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Evaluation Report –Evaluation of Quality Care Pharmacy Program-Quality Maintenance Allowance and Change Management

Evaluation of the Quality Care Pharmacy Program Quality Maintenance Allowance and Change Management Programs

Evaluation Report

Version: 2.0

Prepared by Communio

for

Australian Government Department of Health and Ageing

22 June 2010

Evaluation Report – Quality Care Pharmacy Program-Quality Maintenance Allowance and Change Management

of 58 22 June 2010 Version: 2.0

ABN: 49105208428

Table of Contents

Terms and Abbreviations .................................................................................................................3 Executive summary..........................................................................................................................4 Background ......................................................................................................................................6 The Evaluation .................................................................................................................................8 What others do.................................................................................................................................9 Evaluation Framework ...................................................................................................................12 Consultation ...................................................................................................................................14

Evaluation Findings............................................................................ 18 Effectiveness of the existing QMA in offsetting the implementation costs.....................................18 Sole Proprietor ...............................................................................................................................24 Effect of QMA on Regional, Rural and Remote Pharmacies .........................................................27 Overall Impact of QMA...................................................................................................................30 Effectiveness of change management programs including national communications ..................31 Impact of QMA and Change Management continuous quality improvement ................................36 Effectiveness of Assessment Travel Subsidy Scheme..................................................................39 Profile of accredited and non accredited pharmacies....................................................................43 Barriers to Accreditation.................................................................................................................48 Consumer Awareness....................................................................................................................50 Conclusion .....................................................................................................................................53

Appendices ......................................................................................... 55 Appendix A – Bibliography.............................................................................................................55 Appendix B – Interview and survey selection process...................................................................56 Attachment A – Online Survey and Interview Questions – Community Pharmacies ....................58



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Terms and Abbreviations

Terms used in this document

Terms used in this document are detailed in the following table.

Term Description

Department Australian Government Department of Health and Ageing

DoHA Department of Health and Ageing

Fourth Agreement The Fourth Community Pharmacy Agreement

Guild The Pharmacy Guild of Australia

PhARIA Pharmacy Accessibility Remoteness Index of Australia

PSA Pharmaceutical Society of Australia

QCPP Quality Care Pharmacy Program

QMA Quality Maintenance Allowance

Third Agreement The Third Community Pharmacy Agreement



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Executive summary

Background The Quality Care Pharmacy Program is owned and operated by the Pharmacy Guild

of Australia to increase the level of business and professional quality in community pharmacies. To assist in the uptake of the QCPP the Australian Government Department of Health and Ageing, under the Fourth Community Pharmacy Agreement have funded a range of incentives and subsidies. These include:

a. the Quality Maintenance Allowance (QMA) in assisting pharmacies in the implementation and maintenance of the 2

nd edition QCPP Standards

b. the Guild Change Management Strategies in encouraging and supporting the accreditation of pharmacies under the 2

nd edition QCPP

standards c. the QCPP Travel Subsidy Scheme in offsetting some of the costs in

gaining accreditation in rural and remote locations.

This project Communio was contracted to undertake a review of the impact and effectiveness of

these incentives and subsidies. Having developed an evaluation framework based on a targeted desk top review of the available literature, stakeholder views were gathered through key informant interviews, site visits to 44 pharmacies where pharmacists and 150 of their consumers were interviewed and the distribution of an electronic survey to 1400 pharmacies resulting in 133 responses. Stakeholder input largely matches the profile of community pharmacies overall allowing the findings to be extrapolated to the sector. Analysis of the data has resulted in some key findings. These findings were presented at a verification workshop attended by representatives of the Pharmacy Guild of Australia, Department of Health and Ageing and community pharmacists.

The findings The findings as presented and discussed in this report can be summarised as

follows: • Community pharmacies on the whole understand the business, quality and

consumer benefits of participating in the QCPP. • The availability of the QMA payment has had a significant impact on the

decision to participate in the QCPP for 35% of pharmacies and a minor impact on a further 39%.

• The QMA has relatively high impact on a community pharmacy owner / manager in their decision but it is not as high an impact as professional responsibility and customer service.

• Smaller pharmacies experience a bigger impact of the compliance burden of the accreditation process due to their smaller pool of workforce to distribute work amongst.

• The travel subsidy has low levels of awareness amongst community pharmacies with 44.5% being unaware of its existence and a further 55.5% unaware of their eligibility.

• Eligibility for the travel subsidy depends on the allocation and coordination of assessors in 3 of the 5 eligibility categories, meaning that eligibility is variable and often not known by the pharmacy in advance of the assessment.

Continued on next page



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Executive summary, Continued

The findings (continued)

• The cost of the location of the assessor is borne by the pharmacist. • As intended, the travel subsidy has more of an impact on the decision to

participate in QCPP for rural and remote pharmacies. • Change management strategies have contributed to the increased uptake in

accreditation since Feb 2009. • The direct capacity building approaches of the change management

strategies have been more successful in engaging with community pharmacists in their quest for a quality improvement culture and gaining accreditation.

• Other communication strategies have had little impact on pharmacies decision to participate in QCPP.

• There is good use of the standards and QCPP resources by many pharmacies outside of the accreditation process.

• 33% of pharmacies identify their quality culture as being ad hoc or only in place in the lead up to accreditation.

• Business intent does not have a strong correlation to accreditation status. • Pharmacies where the pharmacists aged 31 – 40 and 60+ are less likely to

be accredited. • Consumers are largely unaware of the existence of QCPP. • The accredited status of a pharmacy is just as likely to influence consumers

choice of pharmacy as not. • For the relatively small number of pharmacists not accredited the main

barriers are cost and availability of human resources to participate. • The most frequently cited cost barrier was the cost to release staff for

training and the cost of training.



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Background

Background The Quality Care Pharmacy Program (QCPP) is a quality assurance and accreditation

program aimed at raising the standards of service provided by community pharmacies to the public. The program is based on business and professional standards developed by the Pharmacy Guild of Australia with industry stakeholders. The QCPP was developed by the Pharmacy Guild of Australia (the Guild) in 1997. Any community pharmacy within Australia (Guild members and non-Guild members) can participate in the program. The 2

nd edition of QCPP standards were introduced in June 2008.

The QCPP is owned and administered by the Guild. The Department of Health and Ageing under the Fourth Community Pharmacy Agreement (Fourth Agreement) has supported the QCPP by providing subsidies and incentives to encourage uptake of the QCPP.

This evaluation aims to assess the impact and effectiveness of:

d. the Quality Maintenance Allowance (QMA) in assisting pharmacies in the implementation and maintenance of the 2

nd edition QCPP Standards

e. the Guild Change Management Strategies in encouraging and supporting the accreditation of pharmacies under the 2

nd edition QCPP

standards f. the QCPP Travel Subsidy Scheme in offsetting some of the costs in

gaining accreditation in rural and remote locations.

Incentives and Accreditation

There has been world wide recognition by policy setters, funders and implementers of accreditation systems that participating in quality improvement and third party assessments is costly. There are a variety of options to offset those costs to participating services ranging from a centrally funded system, funding capacity building, and providing incentives or disincentives. Incentives can be direct for example in the form of direct payment or indirect through increased funding / marketing opportunities. Disincentives can include sanctions such as the removal of the right to operate or access higher fees. The three QCPP incentives being evaluated comprise both direct cost offset incentives and capacity building funding. The incentives are described below. Quality Maintenance Allowance (QMA) Introduced in April 2007, the QMA is an incentive allowance paid to community pharmacies to offset the costs of gaining and maintaining accreditation. The QMA is paid upon accreditation against the second edition QCPP Standards and assists pharmacies to offset some of the costs involved.

Annual QMA payments are made to accredited pharmacies based on the volume of claimable prescriptions a pharmacy dispenses each year, with pharmacies receiving between $3000 and $5000 per payment.

QMA payments are made by Medicare Australia on advice received from the Guild on a monthly basis of those pharmacies that are eligible to receive a QMA payment. The payment process for a pharmacy can take between four to twelve weeks.




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Background, Continued

Incentives and Accreditation (continued)

Assessment Travel Subsidy Scheme

The travel subsidy is managed by the Guild and commenced on 1 December 2003 under the Third Agreement and continued to be funded under the Fourth Agreement.

