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Engaging Pharmacists to Improve Quality and Economic Performance Quality Improvement Initiative Template for Managers (Release Date May 2009) www.ashp.org/qii Developed in cooperation with Darin L. Smith, Pharm.D. Medication Use Quality Defining Quality Institute of Medicine (IOM) definition: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. http://www.iom.edu/CMS/8089.aspx Improved quality delivers Better patient care Lower costs Potential for improved reimbursement Quality Data Initiatives and Requirements Confronting Hospitals 9th Scope of Work Inpatient Reporting System Centers for Medicare & Medicaid Services Outpatient Reporting System Private Collaboratives HCAHPS Hospital Quality Alliance ACE Institute for Safe Medication Practices The Joint Commission SCIP Managed Care Bridges to Excellence IMPACTs 100K/5 Million Lives Campaigns Sentinel Event Reporting Hospitals Institute for Healthcare Improvement National Quality Forum Safe Practices Ambulatory Quality Alliance National Patient Safety Foundation Safe Practices Leapfrog Group Hospital Rewards Program Safe Practices Accreditation Agency for Healthcare Research & Quality Infections HCUP Data Collection Safety Goals Emergency Departments Serious Reportable Events Hospital Measures National Priorities Partnership PSOs National Committee for Quality Assurance Quality & Safety Indicators Partnership for Patient Safety What is Medication Use Quality? Characteristics: • • • • • • Safe (harm-free, preventable errors avoided) Effective (evidence-based, desired outcomes achieved) Patient-centered (patient prioritized over provider or organizational needs) Efficient (avoids waste) Equitable (disparities do not exist) Timely (influence of wait times on outcomes, safety) Medication Use Quality Measures Medication Related Indicator Pneumonia (PNE) 5 of 7 Heart Failure (HF) 2 of 4 Acute Myocardial Infarction (AMI) 5 of 8 Surgical Care Improvement Project (SCIP) 6 of 10 Hospital Outpatient Measures (HOP) 5 of 7 Children’s Asthma Care (CAC) 2 of 3 Pregnancy and Related Conditions (PRC) 0 of 3 Hospital-Based Inpatient Psychiatric Services (HBIPS) 2 of 7 Venous Thromboembolism (VTE) 6 of 6 Stroke (STK) 7 of 8 Medication Use Quality Measures Pneumonia (PNE) Heart Failure (HF) Antibiotic selection (ICU/Non-ICU) ACE/ARB for LVSD Antibiotic within 6 hours Discharge Medication Instructions Pneumococcal vaccination Acute Myocardial Infarction (AMI) Influenza vaccination Aspirin on arrival Blood cultures prior to antibiotic Aspirin on discharge Surgical Care Improvement Project (SCIP) Beta-blocker on arrival (retired) Pre-op antibiotic selection ACE/ARB for LVSD Antibiotic within 1 hour (2 hours) Thrombolytic administration Antibiotic discontinued within 24 hours Perioperative beta-blocker administration VTE prophylaxis ordered VTE prophylaxis administered Beta-blocker on discharge Medication Use Quality Measures Hospital Outpatient Measures (HOP) OP Surgery – Prophylactic antibiotic Initiated within one hour prior to procedure OP Surgery – Prophylactic antibiotic selection for surgical patients Emergency Dept – Median team to fibrinolysis Emergency Dept – Fibrinolytic therapy received within 30 minutes Emergency Dept – Aspirin at arrival Children’s Asthma Care (CAC) Use of relievers for inpatient asthma Use of corticosteroids for inpatient asthma Hospital-Based Inpatient Psychiatric Services (HBIPS) Multiple antipsychotic medications at discharge Multiple antipsychotic medications at discharge with appropriate justification Medication Use Quality Measures Venous Thromboembolism (VTE) Venous thromboembolism prophylaxis Intensive care unit venous thromboembolism prophylaxis Venous thromboembolism patients with anticoagulant overlap therapy Venous thromboembolism patients receiving unfractionated heparin with dosages/platelet count monitoring by protocol Venous thromboembolism discharge instructions Incidence of potentially-preventable venous thromboembolism Stroke (STK) Venous thromboembolism (VTE) prophylaxis Discharged on antithrombotic therapy Anticoagulation therapy for atrial fibrillation/flutter Antithrombotic therapy by the end of hospital day 2 Discharged on statin medication Discharge instructions Present on Admission (POA) Indicators (CMS No Pay Conditions) Indicators With Potential for Pharmacist Intervention Effective Oct 1, 2008 Falls and trauma Surgical site infection-mediastinitis after coronary artery bypass graft (CABG) Proposed Indicators Surgical