objectives - capho.org · olavo fernandes bscphm, acpr, pharmd, fcshp director of pharmacy- uhn,...

Exploring a Collaborative National Process to Co-create Consensus Clinical Pharmacy

Key Performance Indicators for Ambulatory Oncology Pharmacists

Olavo Fernandes BScPhm, ACPR, PharmD, FCSHP Director of Pharmacy- UHN, Toronto ON

Assistant Professor (Status)- Leslie Dan Faculty of Pharmacy

CAPHO 2017 Apr 22 2017, Banff Alberta

HANDOUT

Objectives • After attending and participating in the session, participants will be able

to: 1. Outline key milestone steps that could be used by CAPHO to conduct a

Delphi consensus process for establishing key performance indicators (cpKPI) for Canadian ambulatory oncology pharmacists.

2. Highlight ideal attribute cpKPI selection criteria that could be adapted for establishing key performance indicators (cpKPI) for Canadian ambulatory oncology pharmacists

3. Summarize the merits and challenges of establishing and implementing “disease-specific” vs. “process of care” based cpKPI?

4. List potential Delphi controversial discussion topics that may arise to guide panelists with their voting preferences for cpKPI.

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10 Step Process – Co-Creating Consensus Ambulatory Oncology cpKPI

1. Establish pre-Delphi consensus cpKPI definition

2. A priori consensus selection criteria (ideal attributes)

3. National call- candidate cpKPI

4. Literature Search – establish an inventory bank for candidate cpKPI & evidence summary tables

5. Evidence-informed cpKPI categories (areas of focus)

6. Draft pre-Delphi Candidate cpKPI

7. Survey Instrument/ Core Delphi Voting Question

8. Select and consent Delphi panel

9. 3 round Delphi process (with live meeting after round 2)

10. Final vote 3 • Fernandes, O. et al Annals of Pharmacotherapy. 2015 Jun 1;49(6):656-69.

What? Overall Goal of the National cpKPI Collaborative / National Consensus Process Colla

To develop a core set of national clinical pharmacy KPI for inpatient hospital pharmacists via a systematic national evidence-informed consensus process

4 Graphic: from:http://procentus.files.wordpress.com/ 2013/02/kpi-i-have-a-dream.gif

Key Performance Indicators (KPI) What is it?

“Quantifiable measures that reflect the critical success factors of an organization” 1

Quantitative measures of quality

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,

Can J Hosp Pharm 2011; 64(1):55-57. 5 5 6

Why? 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

Optimal National cpKPI

Literature: 1.Evidence 2.Process

CSHP 2015/ CPhA Blueprint

Front-line Staff/Leaders

Peer Hospital Best Practices

Pharmacy Leadership

HOW? - Information Gathering - Prior to Consensus Building

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How ? - National cpKPI Process

8 • Fernandes, O. et al Annals of Pharmacotherapy. 2015 Jun 1;49(6):656-69.

WHAT IS A CPKPI ? CLINICAL PHARMACY KEY PERFORMANCE INDICATORS DEFINITION: FIVE PILLARS

1. Reflect a desired quality practice

2. Links to direct patient care

3. Links to evidence of impact

on meaningful patient outcomes

4. A pharmacy/ pharmacist sensitive

measure

5. Feasible to measure

cpKPI

• Fernandes, O. et al Annals of Pharmacotherapy. 2015 Jun 1;49(6):656-69.