To gain accreditation a pharmacy must be assessed by a licensed QCPP Assessor. The pharmacy must meet the travel, accommodation and meal costs for the assessor who may have had to travel significant distances to undertake accreditation or reaccreditation assessments. The travel subsidy is paid to the pharmacy and aims to subsidise a portion of these costs.

The maximum level of travel costs that may be subsidised under the travel subsidy are:

i. 100% of eligible travel costs where the pharmacy which is the subject of the application is:

o located in the Northern Territory or the Australian Capital Territory; o located in PhARIA categories 5 or 6 (remote); or o one of three or more pharmacies (each satisfying specific criteria)

that were assessed in the one trip undertaken by the QCPP Licensed Assessor.

ii. 75% reimbursement of eligible travel costs where the pharmacy was one of two pharmacies (each satisfying specific criteria) that were assessed in the one trip undertaken by the QCPP Licensed Assessor.

iii. 50% reimbursement of eligible travel costs where the pharmacy which is the subject of the application was the only pharmacy assessed in the one trip by the QCPP Licensed Assessor.

Change Management Strategy

The Change Management Strategy is designed to educate and assist pharmacies in transitioning their accreditation from the initial QCPP arrangements to the Second Edition of QCPP under the Fourth Agreement.

The Pharmacy Guild’s Change Management Program provides support in the form of educational workshops, in-pharmacy visits, Guild State/Territory Branch appointments and telephone support sessions for those pharmacies. In addition to the above, communication material was developed and distributed to encourage participation in the QCPP and to promote uptake of the incentives.



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The Evaluation

The Project Communio was contracted following a tender process to undertake a review of the

effectiveness, appropriateness and efficiency of the QCPP components listed above. The evaluation occurred between January and June 2010.

Evaluation Approach

In undertaking the evaluation Communio used the following approach: • Key informant interviews • Desk top review • Development of an evaluation framework • Site visits to a random selection of pharmacies to interview both the

pharmacist and a selection of consumers • Development of an on-line survey with Statistical Clearance House Approval • Distribution of on-line survey via an email link to 1400 pharmacies • Data Analysis • Verification workshop • Development of this report.

Below is a diagrammatic representation of the process used in the evaluation.

Figure 1: QCPP Incentive Evaluation Approach

Each of these are summarised below.



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What others do

Desk Top Review A desk top review of available literature on incentives for quality systems and

accreditation programs was undertaken. There is very little literature on the topic, particularly with regards to pharmacy accreditation. Below is a summary of the key findings of the desk top review.

Cost of Compliance

Accreditation is accepted as incurring costs to the service being accredited. Direct costs such as memberships with the accrediting organisation, cost of accreditors visit to the organisation and the cost of reference materials such as standards manuals and licenses are upfront cash costs and can all act as barriers to participation in accreditation. Indirect costs such as staff costs to undertake self assessment, training costs, survey preparation etc. can amount to being quite significant. Depending on the current status of the service the cost of improvements may also be a significant deterrent, particularly if no obvious business gain can be seen. There have been many calls over the years to determine the business case for quality within health care. The cost of poor quality to patients and organisations alike can be enormous, but are rarely costed as such. Equally the financial benefits of health care quality are poorly analysed and understood

1.

Incentives have been variously tried in different sectors but with little information publicly available to support either their implementation or continuance.

Incentive Setting Bender

2 suggested that a model for funding and incentivising accreditation systems

should have three phases: 1. In the initial operating phase, funding should be a mix of direct support from

funders for operations and revenue from services. 2. Over time, more of the funding should come from the applicants, assuring a

customer focus in the accrediting program. 3. In full operation, the goal is for the accrediting program to be self-sustaining

with reasonable fee revenues from the application fees and accredited departments.

Emphasis was placed upon the need for the accreditation system to exercise cost controls, accountability, and affordability. Incentives to participate in voluntary accreditation program was also identified as being effective.

Examples of incentives

Below is a sample list of international and national accreditation programs, which shows a mix of both mandatory (compliance) and voluntary (quality Improvement) programs, direct and indirect incentives. As noted though, there is a dearth of any evaluation literature on the success or otherwise of these incentives.


1 Leatherman S, Berwick D., et al 2003. The Business Case For Quality: Case Studies And An Analysis,

Health Affairs 22:2 2 Bender K. Recommendations from the exploring accreditation for state and local health departments:

Do we have the political will?, Public Health Nursing Vol. 24 No. 5, pp.465-471, 2007.



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What others do, Continued

Example Incentives

Program Incentives

International

American Red cross Performance Standard and Re-Chartering Process

Core requirements are required to maintain charter status. Poor performance scores can result in remediation, takeover of services by national office, or revocation of charter status.

Commission on Accreditation of rehabilitation facilities

Accredited centres received deemed status under Medicare and Medicaid for rehabilitation services. Centres also receive preference for many state contracts and state grants.

Council on Accreditation of Services for Families and children

Some states and localities give preference to accredited agencies in distributing contracts and funding for child and family services.

Joint Commission on Accreditation of Healthcare Organisations (JCAHO)

Accredited institutions are given deemed status for meeting health and safety standards for Medicare and Medicaid.

National

Aged Care Standards Accreditation Agency

All residential aged care homes must be accredited in order to receive funding from the Australian Government through residential care subsidies.

Breast Screen Services that are not accredited may have service funding withdrawn.

GP Practice Incentive Program

General practices that choose to be accredited are eligible to receive up to 13 other incentive payments.

The scheme is funded through the Department of Health and Ageing and administered through Medicare Australia.

General Practice Network Accreditation

Voluntary accreditation for Division of General Practice will attract incentive payment for early adopters of accreditation.

Australian Council of HealthCare Standards

Private hospitals that are accredited are eligible for high rebates from private health insurers.

Medication Review Accreditation Incentive

Incentive payments available to pharmacists who are accredited with either the Australian Association of Consultant Pharmacy or the Society of Hospital Pharmacists of Australia to undertake Home Medicines Review or Residential Medication Management Reviews. Payments include a one off payment on accreditation and an annual incentive to maintain accreditation.

Accreditation then also enables to access remuneration for review services.

Department of Human Services Victoria

Mandatory accreditation of all hospitals. Choice of accreditation program. No financial incentive.




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What others do, Continued

Incentives to encourage participation in public health accreditation

A survey study of over 500 participants of a voluntary health care accreditation system focused on quality improvement, showed the following incentive categories most and least likely to encourage participation in a national accreditation model

3.

Category Examples Most

Likely Least Likely

Financial incentives for agencies considering accreditation

Funds to prepare to apply for accreditation. Funds to address potential agency deficits before applying for accreditation.

X

Financial incentives for accredited agencies

Eligibility to apply for grants and contracts. Access to funding support for quality improvements. X

Grant administration streaming

Fewer reporting requirements. Increasing flexibility to use unobligated funds.

X

Grant application improvements for accredited agencies

Streaming of accreditation process. Accreditation status considered as part of scoring criteria. X

Training and technical assistance

Training technical assistance and consultation to prepare for accreditation.

X

Benefits of participating in accreditation

Provision of team building opportunities for staff. Improvements in working relationships between agency personnel and partners e.g. State & local personnel.

X

Infrastructure and quality improvement opportunities

Identification of areas for health department improvement. Receipt of benchmarking data and consultation on quality activities.

X

National Support Policy statements that indicate federal agency support for accreditation

X

Marketing – recognition of accredited agencies

Awards (e.g. provision of awards to accredited agencies) Classification (e.g. Accreditation with distinction ratings) X

Synopsis Financial incentives to participate in accreditation programs and financial incentives

for accredited agencies are the most likely to achieve increased participation in accreditation. Accreditation programs take time to evolve and increase and maintain levels of participation.

3 Davis, M.V. et.al., Incentives to Encourage Participation in the National Public Health Accreditation

Model: A systematic Investigation, American Journal of Public Health, September 2009.



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Evaluation Framework

Evaluation framework

An evaluation framework was developed to guide the progress of this evaluation. The Framework promotes a triangulation approach, noting that no one source will provide sufficient understanding to draw robust conclusions. Data was gathered from various sources namely; QCPP key informant interview, data provided by the Guild and the Department, consumer surveys/interviews, and community pharmacy interviews / surveys. This approach will ensure that the project evaluation will reveal accurate, credible results.

