The College has collaborated with Health Quality Ontario (HQO), the provincial advisor on healthcare quality, to establish quality indicators for pharmacy. The indicators, selected by an expert panel, will be used for public reporting and quality improvement.
OVERALL SCOPE AND PURPOSE OF THE QUALITY INDICATORS FOR PHARMACY
THE NEED FOR QUALITY INDICATORS IN COMMUNITY PHARMACY
There is a lack of understanding among providers, patients and the public about the profession of pharmacy and the impact it has on patient outcomes. Community pharmacists are the final checkpoint in the medication management system. Prior to dispensing a medication, a community pharmacist determines whether a medication is appropriate, including checking allergies, potential drug interactions and past medication history, among other factors.
A strong focus on indicators already exists in other areas of the health system (for example, in hospitals, primary care, long-term care and home care), however community pharmacy is an area that has not historically been measured. A great deal of work has already been done to establish indicators in hospital pharmacy, including the efforts of the Canadian Society of Hospital Pharmacists. Since the primary gap currently is in community pharmacy, this is the current focus of the indicators work.
Despite all current efforts, it is difficult to understand what part community pharmacy plays in a patient’s health outcomes. Quality indicators are needed to provide the data and information required to understand the quality of pharmacy care and its influence on patient outcomes.
THE ROLE OF THE COLLEGE
The College has a mandate to serve and protect the public. To support its mandate, the College is responsible for encouraging continuous quality improvement within the profession of pharmacy. Establishing quality indicators will enable the College and pharmacy professionals to use data to make evidence-informed decisions and promote a better understanding of the quality of pharmacy care and the impact pharmacy has on patient outcomes.
THE GOALS OF THE QUALITY INDICATORS
The quality indicators for pharmacy are intended to provide the public and health system with information about the overall quality of pharmacy care and to support the sector in gaining a better understanding of pharmacy’s impact on patient outcomes. Unlike other indicators that have recently been released by insurance companies, the quality indicators for pharmacy are not purposed for tracking the performance of individual pharmacy professionals or intended to be used for reimbursement.
QUALITY INDICATORS FOR PHARMACY
MEASUREMENT AREA: PATIENT/CAREGIVER EXPERIENCE AND OUTCOMES
Pharmacists, according to the NAPRA Model Standards of Practice for Pharmacists, are to give patients the information they need to make decisions about their care in a way they can understand. Pharmacy Technicians enable this by managing the technical aspects of pharmacy practice thus freeing up the pharmacists’ time to provide clinical care. However, it is currently difficult to know whether a patient has understood what has been communicated to them by their community pharmacy team. This measurement area provides insight into the quality of care from the lens of a patient/caregiver.
There are four quality indicators that have been selected within this measurement area:
QUALITY INDICATOR: My pharmacist helped me understand why I am taking each of my medications
Importance/relevance to pharmacy: Explaining why each of their medications is necessary is vital to ensuring compliance and prevention of morbidity and mortality in patients. For instance, a patient prescribed two medications for controlling their Chronic Obstructive Pulmonary Disease, may need clarity on the need for both and the difference between the two.
QUALITY INDICATOR: My pharmacist made sure I understood how to take my medication properly
Importance/relevance to pharmacy: Explaining the details regarding proper medication administration is vital to ensuring optimal health outcomes, and the community pharmacist, as the final gatekeeper and education touchpoint for the patient, is in an ideal position to ensure the patient has a good understanding of this.
QUALITY INDICATOR: My pharmacist made sure I understood what results I might expect from my medication, including any side effects or drug/food interactions that may occur
Importance/relevance to pharmacy: Educating patients about the safety of their medications including potential common side effects and drug/food interactions is essential to ensure expectations are managed and medication-related adverse events are prevented. Pharmacists have extensive knowledge in pharmacodynamics and pharmacokinetics and have a duty to educate patients on the safety of their medication.
QUALITY INDICATOR: My pharmacist helped me understand how to know if my medication is working
Importance/relevance to pharmacy: Pharmacists are well placed within the health system to counsel patients on expectations of efficacy. For instance, medical conditions such as hypertension often present without any signs and symptoms, and hence patients lack clarity around whether or not their medication is working.
MEASUREMENT AREA: APPROPRIATENESS OF DISPENSED MEDICATIONS
Pharmacists are responsible, as per their Standards of Practice1, for ensuring that when medications are dispensed, each prescription is reviewed to ensure that the medication is the most appropriate for the patient. Given that this measurement area is quite broad, the expert panel decided to focus on key quality challenges facing the health system today such as the opioid crisis.
QUALITY INDICATOR: Percentage of opioid-naïve patients who were dispensed an initial dose greater than 90 mg morphine equivalents per day.