site infections (total knee replacement, laparoscopic gastric bypass/gastroenterostomy (or ligation), varicose vein stripping) Diabetic ketoacidosis, non-ketotic hyperosmolar coma, diabetic coma, or hypoglycemic coma Delerium Ventilator-associated pneumonia Deep vein thrombosis or pulmonary embolism Staphylococcus aureus septicemia Clostridium difficile associated disease Role of the Pharmacist Role of the Pharmacist Provide medication expertise as it relates to order set development/maintenance Screening targeted patients concurrently Concurrent intervention with healthcare professionals to insure appropriate prescribing/administration Documentation of contraindications Vaccine ordering/administration Role of the Pharmacist Discharge medication counseling/documentation to achieve desired outcomes Error proofing of medication use systems to achieve desired outcomes and enhance safety Provide timely data turn around/feed back to impact change Disease state management (heart failure, diabetes, etc…) Antimicrobial stewardship CMS Recognition of Pharmacist Role Core Measures Specification Manual Previously specified physician/APN/PA only for documentation of contraindications to medications Version 2.4b Effective for discharges 04/01/08 – 09/30/08 Acceptable for PHARMACIST to document contraindications www.qualitynet.org (“Hospitals–Inpatient” →”Specifications Manual” →”Version 2.4b” →”Alphabetical Data Dictionary” → then for look sections related to various medication contraindications Financial Implications Linking Quality and Payment Inpatient Pay for Reporting 10 Measures Minus 0.4 percentage points if not reported Expanded Inpatient Pay for Reporting 27 Measures Add Patient Satisfaction and 30-day Mortality Measures Minus 2.0 percentage points Expand Hospital Pay for Reporting 32 Measures Minus 2.0 percentage points Value-Based Purchasing Pending Congressional Approval? Expand Hospital Pay for Reporting 37 Measures 6 VTE Related Minus 2.0 percentage points Expanded Inpatient Pay for Reporting 21 Measures Minus 2.0 percentage points 2007 2008 Hospital Acquired Conditions 8 conditions Potential Payment Reductions 2009 Outpatient Pay for Reporting 7 Measures Minus 2.0 percentage points 2011 IPPS Proposed Quality Measures ?? Measures Minus ?? percentage points 2010 2011 ? ? FY2005 2006 FY 2006 2010 IPPS Proposed Quality Measures 72 Measures Minus ?? percentage points Candidate Hospital Acquired Conditions 9 additional conditions Potential Payment Reductions Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) Hospitals must report to CMS on 27 quality measures to receive full (3.3%) market basket increase for FY 2008. Hospitals that do not report will lose 2% Medication management measures = 21 Payment System Evolution Past (Pay for Reporting): Structured to pay for services including correcting the results of poor quality or unsafe care Present/Future (Pay for Performance): CMS moving to reimbursement based on quality of care No reimbursement for poor quality or injuries due to error Present on Admission Indicators True Pay for Performance based on quality Value Based Purchasing (draft legislation) Value-Based Purchasing Medicare Hospital Quality Improvement Act of 2008 Senators Baucus and Grassley (draft legislation) Proposed to start in 2012 Funded by a carve out from Medicare inpatient payment (1 to 5%) Increases/decreases in Medicare reimbursement tied to hospital performance on quality indicators (three domains) ● Clinical process of care indicators (RHQDAPU/Hospital Compare) ● Patients’ perspectives of care (HCAHPS) ● Outcomes (Mortality) http://finance.senate.gov/press/Bpress/2008press/prb111908c.pdf Value-Based Purchasing Each clinical process of care indicator evaluated based on: Attainment score: compares the hospital’s performance to national Benchmark and Threshold levels Improvement score: compares the hospital’s performance to its prior year’s performance Indicator is given the higher of the two scores (attainment vs improvement) The hospital’s grand total score (based on all three domains) is entered into an equation to determine a payment percentage Conclusion • The current fee-for-service payment system rewards excessive use of services and poor quality. • Pay for reporting systems are quickly evolving into pay for performance focusing on quality measures. • The majority of current quality measures are medication management related. • Pharmacists can be major contributors to improving medication related quality indicator performance.