Figure 2: A Diagrammatic Approach to the Evaluation of QCPP Incentives




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Evaluation Framework, Continued

Objectives Nine objectives for the evaluation have been specified by the Department. These are

broken down further here into objectives and requirements. Objectives o analyse the effectiveness of the existing QMA in offsetting the implementation

costs of the QCPP for community pharmacists and providing an incentive for them to participate in the program

o analyse the effect of the QMA on sole proprietor community pharmacies, regional, rural and remote pharmacies

o determine the impact of QMA and change management strategies on the entrenchment of quality assurance and continuous quality improvements into the operating culture of individual community pharmacies

o determine the effectiveness of the change management programs including the national communication strategies, QCPP Fast Track; Professional Standards workshop and review; and the other travel subsidies for assessment of regional, rural and remote pharmacies

Requirements o analyse the profiles, business drivers and restraints for a sample group of both

accredited and non-accredited QCPP community pharmacies to determine factors which encourage, or act as a barrier to, accreditation

o identify issues to be addressed in QCPP, take up on the basis of profiles and drivers obtained

o identify a range of options for increasing the uptake of QMA in community pharmacies drawing on other national and international primary healthcare accreditation processes

o determine the benefits of QMA to community pharmacies and consumers o measure the levels of consumer awareness of QCPP.

Exclusions This evaluation is not evaluating the QCPP process or standards which are subject

to other review mechanisms. The Pharmaceutical Society of Australia’s (PSA) Change Management Program is out of scope for this evaluation.

Evaluation Framework

The evaluation approach considers the key incentives/drivers and the barriers that may be present for participating in an accreditation system, being: o Cost of compliance with standards

o Direct costs – membership, assessment costs, reference materials, infrastructure costs to meet standards

o Indirect costs – staff time, training costs, survey preparation o Business benefits of being accredited

o Cost effectiveness of accreditation o Improved quality of service and business efficiency o Decreased risk

o Availability and accessibility of support tools o Complexity and capacity – the extent of improvements required to meet the

standards o Performance recognition in voluntary accreditation programs. In undertaking the evaluation, data was sought to establish the extent to which these drivers and barriers exist for the QCPP and the impact and effectiveness of the QCPP incentives in mitigating the barriers and enhancing the drivers. Options for improvements or modification to the incentives approach have also been explored.



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Consultation

Key Informant Interviews

Key informant interviews were undertaken at the commencement of the project to gain a better understanding of the QCPP, the incentives, processes involved, and perceived successes and barriers. Face to face interviews were conducted with:

o 5 Department pharmacy branch representatives o 4 Pharmacy Guild National Office Staff representatives o 2 Pharmacy Guild Branch Directors o 1 previous Chair of Guild quality committee o 6 QCPP state managers.

Site Visits Random selections of pharmacies were identified for invitations to participate in site

visits. Pharmacies were selected for a site visit by:

1) randomising the list of community pharmacies 2) selecting two regions of each of the states planned for site visits 3) contacting pharmacies in that region in the randomised order until the

confirmed number of site visits was achieved. 68 pharmacies were contacted, 20 declined and 4 cancelled on the day of the visit. Detailed selection process is included in Appendix B. The 44 pharmacies visited had the following geographical spread.

Figure 3: Map of Site Visits




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Consultation, Continued

Site visits continued

The purpose of the site visits were two fold: 1) explore with pharmacists the relationship of the incentives with the decision

to become accredited, in more depth than the on-line survey allowed 2) assess consumer awareness of the QCPP and the impact accreditation has

on consumer choice. Randomly selected pharmacies were contacted by telephone to seek their permission to participate in an on site visit and to arrange a suitable time. All site visits were conducted by a member of the Communio project team who had undergone a project briefing to ensure consistency of approach. Interviews used the on-line survey questions as the broad outline of the interview, exploring responses in more detail. Following the interview with the pharmacist, consumers waiting to have prescriptions filled or who were in the pharmacy for other reasons were approached and invited to participate in a short survey. 150 consumers agreed to participate in an interview.

On-line survey An on-line survey was developed to be able to gather widespread views of

community pharmacists. The survey was designed to minimise completion time whilst providing sufficient information to be able to draw robust findings against the evaluation objectives. The survey was developed with input from both the Department and the Guild. The survey was tested in house by Communio staff and two community pharmacists to determine the suitability, readability and interpretation of the questions. The survey was then submitted to the Australian Bureau of Statistics, Statistical Clearing House for approval. Following minor amendments to the survey design Statistical Clearing House approval was granted. The survey was distributed to 700 randomly selected pharmacies (excluding those selected for a site visit) via email advising them of the surveys intent and short completion time. 56 responses were received to this request. In order to achieve a reasonable sample size of at least 100 responses another 700 pharmacies were contacted. In total 133 pharmacies completed the on-line survey (9.5% response rate). On average the survey took 8 minutes to complete. 94.8% of respondents who started the on-line survey completed it in full. The majority of surveys were completed within two days of receiving the email request and a significant number of pharmacists completed the survey on the weekend. The on-line survey is included at Attachment A. Not all respondents answered all questions. The survey also used skip logic to direct respondents to questions based on their answers. Consequently the number of responses for any one question varies. The number of respondents is noted for particular questions.




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Geographical spread

A reasonable geographical spread of responses between both on-line surveys and site visits was achieved as shown in Figure 4.

0

10

20

30

40

50

60

70

80

NSW Qld Vic WA SA ACT Tas

Figure 4: Geographical Spread of Stakeholder Consultation (n=177)

Profile of respondents to interview and on-line survey

The profile of on-line survey respondents matched or exceed the profile of community pharmacies overall

0% 20% 40% 60% 80% 100%

1

2

3

4

5

6

Ph

AR

IA

Percent profile of all CommunityPharmacies

Response Percent

Figure 5: PhARIA Profile of Respondents (n = 177)

The response rate of community pharmacies for PhARIA Rated 2, 3 and 4 was higher than the proportional make up of all community pharmacies with a corresponding decrease in PhARIA 1.




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Accredited / Non- Accredited

The respondents closely matched the overall rate of accredited pharmacies for all Community Pharmacies which is currently sitting at around 77% of pharmacies. The rate of registration and accreditation for respondents against the overall QCPP profile is shown in Figure 6. The profile of the respondents slightly favours those who are registered and accredited.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Registered &

Never Accredited

Registered &

Accredited

Registered &

Lapsed

QCPP Data

Responses

Figure 6: Accreditation Status of Respondents (n responses =177)

Sample base The sample data achieved for this review is largely reflective (albeit with slightly

higher PhARIA 3, registered and accredited pharmacies, and NSW respondents) of the overall geographical and accredited distribution of community pharmacies. The sample size is reasonable and given its random selection and close proximity to the overall community pharmacy profile, suggests that it is reasonable to extrapolate findings to the wider community pharmacy sector.



ABN: 49105208428

Evaluation Findings

Effectiveness of the existing QMA in offsetting the implementation costs

History and Process

The QMA was introduced in April 2007 to offset the implementation costs of participation in the QCPP. Figure 7 depicts the timelines for the QMA incentive payments.

0

1,000

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Community pharmacies reported at June (Medicare )

QCPP Registered com munity pharm acies

QCPP Accredited community pharmacies

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Figure 7: Rates of QCPP Registered and QCPP Accredited Time Line

Registration Rates

Whilst the registration rate of pharmacies has remained fairly constant the uptake of actual accreditation has been inconsistent. The above graph would suggest there is little correlation to the QMA becoming available and providing an increased incentive to become accredited. The on-line survey and interview responses discussed below explore this further. Based on Medicare data, since the implementation of the QMA in April 2007 there has been a continuing increase it the QMA Payments to June 2009 based on a 6 month rolling average as shown in Figure 8.




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Effectiveness of the existing QMA in offsetting the implementation costs, Continued

Month

Paym

en

ts

Source: the data on QMA claims is based on the 3526 community pharmacies that had not had a change in their Medicare identifier in the data collection period up to February 2010

Figure 8: Total QMA Payments by month and Six month rolling average

4


4 Those pharmacies who have received more that one payment in some instances have received multiple part

payments



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Costs incurred to become accredited

The table below shows all respondents estimations of the costs they incurred in gaining and maintaining accreditation.

