healthcare quality indicators
It was developed to minimize influence from more vocal
group members, and utilizes surveys or questionnaires
instead of discussion.
frequently used with expert panels to generate consensus on
healthcare issues
To arrive at consensus, a modified Delphi technique will be
used.
This ‘modified” technique is an iterative process that builds
consensus using three rounds of anonymous panelist ratings with a
live/tcon meeting
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Delphi Rounds
A. Standardized Orientation
•
Audio PowerPoint + Mandatory Pre-Reading
B. Round 1
•
Demographic Information; Panelist ranks Semchuk 26 cpKPI, For
each Slavik 11 and Overall Ranking, Suggest new cpKPI
C. Round 2
•
•
•
•
Review R1 aggregate summary/ report card for each cpKPI
Frequency Graphs Summary
Review anonymous qualitative comments
Panelist re-ranks all cpKPI
D. Live Meeting – Debate and Discussion to inform individual rankings
•
identify meet other panelists for the first time
E. Round 3
Review Feb 5 Live Minutes , R2 summaries (as above), Final
Rankings
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Delphi Rounds
1.
2.
3.
4.
Individual cpKPI ratings
Opportunity to suggest additional candidate cpKPI (round 1 only
to allow panel feedback)
Ranking of priority of “Doucette 8” Critical Activities and “Slavik
11” Selection Criteria
Combining cpKPI, Creating New cpKPI by modifying working (ie
cpKPI 27, 28, 30)
• Threshold for consensus consideration:
•
•
75% of panelists assign a rating of 7-9 on the 9 point Likert scale
MAGIC NUMBER = 20
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Round 1 Qualitative Panelist Discussion Themes
•
Qualitative discussion themes while comparing cpKPI
included:
1. Varying degrees of sensitivity to pharmacists’
contribution
2. Varying degrees of feasibility of measurement
3. Varying degrees of generalizability across practice
areas (i.e.. psychiatry, surgery) as well as across
different types of hospitals (i.e. urban versus rural)
4. Inter-relationships between: medication
reconciliation cpKPIs; discharge/ inpatient
counselling cpKPIs
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Round 1 – 3 New cpKPI Submitted by Panelists
1.
cpKPI #27: combined pharmacist admission Med Rec + BPMH
Number (or proportion) of patients who receive formal
documented admission medication reconciliation by a
pharmacist (includes a pharmacist-BPMH OR pharmacistBPMH-review as part of reconciliation as well as resolution of
identified discrepancies).
2.
cpKPI #28: Proactive bundle; Number (or proportion) of
patients receiving “proactive comprehensive, direct patient
care by a pharmacist in collaboration with the health care
team” (Makowsky Collaborate RCT Bundle).
3.
cpKPI #29: Time on Ward Committed decentralized clinical
pharmacist time per patient day per patient service.
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Live Feb 5: Meeting Issues and Controversies
1. How to optimally handle process of care vs.
disease/drug-specific indicators?
•
2.
3.
4.
5.
High Value Action “DTP resolved” as a subset
Grape Theory: Bundles and Critical Elements
Number vs. proportion
A priori Suite properties
“High Risk vs. All Patients”
Final Delphi Results
Round 3 Final Rankings
8 cpKPI have officially met consensus
6/8 Doucette Categories represented with combos
Final 8: cpKPI Number and Description
Proportion of patients who receive formal documented
discharge medication reconciliation and resolution of
identified discrepancies by a pharmacist (#11)
Number (or proportion) of patients who receive formal
documented admission medication reconciliation by a
pharmacist (combined BPMH) (#27)
Number (or proportion) of patients for whom clinical pharmacists
have completed (executed/implemented) a
pharmaceutical care plan (#27)
Number (or proportion) of pharmacists who actively participate in
interprofessional patient care rounds to improve medication
management
Final 8: cpKPI Number and Description
Number of total drug therapy problems (DTPs) resolved by
pharmacists
Number (or proportion) of patients receiving "proactive
comprehensive, direct patient care by a pharmacist in collaboration
with the health care team" (Makowsky Collaborate RCT Proactive
Bundle) (#28)
Number (or proportion) of hospitalized patients who receive
medication counselling by a pharmacist at discharge
Number (or proportion) of patients who have received in person
education from a pharmacist about their disease(s) and
medication(s) during their hospital stay
How do the final national clinical pharmacy key
performance indicators align with national consensus
selection criteria?
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National cpKPI Collaborative
Next Steps
7 Post-Delphi Phases
1.
cpKPI knowledge translation kit- practical getting started kit
•
2.
Final 8 : Practical Outstanding Questions
•
3.
Wording, outstanding questions, practical definitions, practical measurement issues
Exploring external stakeholder feedback
•
4.
5.
6.
7.
Final 8 cpKPI-specific measurement summaries, background, 7 step change
management framework
Interprofessional : physicians, nurses, Ministry of Health, pharmacists- US,
UK, NZ, Aus, patients, hospital administrators
National information capture systems / measurement systems (“apps”)
Pan-Canadian Communication of Final Delphi Results
2 Manuscript Publications/ 7 Conference Abstracts
Formal “Pilot” Sites