www.pharm.monash.edu.au

Professor Michael Dooley

Director of Pharmacy, Alfred Health

Professor of Clinical Pharmacy

Faculty of Pharmacy and Pharmaceutical Science, Monash University

Achieving quality with limited data - growing an

organisational culture for improvement

Changing clinical practice

Achieving quality

Limited data

growing an

organisational culture for

improvement

Imp

act

Difficulty in implementation Low High

Low

High

Changing clinical practice….. Thinking about what to do

Do first

Don’t do

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Anticoagulation management

Disease Management Clinic

Pre-admission clinic

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Changing clinical practice

Defined scope of practice

Multi-disciplinary support

Formal competency assessment

Formal evaluation

Agreed clinical need

Multi-disciplinary education

Unit based – Team based

Changing clinical practice

Defined scope of practice

Multi-disciplinary support

Formal competency assessment

Formal evaluation

Agreed clinical need

Multi-disciplinary education

Unit based – Team based

Significant problems with

anticoagulation management

Long time to get patients to

therapeutic dose in HITH

program

Why couldn’t we reduce this

by several days

Anticoagulation

• Pharmacist led anticoagulation

program was developed

• Pharmacists independently responsible

for managing and dosing warfarin

• 7 day a week service

• Formal credentialing program

developed

• Implemented in HITH and expanded to

general medical inpatients

Anticoagulation

Anticoagulation

Dooley MJ, McGuiness JV, Choo S, Ngo-Tai L, Tong E, Neave K, Poole SG.

Successful implementation of a pharmacist-led anticoagulant dosing service. J Pharm

Pract Res 2011; 41: 208-11

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Anticoagulation management

TDM charting

Smoking cessation

Disease Management Clinic

Pre-admission clinic

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Changing clinical practice

Defined scope of practice

Multi-disciplinary support

Formal competency assessment

Formal evaluation

Agreed clinical need

Multi-disciplinary education

Unit based – Team based

Significant problems with the

dosing of aminoglycosides

and vancomycin

Clinical pharmacists would

make recommendations

regarding levels and dosing

Why couldn’t pharmacists

order the levels and dose

directly on the medication

chart?

Therapeutic drug monitoring

Therapeutic drug monitoring

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Partnered charting

Anticoagulation management

TDM charting

Smoking cessation

Disease Management Clinic

Pre-admission clinic

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Changing clinical practice

Defined scope of practice

Multi-disciplinary support

Formal competency assessment

Formal evaluation

Agreed clinical need

Multi-disciplinary education

Unit based – Team based

Significant problems with

medications at admission ie

wrong, delayed, unknown

Pharmacist involvement

traditionally retrospective

Why couldn’t medications get

‘sorted” as soon as the

patient presents

Partnered charting

• Pharmacist charting credentialing

program was developed with input

from medical and nursing

• Formal guideline developed for

charting model

• Implemented in two weeks

Partnered charting

© 2015 Confidential Draft

Discussion Document

17

Partnered charting

© 2015 Confidential Draft

Discussion Document

18

Partnered charting

© 2015 Confidential Draft

Discussion Document

19

Partnered charting

© 2015 Confidential Draft

Discussion Document

20

Partnered charting

Partnered charting

Demographics and clinical

characteristics of patients

Variable Doctor

Charting

(n=473)

Partnered

Pharmacist charting

(n=408)

Age (years)* 71.5 (18.4) 75.0 (16.3)

Male sex 218 (46.1%) 175 (42.9%)

Managed in general medical unit 268 (56.7%) 220 (53.9%)

Number of regular medications 7 (4-11) 8 (5-11)

Number of PRN Medications 1 (0-3) 1 (0-2)

Triage category

- ATS 1 1 (0.2%) 1 (0.2%)

- ATS 2 67 (14.7%) 52 (13.4%)

- ATS 3 237 (51.9%) 204 (52.7%)

- ATS 4 149 (32.6%) 126 (32.6%)

- ATS 5 3 (0.7%) 4 (1.0%)

Past history

- Myocardial infarction 47 (9.9%) 45 (11.0%)

- Congestive cardiac failure 61 (12.9%) 66 (16.2%)

- Cerebrovascular disease 77 (16.3%) 66 (16.2%)

- Dementia 48 (10.1%) 41 (10.0%)

- COPD 100 (21.1%) 86 (21.1%)

- Connective tissue disorder 28 (5.9%) 32 (7.8%)

- Liver disease- mild 37 (7.8%) 11 (2.7%)

- Mod-Severe 9 (1.9%) 3 (0.7%)

- Diabetes- uncomplicated 77 (16.3%) 84 (20.6%)

- Diabetes- complicated 33 (7.0%) 25 (6.1%)

- Peptic ulcer disease 12 (2.5%) 10 (2.4%)

- Peripheral vascular disease 41 (8.7%) 32 (7.8%)

- Leukaemia 7 (1.5%) 7 (1.7%)

- Malignant Lymphoma 11 (2.3%) 4 (1.0%)

- Solid tumour- localised 28 (5.9%) 25 (6.1%)

- Metastatic 13 (2.7%) 11 (2.7%)

- AIDS 0 0

Charlson Comorbidity Index 5 (2-7) 5 (3-7)

* Statistically significant

Partnered charting

Clinical significance of errors

Pharmacist charting Medical Charting

No. of errors No. of errors P-value

Total 19 1573 <0.0001

Insignificant 11 (0.3%) 904 (20%) <0.0001

Low risk 1 (0.02%) 58 (1%) <0.0001

Moderate risk 6 (0.15%) 292 (7%) <0.0001

High risk 1 (0.02%) 285 (6%) <0.0001

Extreme risk - 34 (0.8%) <0.0001

Partnered charting

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Partnered charting

Opioid descalation

Anticoagulation management

Smoking cessation clinic

Stroke call-out

TDM charting

Partnered Pharmacist Medication

Charting Expansion project

Smoking cessation

Discharge summary

IBD clinic

Cardiac clinic

Disease Management Clinic

Pre-admission clinic

Gen med clinic

Lung Transplant

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Haematology clinic

Changing clinical practice

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Partnered charting

Opioid descalation

Anticoagulation management

Smoking cessation clinic

Stroke call-out

TDM charting

Smoking cessation

Discharge summary

IBD clinic

Cardiac clinic

Disease Management Clinic

Pre-admission clinic

Gen med clinic

Lung Transplant

Unit based clinical

pharmacy services

Weekend clinical

pharmacy services

Haematology clinic

Changing clinical practice

Career

Progression

Model

Clinical

Fellowship

Program

Part-time

PhD

Program

Clinical

Residency

Program

2017 2014 2015 2016 2013 2012 2011 2010 2009 2008 2007 2006

Changing clinical practice

Achieving quality

Limited data

growing an

organisational culture for

improvement

Po

sitiv

ity

Productivity Low High

Low

High Happy but not

much getting

achieved

Unhappy and

not much

getting done

Happy and

getting a lot

done

Getting a lot

done but not

happy

Changing clinical practice….. Thinking about the team as well

Changing clinical practice….. Thinking about the team as well

Changing clinical practice….. Thinking about the team as well