Gain Accreditation Gain Accreditation Gain Accreditation Gain Accreditation Maintain Accreditation Maintain Accreditation Maintain Accreditation Maintain Accreditation Training $1001-$2000 $100-$1000Staff Hours >50 hours 31-40 hoursComputers & software $500-$1000 < $500Stationary and materials $100-$1000 $100-$1000Equipment $500-$1000 < $500

Median survey response for cost incurred to:

Table 1: Median Approximated Cost Components to Gain and Maintain Accreditation

In addition to the cost estimates in preparing for, and maintaining, accreditation pharmacists are also required to pay for QCPP membership (for Guild members $1,699 and for non Guild members $2,099

5) and purchase the standards manual

6

($550 for Guild members and $825 for non-Guild members), and pay for the travel and accommodation costs for the assessor (various dependent on the location of the assessor). Table 2 shows the estimated cost of accreditation excluding assessor travel costs, using the mid point value or the cost information supplied in survey and interview.

Gain Accreditation Gain Accreditation Gain Accreditation Gain Accreditation Maintain Accreditation Maintain Accreditation Maintain Accreditation Maintain Accreditation Training 1,500$ 450$ Staff Hours 1,687$ 1,181$ Computers & software 750$ 250$ Stationary and materials 450$ 450$ Equipment 500$ 250$ QCPP fee 1,899$ QCPP manual 687$ Average Cost 7,4737,4737,4737,473$ $ $ $ 2,5812,5812,5812,581$ $ $ $

*using a mid range value and excluding travel costs Table 2: Average Approximated Total Costs to Gain and Maintain Accreditation

There was no significant difference in cost estimates based on PhARIA or type of business structure of pharmacies. The total median amount a pharmacy can obtain in QMA payments is $4000. Therefore as a cost offset the QMA provides approximately 53% of the initial costs and thus would appear to be a reasonable cost offset.


5 15 – 20% of those participating in QCPP are non-Guild members.

6 All accredited pharmacies were provided a free manual at the transition to 2

nd edition. Therefore only

lapsed pharmacies rejoining and new pharmacies are currently incurring this cost. A number of manuals were also supplied free to encourage pharmacies to participate in QCPP.



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QMA Impact on decision to accredit

The on-line survey and pharmacy interviews explored the relationship between the availability of the QMA incentive on the decision for pharmacies to become accredited.

26%

39%

35%

No impact

Minor impact

Significant impact

Figure 9: Impact of QMA Incentive on Decision to Participate in QCPP (n= 138)

For 34.8% of the 138 business that responded to this question the QMA has a significant impact on their decision to become accredited under the QCPP program and a minor impact on a further 39.1%.

Influences on decision to accredit – all respondents

Survey respondents were asked to nominate on a scale of 1 – 5, with one being no impact to five being significant impact, the impact of the following drivers on their decision to purse accreditation:

• to promote accreditation status to gain a competitive edge • to access incentives • to improve business practice • to improve quality of service to customers • professional responsibility.

Accessing incentives ranked 2

nd lowest overall but still had an average impact rating

of 3.98 suggesting that whilst accessing incentives were not the main driver for participating they have a reasonably high level of impact.




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1.0 2.0 3.0 4.0 5.0

Professional responsibility

To access incentives

To improve business practice

To promote accreditation status for a competative

market advantage

To improve quality of services to customers

Other

Average All Scores (1 = Strongly Disagree 5 = Strongly Agree)

Figure 10:Average Rating of Influences on Decision to Participate in QCPP (n=141)

Qualitative Responses

The survey and interview responses added further depth to these ratings with the themes emerging around providing a good business structure, accessing additional business, professionalism and improved consumer service, and a framework for staff development. Example comments are listed under each theme below. None of the qualitative comments specifically referred to the QMA. Good Business Structure

• Mitigation business risk especially in small country towns.

• When buying into a business the accreditation process is a good way to put new procedures in place with employees who are used to old and inefficient ways.

• QCPP provides a structure and guidelines.

• Promotes a clear Policy and Procedure framework.

• QCPP provides guidelines for employment contracts re staff behaviour and customer service.

• Ensure formalised standards are used and supports the industry to maintain a high degree of trust in the community.

• To help maintain an industry standard.

• Smoother, systematic functioning of pharmacy.

• provides a good chance for the pharmacy to document its procedures.

• QCPP is a perfect way of improving all the business categories. Accessing additional business

• Competitive for achieving aged care business.

• Had to so pharmacy could participate in a primary care diabetes management pilot.




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Qualitative Responses (continued)

Framework for staff development • It is easier to get staff to perform to a standard with external guidelines.

• Improves your time management skills and staff training.

• Helps with team building. Professionalism and improved consumer service

• Part of professional image - while consumers don't often know about accreditation, signs and symbols help enhance the subliminal message to consumers that they are dealing with a quality service.

• It is important in a small rural community to be seen to keep up standards. Other comments included:

• QCPP doesn't offer any marketing advantage - needs more promotion.

• compulsory requirement in reality.

• Provide "bargaining" tool for Guild in negotiations with Government re Agreements & in particular with regard to relaxation of ownership regulations & supermarkets.

• financial rewards.



ABN: 49105208428

Sole Proprietor

Effect of the QMA on sole proprietor

A total of 83 sole proprietors provide feedback: 20 site visits and 63 survey respondents.

Registration and accreditation rates of sole proprietor pharmacies

0%

10%20%

30%40%

50%

60%70%

80%90%

100%

Registered but

never accredited

Registered and

accredited

Registered with

lapsed

accreditation

All respondents

Sole Proprietors

Figure 11: Sole Practitioner Accreditation Status (n=83)

The profile of QCPP registration and accreditation for sole proprietors was the same as the broader group of interviews and survey respondents.




ABN: 49105208428

Sole Proprietor, Continued

Influences on decision to accredit – sole proprietors

Figure 12: Average Impact of Influences on Decision to Participate in QCPP – Sole

Proprietors (n=68)

X axis = 5 point rating scale (1) strongly disagree to (5) strongly agree

What influenced sole proprietor’s decision to participate in the QCPP was very similar to that of the broader group, with the highest ranked average responses being to improve quality of service and professional responsibility. “To Access incentives” was rated slightly lower at 3.89 indicating it has a reasonable impact or this group as well.

Interview feedback

A theme emerging from the interviews with sole proprietors was the inequity of the QMA payment based on the volume of claimable prescriptions dispensed. Sole proprietors interviewed expressed the view that smaller pharmacies have a smaller human resource pool to assist in QCPP processes and in preparation for accreditation. However there is a minimum amount of work required to prepare for accreditation regardless of the size of the pharmacy. These stakeholders felt that the allocation based on volume was not equitable. Other respondents noted that depending on the type of business the pharmacy was targeting, script volume may not necessarily correlate to the size and turnover of the pharmacy.




ABN: 49105208428

Sole Proprietor, Continued

Interview feedback (continued)

From the comments received from sole proprietors in relation to the QMA with three main themes emerging:

1. decrease cost / increase incentive to participate 2. increase incentive to small pharmacies 3. improve reimbursement turnaround time.

Sample comments included:

• Increase incentive - reduce the net cost to the pharmacy.

• Increase the value for money to participate, increase assistance or increase value by raising awareness of public of QCPP.

• The script throughput method for judging costs is not necessarily fair - pharmacies with low throughput have same base costs for QCPP as high throughput and reimbursement should reflect this (perhaps reimburse by number of staff employed or a combination of these)

• Faster reimbursement.

• Make the Guild process our accreditation faster so we can access our QMA payment quicker.




ABN: 49105208428

Effect of QMA on Regional, Rural and Remote Pharmacies

Regional, rural and remote pharmacies

The measure used to define remoteness for community pharmacies is the Pharmacy Accessibility Remoteness Index of Australia (PhARIA). This is a composite index, which incorporates measurements of general remoteness, with a professional isolation component represented by the road distance to the five (5) closest pharmacies. PhARIA 3 and 4 identifies regional and rural pharmacies. PhARIA 5-6 identifies remote pharmacies.