Importance/relevance to pharmacy: This indicator was drawn from indicators outlined in the HQO Quality Standards for Opioid Prescribing for Acute Pain and Opioid Prescribing for Chronic Pain. As the HQO Quality standards describe, starting a patient on a high dose of opioids (greater than 90 mg morphine equivalents per day) can increase the risk of overdose and hence is rarely indicated, particularly in opioid naïve patients. Pharmacists, as the final gatekeeper before a medication is dispensed to a patient, should be vigilant in assessing new opioid starts in opioid-naïve patients and they are expected to collaborate with prescribers and patients to ensure appropriateness.
MEASUREMENT AREA: MEDICATION-RELATED HOSPITAL VISITS
Pharmacy professionals are responsible for ensuring optimal medication management and identifying and preventing medication-related incidents in their patients’ medication regimens. By preventing these incidents, pharmacy professionals have an opportunity to, in collaboration with other health system providers, impact the number of medication-related emergency department visits and hospitalizations. Given the broad reach of this measurement area, the current focus is on opioid-related hospital visit data which is well coded and timely.
QUALITY INDICATOR: Hospital visits for opioid poisonings among patients that are actively treated with an opioid prescription.
Importance/relevance to pharmacy: Broader outcome indicators such as this are influenced by many different parts of the healthcare system. Pharmacists, in collaboration with their health system partners are responsible for ensuring opioid prescriptions dispensed are appropriate, and follow-up touchpoints are conducted with patients when appropriate to continuously discuss the patient’s treatment regimen and to offer tapering in a timely manner. Technical specifications of this indicator including definitions of hospital visits, opioid poisonings, and actively treated will be developed in the next phase of the indicators work.
MEASUREMENT AREA: TRANSITIONS OF CARE
Transitions of care are vulnerable points within the healthcare system involving multiple healthcare providers and an overwhelming amount of information provided to patients and caregivers. When a patient discharged from the hospital presents to a community pharmacy, the pharmacist has a responsibility to ensure the patient has a thorough understanding of their medication regimen, and is aware of which medications have been discontinued or added since their hospital visit.
QUALITY INDICATOR: Percentage of people who have had a medication review within 14 days of discharge home from hospital.
Importance/relevance to pharmacy: Community pharmacy professionals play an essential role in ensuring patients discharged from hospital to home understand their medication regimen and any changes that may have taken place during the transition. Hospital pharmacy professionals also have a duty to ensure continuity of care for patients by connecting and collaborating with their community pharmacy colleagues when a patient is discharged. A medication review helps provide an updated medication list as well as answer any questions the patient/caregiver may have.
MEASUREMENT AREA: PROVIDER EXPERIENCE AND ENGAGEMENT
There is a well-established link between provider experience and engagement and patient outcomes. Pharmacy professional experience and engagement is a critical area to measure, however currently, there are no pharmacy-specific measures available in the literature. This measurement area will be prioritized for future development and the College will be reaching out to various stakeholders, including frontline pharmacy professionals, to collaborate on further development and refinement of this area.
|Measurement Area||Quality Indicators for Pharmacy|
|Patient / Caregiver Experience and Outcomes||My pharmacist helped me understand why I am taking each of my medications
My pharmacist made sure I understood how to take my medication properly
My pharmacist made sure I understood what results I might expect from my medication, including any side effects or drug/food interactions that may occur
My pharmacist helped me understand how to know if my medication is working
|Appropriateness of Dispensed Medications||Percentage of opioid-naïve patients who were dispensed an initial dose greater than 90 mg morphine equivalents per day|
|Medication-related Hospital Visits||Hospital visits for opioid poisonings among patients that are actively treated with an opioid prescription|
|Transitions of Care||Percentage of people who have had a medication review within 14 days of discharge home from hospital|
|Provider Experience and Engagement||Panel recommends this as an area for further review and refinement before reporting the provider experience and engagement
Since quality indicators are relatively new territory for community pharmacy in Ontario, engagement of key stakeholders such as patients, frontline pharmacy professionals, corporate pharmacy sector leaders, academia and health system data experts will be vital for discussions around indicator implementation. Tools and resources to support pharmacy professionals in their quality improvement efforts will need to be determined to enable implementation.
Pharmacy sector engagement sessions during the selection process introduced a variety of implementation considerations including the importance of viewing the indicator data in context and recognizing how differing patient populations in pharmacies may affect indicator values. Additionally, the sector highlighted the importance of ensuring clarity behind the definitions and technical details of each indicator. Technical working groups will be convened to develop technical specifications for the indicators.
For many Ontarians like me, our local pharmacist constitutes our most recognizable and frequent contact point with the provincial healthcare system. Consequently, this timely introduction of Quality Indicators for Pharmacy by HQO and the OCP is a very appropriate and worthwhile development.
– Harvey Naglie, Patient Partner