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”

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Ambulatory pharmacy metrics Schmidt L. et al Am J Health-Syst Pharm. 2017; 74e76-82

Growth of pharmacist’s services in ambulatory care settings

Gap : No established international consensus indicators

11


What are the options of metrics to gauge impact that pharmacists have on patient care? 1. Direct clinical outcomes (calculating hospitalization or

disease exacerbation) 2. Indirect measure of clinical outcomes

1. Lab values within a goal rate 2. Pharmacist Intervention rates 3. Compliance with guideline recommendations 4. Patient medication adherence rates 5. Efficiency and satisfaction scores (patient experience)

3. Other 1. Adverse event rates, intervention rates, clinical outcomes,

hospitalization or readmission rates, adherence 12


Challenges: 1. Labour intensive manual data collection 2. Different clinics often use different metrics

and apply them inconsistently 3. Individualized nature of metrics in use was a

barrier to generalization across clinics

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How ? - Implementation of Performance Metrics to assess pharmacists’ activities in ambulatory Care Schmidt L. et al Am J Health-Syst Pharm. 2017

Focal points for Metric Developments (Milwaukee, WI) - Pharmacists provide services in 11/159 clinics 1. Pharmacist Interventions 2. Cost Avoidance 3. Patient Satisfaction

14 • Schmidt L. et al Am J Health-Syst Pharm. 2017; 74e76-82.

Question 5 - Application to Ambulatory Care

Which one strategy can reduce 30 –Day re-hospitalization when implemented alone?

a) “home visit” b) “patient education” c) “follow-up telephone call” d) “medication reconciliation” e) None of the above

Interventions to Reduce 30 –Day Re-hospitalization: Systematic Review Hansen LO et al. Ann Intern Med. 2011;155:520-528.

Interventions to Reduce 30 –Day Re-hospitalization: Systematic Review Hansen LO et al. Ann Intern Med. 2011;155:520-528.

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How To Identify & Select cpKPI: 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.)

19 Fernandes O et al? [Abstract] Pharmacotherapy 2013;33(10):e208.

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) 20 Fernandes O et al? [Abstract] Pharmacotherapy 2013;33(10):e208.

How To Identify & Select cpKPI: Slavik -11- Consensus Criteria – Ideal Attributes

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”

(patient medication education) 5. follow-up after discharge

pRCT 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)

Chisholm-Burns MA et al 2010,

systematic review w/ focussed meta-analyses HbA1c , LDL Cholesterol, Blood Pressure Adverse Drug Events 21

How ? Prepare 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: used to refresh and focus outcome evidence for streamlining Used by Delphi panelists to support ranking and decision making

22

23 24

25 26

EVIDENCE MAP

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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HOW? 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

A modified Delphi technique used to arrive at consensus 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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HOW ? 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

29

10 Step Process – Co-Creating Consensus Ambulatory Oncology cpKPI










10. Final vote 30 • Fernandes, O. et al Annals of Pharmacotherapy. 2015 Jun 1;49(6):656-69.

31

Electronic Survey Instrument WHO? DEMOGRAPHICS OF cpKPI DELPHI PANEL

32 • Fernandes, O. et al Annals of Pharmacotherapy. 2015 Jun 1;49(6):656-69.

cpKPI #25: Number (or proportion) of inpatients receiving venous thromboembolism (VTE) prophylaxis

Overall Rating for cpKPI #25

mean 6.58 median 7

0

1

2

3

4

5

6

7

8

9

10

Stronglydisagree (1)

Disagree (3) Neitheragree or

disagree (5)

Agree (7) Stronglyagree (9)

Number of Panelists (N = 26)

Overall Rating: Measuring cpKPI#25 is useful in advancing clinical pharmacy practice to improve the

quality of patient care

16


cpKPI #30 (NEW): Number (or proportion) of patients for whom clinical pharmacists have completed (executed/implemented) a

pharmaceutical care plan.

Overall Rating for cpKPI #30

mean 7.62 median 8

0

2

4

6

8

10

12

14

16

Stronglydisagree (1)

Disagree(3)

Neitheragree or

disagree (5)

Agree (7) Stronglyagree (9)

Number of Panelists (N = 26)

Overall Rating: Measuring cpKPI#30 is useful in advancing clinical pharmacy practice to improve the

quality of patient care

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cpKPI #30 (NEW): Number (or proportion) of patients for whom clinical pharmacists have completed (executed/implemented) a

pharmaceutical care plan.