Rate of QMA for Regional, pharmacies

PhARIA 3 PhARIA 4

Rate of the QMA payment to regional pharmacies

Figure 13: Rates of QMA Payments and Six Month Roiling Average for PhARIA 3 & 4

Source: sample of 2700 pharmacies we were able to match with PhARIA data provided by the pharmacy guild and pharmacies with February 2010 section 90 Medicare Identifier.

QMA payments to regional and rural pharmacies have increased based on a 6 month rolling average since its introduction until mid 2009 when there appears to be a levelling off in QMA payments to this group. The total number of community pharmacies in these areas only represents just over 8% of all pharmacies and any trends on such numbers should be made with caution. However, of the survey respondents in these PhARIA groups there were a number (n=4) with lapsed accreditation status. 7 respondents in these PhARIA areas also indicated that they intended to retire or sell in next 3- 5 years. These factors may be impacting on accreditation, and thus QMA payment rates, in these areas.




ABN: 49105208428

Effect of QMA on Regional, Rural and Remote Pharmacies, Continued

Rate of QMA for rural and remote pharmacies

PhARIA 5 PhARIA 6

Figure 14: Rates of QMA Payments and Six Month Roiling Average for PhARIA 5 & 6

Source: sample of 2700 pharmacies we were able to match with PhARIA data provided by the pharmacy guild and pharmacies with February 2010 section 90 Medicare Identifier.

QMA payments to remote pharmacies have increase based on looking at a 6 month rolling average since its introduction until mid 2009. However with such small numbers it is not possible to identify any trend.

Impact of QMA on decision to accredit for regional rural and remote

30% percent of the PhARIA 3-6 pharmacies reported that the QMA made a significant impact and 53% a minor impact on their decision to become accredited. Only 3 of the 36 respondents had never been registered or accredited for QMA.

Figure 15: Impact of QMA on Decision to Participate in QCPP – PhARIA 3 – 6 (n=30)




ABN: 49105208428

Effect of QMA on Regional, Rural and Remote Pharmacies, Continued

Comments from PhARIA 3-6 pharmacies on how the QMA could be improved

Of the comments received from PhARIA category 3-6 responses many noted issues around the level and expedience of the QMA incentive. A representative sample of comments received are:

• It's nice to get it, but it doesn't cover the costs - could be more.

• Increase (QMA) to cover staff wages.

• Accredited Pharmacies could be paid automatically without application.

• Faster reimbursement.

• The payments don't reflect the amount of work put in. Incentives should be increased to increase participation and not just rely on pharmacists sense of professionalism and duty.



ABN: 49105208428

Overall Impact of QMA

Discussion The QMA is but one consideration for community pharmacy owners or managers to

participate in accreditation. There also appears to be a good level of understanding of the business benefits of participating in an accreditation system. The current QMA rate does provide a reasonable level of cost offset which plays a role in pharmacies deciding to become accredited. The QMA was considered to have a significant impact for 35%, and a minor impact for 39% of survey respondents. For rural and regional pharmacies these rates were 30% and 53% respectively. Pharmacists appear to be as, or more driven by the potential quality improvements to be gained by participating in the accreditation process. Small pharmacies appear to experience a higher resource burden for participating in accreditation which is not matched by the QMA payments currently stratified with dispensing volume. Comments received from the pharmacies in PhARIA 3 – 6 and sole proprietors would indicate a need for a revision of the level of payment for those pharmacies for the incentive to continue to be a considerable cost offset. Suggestions for improvement from respondents included basing the incentive on staff numbers, making the incentive the same regardless of the size of pharmacy, and increasing the incentive particularly to cover up front costs. For some pharmacies, particularly the rural and remote, the expedience of the QMA payment process was an issue. Suggestions for improvement included improving the ability to track when accreditation payments are due, how to claim them and when they have been paid.



ABN: 49105208428

Effectiveness of change management programs including national communications

Change Management Strategies

The Guild is funded by the Department to provide change management support transition from the 1

st edition standards to the 2

nd edition. A secondary aim was also

to entrench a culture of continuous quality improvement across community pharmacies. In meeting these aims the Guild employs state QCCP managers to support QCPP and assist pharmacies to prepare for accreditation and to implement a continuous quality improvement program within pharmacies. In addition the state managers are responsible for credentialing accreditors and the coordination of accreditation visits for QCPP accreditation. As part of the change management program a range of communication, promotion and education resources have been developed.

Change Management Strategies – Communications and Media

The following lists the materials developed and distributed as part of the QCCP change management program.

Communication strategy / media Dates Delivered

Brochures x 4 sent with administration mails in sync with the pharmacy accreditation life cycle e.g. due of assessment, completed assessment etc.

Ongoing from Feb 09

Trade Press Campaign x 4 trade press and Guild publications

Jan 09 – June 09

Promotions Pack (Accredited pharmacies Only) March 09

Letter to lapsed pharmacies from President March 09

Letter to never accredited pharmacies from President March 09

Marketing Fast Track (webcast, email, print, direct marketing)

March – April 09

Fast Track Live Webcast 1 15 April 09

Fast Track Live Webcast 2 29 April 09

Fast Track DVD posted to Pharmacies in PhARIA 3-6 July 09

QCPP Evidence Folder sent to State Managers July 09

Fast Track USB sent to State Managers Dec 09

Table 3: Communication Strategy Time Line




ABN: 49105208428

0

1,000

2,000

3,000

4,000

5,000

6,000

Jun-

05

Aug-0

5

Oct-0

5

Dec-0

5

Feb-0

6

Apr-0

6

Jun-

06

Aug-0

6

Oct-06

Dec

-06

Feb-

07

Apr-0

7

Jun-

07

Aug-0

7

Oct-0

7

Dec

-07

Feb-

08

Apr-0

8

Jun-

08

Aug-0

8

Oct-0

8

Dec-0

8

Feb-

09

Apr-0

9

Jun-

09

Aug-0

9

Oct-0

9

Dec-0

9

Co

mm

un

ity P

ha

rma

cie

s

Community pharmacies reported at June (Medicare)

QCPP Registered community pharmacies

QCPP Accredited community pharmacies

2n

dS

tan

da

rds

QM

A I

ntr

od

uce

d

Fast Track Webcast 1

Fast Track Webcast 1

Marketing of fast track webcast

Brochures with administration

mail

Promotions Pack

Letters from President to lapsed and

never accredited pharmacies Trade press

advertising

DVD Post to PhARIA 3-6 pharmacies

Evidence folders sent to QCPP State Managers

Fast Track USB sent to State

Managers

Effectiveness of change management programs including national communications, Continued

Timeline of QMA and change management strategies

Figure 16 shows the timeline of communications strategies against the accreditation and registration rate. The strategies implemented since February 2009 appear to have a correlation with an increased uptake of accreditation.

Figure 16: Change Management Strategy Timeline Against Rate of Accreditation




ABN: 49105208428


Participation in accreditation support and change strategies

Survey respondents were asked to identify which programs they had participated in. The responses shown in Figure 16 indicate that 39% had not participated in any. Of those that had participated the Fast Track DVD, in pharmacy sessions and telephone support sessions were the most utilised. Figure 18 explores the usefulness of the strategies with the one on one sessions either in pharmacy or by telephone proving to be the most useful. This was supported by many of the comments received around the benefit of these direct capacity building strategies.

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Fast track - workshop - 4 Sessions over 4 weeks

Fast track - workshop - 2 Sessions over 2 weeks

Fast track - workshop - 1 hour Sessions

Fast track - USB

Fast track - DVD

Fast track - webinar

Fast track - in pharmacy sessions with QCPP state manager

Fast track - in branch sessions with QCPP state manager

Fast track - telephone support sessions

None

Figure 17: Participation in QCCP Change Programs (n=140)




ABN: 49105208428


0.0 0.5 1.0 1.5 2.0 2.5 3.0

Fast track - workshop - 4 sessions over 4 weeks

Fast track - workshop - 2 sessions over 2 weeks

Fast track - workshop - 1 hour sessions

Fast track - USB

Fast track - DVD

Fast track - webinar

Fast track - in pharmacy sessions with QCPP state manager

Fast track - in branch sessions with QCPP state manager

Fast track - telephone support sessions

Avg rating: Rating scale (1) no useful to (3) very useful

Figure 18: Usefulness of Support Strategies (n=89)

Awareness of communication material

Of the survey respondents there was a 50% or greater awareness of the QCPP national materials with the exception of the 10 Year report card where there was a very low level of awareness.

0%10%20%30%40%50%60%70%80%90%

100%

Trad

e pr

ess ar

ticles

Broch

ures

Poste

rs

Staff

badg

es

Cou

nter

mat

10 y

ear r

epor

t car

dNot Aware

Aware

Figure 19: Awareness of QCPP National Communication Activities (n=138)




ABN: 49105208428


Impact on decision to participate in QCPP

The majority of respondents (52.2%) believed the communications material to have no impact on their decision to participate, whilst 7.2% believed them to have had a significant impact as shown in Figure 20. The report undertaken by ORIMA Research for the Guild on their refreshed communications for QCPP in 2009 provides further information. In their survey of 70 accredited and 70 non-accredited pharmacies results included:

• Accredited and unaccredited pharmacies recorded no significant differences in awareness levels

• Less than two-thirds of respondents who were aware of the refreshed QCPP materials indicated they had read or made use of them.

• 81% agreed that the material increased their willingness to participate (or continue to participate) in the QCPP and 76% made them think of the QCPP as easier to implement.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

No impact Minor impact Significant impact Don't know

Figure 20: Impact of Communication Materials (n=138)



ABN: 49105208428

Impact of QMA and Change Management continuous quality improvement

Use of material beyond accreditation

80% of respondents (n=141) indicated that they use the standards for more than preparing for accreditation. 85% of these respondents use the materials for maintenance and review of procedures relating to staff training. Other examples of strategies implemented by pharmacies included:

• Standardisation and systematisation of policies and procedures • New employee guidelines, standards for storage and display of products • Staff Induction • Staff dress and behaviour standards • Procedures followed for hiring out equipment • System for incident reporting.

Figure 21: Use of QCPP Resources Beyond Accreditation (n=141)

Figure 22: Use of QCPP Resources Post Accreditation (n= 110)




ABN: 49105208428

Impact of QMA and Change Management continuous quality improvement, Continued

Change as a result of accreditation continued

67 % of all interview and survey respondents reported a planned and continuous quality improvement culture in their pharmacy.

67%

16%

17%

Planned and continuous

Only when leading up to

accreditation

Ad hoc

Figure 23: Continuous improvement practice and culture in pharmacies (n=139)

These quotes represent common theme in examples provided by respondents.

• Currently increasing the regularity of planned and continuous processes with monthly audits of key issues, parts of the standards - coordinated centrally.

• aiming for more resources to move to planned and continuous approach.

Changes post accreditation

For those who have undertaken accreditation they were asked whether they had implemented changes as a result. 83.5% of respondents indicated that they had.

83%

17%

Yes

No

Figure 24: Changes since accreditation (n = 139)




ABN: 49105208428

Impact of QMA and Change Management continuous quality improvement, Continued

Changes post accreditation (continued)

Many examples (n=103) were provided and included: • We changed our hire agreements to include all necessary information.

• Responsible sale of S2/S3 items.

• Documentation, policies & procedures.

• Incremental improvements in provision of DAA's.

• Use of diary to enable better communication between staff members.

• Better hire procedure.

• Use of special order book-good because we don't have same staff on every day.

• Using consumables check list each month to order what is getting low.

• Procedures for staff purchases have been established.

• "Being prepared for business" has instilled in the staff the necessity to be prepared and ready at the beginning of the day.

• Webster chart that monitors when the packs have been done by the pharmacy assistant and checked by the pharmacist.

• introduce induction checklist for new staff so staff member get into the working environment quicker and hence able to provide better customer service.

• changing devices at regular intervals (e.g. methadone syringes).

• Added a consulting/counselling area.

• Equipment hire policies, documentation and procedures were tightened up.

Discussion There appears to be a strong culture of continuous quality improvement amongst

those pharmacies that participate in the QCPP. This is supported by the views of the QCPP managers across the country that observe the practice within the pharmacies when they return for follow up support or second accreditations. The majority of all accredited pharmacies report that they use the QCPP materials beyond the accreditation assessment period and that they are conducting some regular activities to review practice against the QCPP standards. A strong emphasis appears to be on staffing and dispensing practices which is most appropriate as this is likely to be where the bulk of quality gains and potential risk lies. With 33.1% of pharmacies identifying that they rate their quality improvement culture as being ad hoc or only in place in the lead up to accreditation there remains room for improvement for a greater number of pharmacies to embrace a sustained continuous quality improvement culture.



ABN: 49105208428

Effectiveness of Assessment Travel Subsidy Scheme

Travel Subsidy Scheme

The travel subsidy commenced on 1 December 2003 under the Third Agreement and is managed by the Guild.

As part of the assessment process for accreditation, the pharmacy must meet the travel, accommodation and meal costs for the assessor. The costs vary dependent on the distance between the assessors home base and the pharmacy. The maximum levels of travel costs that may be subsidised under the travel subsidy are:

i. 100% of eligible travel costs where the pharmacy which is the subject of the application is:

o located in the Northern Territory or the Australian Capital Territory; o located in PhARIA categories 5 or 6 (remote); or o one of three or more pharmacies (each satisfying specific criteria)

that were assessed in the one trip undertaken by the QCPP Licensed Assessor.

ii. 75% reimbursement of eligible travel costs where the pharmacy was one of two pharmacies (each satisfying specific criteria) that were assessed in the one trip undertaken by the QCPP Licensed Assessor.

iii. 50% reimbursement of eligible travel costs where the pharmacy which is the subject of the application was the only pharmacy assessed in the one trip by the QCPP Licensed Assessor.

The pharmacist must apply for the travel subsidy.

Awareness of Assessment Travel Subsidy Scheme

44.5% of pharmacists were unaware of the travel subsidy scheme and 55.5% were unsure of whether or not they were eligible (Figure 25).

45%

55%Yes

No

Figure 25: Overall Awareness of Travel Subsidy Scheme (n=137)




ABN: 49105208428

Effectiveness of Assessment Travel Subsidy Scheme, Continued

Awareness of Assessment Travel Subsidy Scheme, rural, regional and remote

Awareness of the travel subsidy was much higher in PhARIA 3 - 6 pharmacies with only 8 pharmacies (27%) unaware of the travel subsidy scheme

Figure 26: Awareness of Travel Subsidy Scheme PhARIA 3-6 (n=30)

Awareness of eligibility for Assessment Travel Subsidy Scheme

28%

21%

51%

Yes

No

Don't Know

Figure 27: Awareness of Eligibility of Travel Subsidy Scheme (n=138)

Several interview responses indicated that it is the assessor who informs each community pharmacy at the time of accreditation if they are eligible with the claim then completed at the time of assessment.




ABN: 49105208428


Importance of the Assessment trave subsidy scheme in decision to participate in QCPP – All Respondents

Figure 27: Impact of Travel Assessment Scheme on Participation in QCPP All Respondents (n=115)

Importance of the Assessment trave subsidy scheme in decision to participate in QCPP – Rural regional and remote

Pharmacies with a PhARIA 3-6 who participated in the survey and were much more likely to agree or strongly agree that the assessment travel subsidy is important to their decision to participate in QCPP.

Figure 28: Impact of Travel Assessment Scheme on Participation in QCPP PhARIA 3 – 6

(n=29)




ABN: 49105208428


Discussion Review of the QCPP accreditation processes were outside the scope of this project.

Therefore a detailed analysis of how assessors are booked, how travel costs are determined or how variable the costs are has not been undertaken. It is understood that this has recently been reviewed and improvements implemented. It is incumbent on all accrediting systems to ensure efficient processes to minimise the costs of administration, including travel costs, in order that the costs borne by the services being accredited are kept to a minimum. It is unusual for an accreditation system to charge the service being assessed travel and accommodation costs

7. The travel and accommodation costs are not known

upfront for the pharmacy as they are based on the location of the assessor. Eligibility for subsidy is also not known upfront as for 3 of the 5 eligibility categories are determined based on how assessments are scheduled which is out of the control of the pharmacy. The lack of awareness of the subsidy, the lack of awareness of eligibility for the subsidy and the complex nature of eligibility would suggest that there is room to improve the administration and effectiveness of this subsidy. Lack of awareness of, and the uncertainty regarding eligibility for, the subsidy would also suggest that whilst the travel subsidy may be a cost offset, it is not operating as an effective incentive to participate in the accreditation process. Suggestions for improvement included:

• That the cost of assessor visits be offset centrally. This would reduce the administrative costs of paying the subsidy and drive improvements in the efficiency in the location and allocation of assessors.