Composite mean Slavik 11 rating = 7.55; Overall rating mean = 7.62

1 2 3 4 5 6 7 8 9

I. Indicator is supported by high quality evidence.

II. Indicator is associated with a relevant impact on…

III. Indicator is a reflection of a role that is best-…

IV. Indicator is attributable to direct patient care.

V. Indicator is specific to a pharmaceutical care…

VI. Indicator is aligned with professional goals,…

VII. Indicator is an accepted disease-based quality…

VIII. Indicator is feasible to measure.

IX. Indicator is efficient to measure.

X. Indicator is a valuable quality measure.

XI. Indicator is generalizable to all hospital pharmacy…

Average ratings from 1 (Strongly disagree) to 9 (Strongly agree) using each of the Slavik 11 for cpKPI#30

FINAL 8 CANADIAN NATIONAL CONSENSUS CPKPI

Admission medication

reconciliation

Discharge medication

reconciliation Pharmaceutical

care plan Drug

therapy problems

Inter-professional patient care

rounds

Proactive patient care

bundle Patient

Education Discharge

patient education

• Fernandes, O, Gorman S, Slavik R, Semchuk WM, ….K Toombs. [Abstract] Pharmacotherapy 2013;33(10):e208.

National cpKPI Knowledge Mobilization Guide – Dec 2015

Patient care bundle

40

1. All Patients vs. Priority (High Risk) Patients? • Quick wins vs. complex patients

2. Documentation - What & Where?

3. Required Extent of Pharmacist Involvement? • Other HCP/Student/Staff involvement?

4. DTP Reporting

• Sub-type & Severity? • High-Value Action DTPs?

Top 5 : cpKPI Issues & Controversies

41

5. Definitions:

• Active Participation on Inter-professional Rounds?

• Pharmaceutical Care Plan?

• In-Person vs. Discharge Patient Education?

• Proactive Bundle – Which cpKPI activities required?

Top 5 : cpKPI Issues & Controversies

HOW? TO DO OR NOT TO DO?

merits and challenges of “disease-specific” cpKPI vs. “process of care”

Example percentages of patients receiving ACEI post MI vs. percentages of patients receiving pharmaceutical care

“high value action items” for this ambulatory ONCOLOGY.

42

HOW? TO DO OR NOT TO DO?

merits and challenges of “disease-specific ”cp�� vs. “process of care”

Process of Care considerations : Less li�el� to change month to month �ased on pharmacotherap� trials Ma� �e a �etter reflection “pharmacist-centric” interventions Ma� �e more generali�a�le to heterogeneous pharmac� practices

4� 44

•Num�er of events vs. Proportion of Patients?

•�isease �pecific Indicators • �� •��

•All patients vs. Priorit� Patients •�� ALL PATIENT� �� IG� �I�K PATIENT��

•Complexit� of patients and medication regimens:

•�o� do �e account for this? •�uic� �ins vs. complex patients

GENE�AL : cpKPI Issues & Controversies

4�

•�requenc� and length of measurement

•��

•��

•�ocumentation •What & �here documentation must occur? •Patient chart vs. Pharmac� record� profile? •�ard cop� or electronic?

•�enominator •What is the denominator? •�� •�� •��


4�

•Extent of Measurement •��

•�requenc� of National �eporting

•��

•�tudents�Learners •�� •� ��


�o� �o Patient� Non-Patient �ta�eholder and �ospital Pharmacist Perspectives on Clinical

Pharmac� Ke� Performance Indicators for �ospital Pharmacists Compare?

Preliminar� �esults

Local �ospital Perspectives :

��

��

�o� to Identif� and �elect �ualit� Measures- �ta�eholder Perspectives

SUMMARY: 10 Step Process – Co-Creating Consensus Ambulatory Oncology cpKPI










10. Final vote

48


4�

Questions

email [email protected]

objectives - capho.org · olavo fernandes bscphm, acpr, pharmd, fcshp director of pharmacy- uhn,...

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