• That the eligibility criteria be adjusted to a more fixed basis for example subsidies attached to bands of costs incurred where the more cost incurred the greater the subsidy

• That the subsidy be paid automatically to the assessor and reduce the administrative burden on the pharmacist.

7The Aged Care Standards and Accreditation Agency, Australian General Practice Accreditation Limited and the

Australian Council for HealthCare Standards charge fixed fees based on the size of the organisation and other variables and do not charge separately for accommodation and travel (some exceptions apply).



ABN: 49105208428

Profile of accredited and non accredited pharmacies

Introduction A review of the business profile of pharmacies, pharmacists and business intent was

undertaken in order to determine whether any profile characteristics were more likely to impact on participation in QCPP.

Pharmacy business structure

0

10

20

30

40

50

60

70

80

90

100

Independent Banner Franchise

Accredited

Accredited

Accredited

Not accredited Not accreditedNot accredited

Figure 29: Business Structure of Pharmacies

(n=163)

0 10 20 30 40 50 60 70 80

Sole Proprietor

Partnership

No of Respondents

Not accredited

Accredited

Accredited

Not accredited

Figure 30: Partnership / Solo Proprietor Profile (n=158)




ABN: 49105208428

Profile of accredited and non accredited pharmacies, Continued

Age ranges of owners and accreditation status

There are larger proportion of accredited community pharmacies where the pharmacists are ages 41 - 60 and larger proportions of non accredited pharmacies where the age range of the community pharmacist is 31 - 40 and 61+.

0

10

20

30

40

50

60

Under 30 31 - 40 41 - 50 51- 60 61+

Age Range

%

Accredited

Not Accredited

Figure 31: Age Range of Pharmacy Owners (n accredited =146, n non- accredited = 20)

Pharmacists employed and accreditation status

Those pharmacies that employ 3 or more pharmacists are more likely to be accredited. This is consistent with the qualitative comments that suggest the smaller the workforce the higher the burden of accreditation.

0

10

20

30

40

50

60

Employs 1

pharmacist

Employs 2 or 3

pharmacists

Employs 3 or

more

pharmacists

%

Accredited

Not accredited

Figure 32: Number of Pharmacists Employed (n accredited =146, n non- accredited = 20)




ABN: 49105208428


Plans for the pharmacy and accreditation status

There was a slightly larger proportion of unaccredited pharmacies who planned to grow their business. There was a correspondingly larger number of accredited pharmacies who planed to ‘maintain their business’.

0

10

20

30

40

50

60

70

80

90

100

grow your

business

maintain your

business

retire sell

%

Accredited

Not Accredited

Figure 33: Pharmacist Plans in Next 3 – 5 Years

(n accredited = 146, n not accredited = 20)

Geographical factors

Victoria and the ACT have the lowest percentage of pharmacies accredited. This evaluation did not reveal any reasons as to why there were any jurisdictional differences in the uptake of QCPP accreditation. Proportionally the rate of accreditation by PhARIA is comparable, at about 80% with the exception of those in PhARIA 1 and 5 where the accredited percentage is about 5% lower. The largest number of unaccredited pharmacies is in the PhARIA 1 grouping.




ABN: 49105208428


Accreditation Status by State

State

Perc

en

tag

e

Figure 34: Accreditation Percentage by State

Accreditation Status by PhARIA percentage (%)

PhARIA Rating

Pe

rce

nta

ge

Accreditation Percentage by PhARIA

Source: Pharmacy Guild of Australia

Figure 35: Accreditation Percentage by PhARIA




ABN: 49105208428


Discussion The following profile of pharmacies with respect to accreditation status was

identified: • A greater percentage of independent pharmacies were accredited. • A greater percentage of franchise pharmacies were not accredited. • There was no significant difference in the profile of the number of accredited

and non accredited pharmacies between ownership structures of sole proprietor and partnerships.

• The more pharmacists employed, the more likely the pharmacy is to be accredited.

• Pharmacies where the average age of the pharmacists is under 30, or between 41 and 60 are more likely to be accredited

• There was no clear distinction of business intent and accredited status. This profile information may assist in targeting support for change management support particularly with those pharmacies:

• That employ less than 3 pharmacists • Whose pharmacists are between 30 and 40 years of age or over 60 • Located in Victoria or ACT.



ABN: 49105208428

Barriers to Accreditation

Barriers Non Accredited pharmacies

Survey respondents who are not accredited were asked to identify barriers to accreditation. Their responses are shown here.

0 0.5 1 1.5 2 2.5 3

Cost

No perceived benefit

Too dif ficult

Too much improvement or investment required

to meet QCPP Standards

I don't know about the QCPP Standards

Other

Avg rating" (1) strongly disagree to (5) strongly agree

Figure 36: Barriers for Pharmacies Not Accredited (n= 16)

X axis = 5 point rating scale (1)

“Other” responses were mainly centred on intent to become accredited, with 5 pharmacies indicating they were intending to become accredited, often after having purchased the pharmacy and finding it needed considerable work to get to accredited status. Other comments could be grouped in the following themes:

1. No perceived benefit 2. Cost 3. Too difficult 4. Too much investment required to meet standards.

Comments from pharmacies not accredited included:

• Don’t have the time and staff required to divert to accreditation.

• Cost of S2 and S3 training for 80 employees outweighs the benefit of the government subsidy or marketing benefit.

• This Pharmacy was recently purchased from a long standing owner (35yrs) who had not invested much in the business. The first activity on buying the business had been to protect the investment and upgrade basics like computer hardware, inventory and ordering systems etc. QCPP is seen as a luxury in comparison with these issues. Remote areas also have problems attracting and retaining staff - many are not interested in increasing their skills and so are not willing to travel or invest in training like QCPP (especially when the benefits are not well understood).




ABN: 49105208428

Barriers to Accreditation, Continued

Discussion The barriers identified by pharmacists as to why they have not pursued accreditation

are consistent with those cited by other systems namely cost, time and perceived benefit. Having achieved a high rate of accreditation in the sector, along with the number of respondents through this project that indicate the intent to become accredited it may be that the community pharmacy sector has reached the maximum level of accreditation under a voluntary system. Significant gains in participation rates have been made over the years and further gains will be at most minimal. Targeting support to those types of pharmacies who are less likely to be accredited identified elsewhere in this report may assist. It will be important to ensure that the accreditation system is seen as relevant to the sector, that the costs are kept minimal and benefits highlighted in order to ensure those already accredited maintain their accreditation status. Promoting the business case for quality across the pharmacy sector may assist in convincing those currently not accredited to pursue accreditation and may assist in motivating currently accredited pharmacies to remain accredited. The accreditation system has been operating a sufficient length of time now to be able to identify some case study examples of the benefits of accreditation that can focus on some of the benefits revealed through this review. This will assist in reducing the perception that there is little benefit in accreditation and that it is costly.



ABN: 49105208428

Consumer Awareness

Level of consumer awareness

During the site visits to pharmacies consumers were approached by the project team and asked if they were willing to participate in a short interview where their responses would be kept anonymous. A very high percentage of consumers agreed resulting in a total of 150 consumer responses. Of the 150 consumers interviewed only 13 (8.8%) were aware of the QCPP, 4 of these people advised that they also currently or in the past had worked for a community pharmacy.

9%

91%

Yes

No

Figure 37: Consumer Awareness of QCPP (n = 150)

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Saw signage Informed by pharmacy staff Saw promotional material

(brochure, poster, counter

mat)

Figure 38: Basis of Consumer Awareness




ABN: 49105208428

Consumer Awareness, Continued

Pharmacies accreditation status

Yes

No

Don’t know

Figure 39: Awareness of Pharmacies Accreditation Status (n=150)

The majority of consumers did not know if their pharmacy was accredited under the QCPP standards.

Influence on consumer choice

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Relationship with

Pharmacist

Price Knowledgeable /

Professional

Staff

Location /

Convenience

Quality of service

Figure 40: Influence on Consumer Choice of Pharmacy (n = 150)

The main reason consumers chose their pharmacy was location and the convenience of that pharmacy’s location.




ABN: 49105208428

Consumer Awareness, Continued

Influence on consumer choice continued

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Most likely Somewhat likely Somewhat unlikely Most unlikely

Figure 41: Impact on Accreditation Status on Consumer Choice (n = 150)

50% of consumers were either most likely or somewhat likely to shop at a pharmacy that is associated with a quality improvement program. Equally 50% of consumers were somewhat unlikely or most unlikely to shop at a pharmacy associated with a quality improvement program.

Discussion Consumers were largely unaware of the QCPP and the accreditation status of the

pharmacy where they shopped. Given that consumers were equally matched between likely and most likely to choose a pharmacy with an accreditation program as those that weren’t and that location and convenience were the strongest factors that influenced where consumers shopped it may be reasonable to assume that consumers choice of using a pharmacy associated with a quality improvement program would only occur if the location and convenience factors were also met.



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Conclusion

Conclusion, Continued

Conclusion The evaluation of the QCPP incentive components of the QMA incentive, change

management support and the travel subsidy occurred between January 2010 and June 2010. There was a high degree of cooperation from the Department, the Guild, participating pharmacies and their consumers. This resulted in a good data set allowing robust conclusions to be drawn. The consultation process engaged 19 key informants. 44 pharmacists were interviewed in their pharmacies. Of the 1400 requests sent by email, 133 on line survey responses were completed by pharmacy owners or managers. 209 (15%) emails requests were returned as undeliverable as the emails provided were not contactable. 150 consumers were interviewed while they were in a pharmacy using a pharmacy service.

Findings Using a triangulated approach to the data analysis the following findings are made:

• Community pharmacies on the whole understand the business, quality and consumer benefits of participating in the QCPP.

• The availability of the QMA payment has had a significant impact on the decision to participate in the QCPP for 35% of pharmacies and a minor impact on a further 39%.

• The QMA is has relatively high impact on a community pharmacy owner / manager in their decision but it is not as high an impact as professional responsibility and customer service.

• Smaller pharmacies experience a bigger impact of the compliance burden of the accreditation process due to their smaller pool of workforce to distribute work amongst.

• The travel subsidy has low levels of awareness amongst community pharmacies with 44.5% being unaware of its existence and a further 55.5% unaware of their eligibility.

• Eligibility for the travel subsidy depends on the allocation and coordination of assessors in 3 of the 5 eligibility categories, meaning that eligibility is variable and often not known by the pharmacy in advance of the assessment.

• The cost of the location of the assessor is borne by the pharmacist.




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Conclusion, Continued

Findings (continued)

• As intended, the travel subsidy has more of an impact on the decision to participate in QCPP for rural and remote pharmacies.

• Change management strategies have contributed to the increased uptake in accreditation since Feb 2009.

• The direct capacity building approaches of the change management strategies have been more successful in engaging with community pharmacists in their quest for a quality improvement culture and gaining accreditation.

• Other communication strategies have had little impact on pharmacies decision to participate in QCPP.

• There is good use of the standards and QCPP resources by a number of pharmacies outside of the accreditation process.

• 33% of pharmacies identify their quality culture as being ad hoc or only in place in the lead up to accreditation.

• Business intent does not have a strong correlation to accreditation status. • Pharmacies where the pharmacists aged 31 – 40 and 60+ are less likely to

be accredited. • Consumers are largely unaware of the existence of QCPP. • The accredited status of a pharmacy is just as likely to influence consumers

choice of pharmacy as not. • For the relatively small number of pharmacists not accredited the main

barriers are cost and availability of human resources to participate. • The most frequently cited cost barrier was the cost to release staff for

training and the cost of training.



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Appendices

Appendix A – Bibliography

Bender, K. Recommendations from the exploring accreditation for state and local

health departments: Do we have the political will?, Public Health Nursing Vol. 24 No. 5, pp.465-471, 2007. Background paper, Quality Care Pharmacy Program, provided by Community Pharmacy Branch, DoHA. Chapman, J., Roberts, M. and Stokes, J. Australian College of Pharmacy Practice and Management, Quality Medication Care Pty Ltd and the Therapeutics Research Unit, University of Queensland, Final Report on the Evaluation of the Quality Care Pharmacy Program, 2005. Davis, M.V. et.al., Incentives to Encourage Participation in the National Public Health Accreditation Model: A systematic Investigation, American Journal of Public Health, September 2009. Leatherman S, Berwick D., et al 2003. The Business Case For Quality: Case Studies And An Analysis, Health Affairs 22:2 Marie-Pascale Pomey, Andre´-Pierre Contandriopoulos, Patrice Franc¸ois and Dominique Bertrand, Accreditation: a tool for organizational change in hospitals?, International Journal of Health Care Quality Assurance Volume 17 · Number 3 · 2004 · pp. 113-124 Mays, G.P., Can Accreditation Work In Public Health? Lessons From Other Service Industries Working Paper Prepared for the Robert Wood Johnson Foundation, Department of Health Policy and Management College of Public Health University of Arkansas for Medical Sciences, November 30, 2004 http://www.rwjf.org/files/publications/other/publichealth_Mayssummary.pdf Orimar Research. 2009. Top line chart pack – Pharmacy Guild of Australia 2009 Communications Research. Renhard, R., Quality in Health and Community Services, Australian Institute for Primary Care, La Trobe University. The Evidence for Effectiveness for Quality Initiatives in Human Services. A Critical Review, Nov 2001. Rural, regional and remote health, A guide to remoteness classifications, AIHW, 19 March 2004. http://www.aihw.gov.au/publications/index.cfm/title/9993



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Appendix B – Interview and survey selection process

Data Source Community pharmacy contact information was sourced from a data set provide by

the National Pharmacy Guild on 5th March 2010.

Online surveys

Step Using Microsoft Excel Number of potentials

1 All QCPP pharmacies 4942 2 Apply auto filter to all headers 3 Filter for “Community Pharmacy = “yes” 4928 4 Exclude those with no email address provided

4041

5 Add additional column 6 Apply randomizer number 0-1 using excel function

“=RAND()”

7 Copy all, and paste-special “values” to new excel worksheet

8 Sort randomizer column in ascending values ascending

9 Add additional column 10 Add “survey recipient column” and number all rows

according to randomizers ascending order

11 Select the first 700 in the survey recipient column for online survey send out

700

12 Second round selection – the 700 randomly allocated to the bottom of the interview list for face to face interview. This is to minimize the possibility of interviewees receiving an online survey. And eliminating the chance of receiving a second on line survey.

700

Face to face interviews randomized ordering

Step Using Microsoft Excel Number of potentials

1 All QCPP pharmacies 4942 2 Apply auto filter all headers 3 Filter for “Community Pharmacy = “yes” 4928 4 Add column with formula to tag “exclude” if the

pharmacy has been selected for on line survey 3342

5 Filter to remove “excluded pharmacies” 6 Apply randomizer number 0-1 using excel function

“=RAND()”

7 Copy and paste special “values” to new excel worksheet

8 Group by State 9 Create new document in excel 10 Divide into new workbooks for each state 11 Sort randomizer column in ascending values

ascending

12 Add additional column 13 Add “priority for interview” and number all rows

according to randomizers ascending order




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Appendix B – Interview and survey selection process, Continued

Face to face interview selection

Metro Number

Confirm date range for interviews Accredited pharmacies - Call metro pharmacies in order of priority applied until you have acceptance for 3 interview

3

Non accredited pharmacies - Call metro pharmacies in order of priority applied until you have acceptance for 1 interview

1

Regional

Select 2 state regions with in PhARIA ranking 3-5

Accredited pharmacies - Call regional pharmacies in order of priority applied until you have acceptance for 3 interview

2-3

Non accredited pharmacies - Call metro pharmacies in order of priority applied until you have acceptance for 1 interview

1-2

Remote

Select remote pharmacy in PhARIA 5-6, that can be accessed by commercial flights and call until one accepts

1 SA, and QLD



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Attachment A – Online Survey and Interview Questions – Community Pharmacies

Included as separate document.

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