workshop 4 clinical dashboards ho - ashp advantage 4_clinical... · practice model transformations:...

PRACTICE MODEL TRANSFORMATIONS:Achieving excellence through accountability and innovation

Clinical Dashboards:Clinical Dashboards: Integrating Institutional & Pharmacy Measures for

Success

Mi h l N di Ph D MHSMichael Nnadi, Pharm.D., MHSand

Steve Pickette, Pharm.D., BCPS


Measurement of a Pharmacy yClinical Practice Model and Dashboard Development:

Strategy

Mi h l N di Ph D MHSMichael Nnadi, Pharm.D., MHSVP of Pharmacy Services

Novant Health

6

Forsyth 932 60,978 104,752 25,359

Licensed Adjusted Emergency IP and OPBeds Discharges Visits Surgeries

2009 Statistics

Presbyterian 531 49,434 81,939 22,452

Rowan 268 21,588 58,320 9,666

Prince William 170 28,048 68,925 8,543

Thomasville 149 10,125 33,812 3,748

Upstate Carolina 125 7,793 31,609 3,190

Matthews 114 18 488 48 812 6 191Matthews 114 18,488 48,812 6,191

Orthopaedic Hosp 156 5,129 NA 6,889

Huntersville 60 13,292 33,935 5,731

Brunswick 60 8,617 24,223 3,798

Franklin 70 5,127 19,246 2,255

Medical Park 22 5,848 NA 11,416

Objectives

• Discuss the role of strategic planning in determining pharmacy dashboard.

• Describe effective pharmacy dashboards for measuring and demonstrating the success of pharmacy departments' clinical initiatives.

• Describe ways to communicate pharmacy services usingDescribe ways to communicate pharmacy services using dashboards.

7

Questions to Consider

• How do you determine what to measure?

• Why is it important?

• What do you measure?

• How and to whom do you communicate results?

It all begins with Strategic Planning

8

Strategic Management Framework

Pharmacy Strategic Plan2011‐2015

AdvancingNovant Pharmacy Services

In the 21st CenturyIn the 21st Century

9

Pharmacy in 2015

C Ph S h S

• Product‐based pharmacy services•Minimal clinical pharmacy services

•loose coalition of localized pharmacy services Strategy

• Patient centered • Operational efficiency & standardization

• Member of triad of care rounding on nursing units

• Represented in service lines as a member of the care team and in

plans

budgets

Current Pharmacy State Future Pharmacy State

of localized pharmacy services• Pharmacists manage all drug distribution •Operational inefficiencies

Strategy member of the care team and in transitions of care

• Technicians manage technology‐driven and safe medication

distribution • Safe medication practice is the

culture

plans

budgets

2015 Pharmacist

PharmacistNurse

MD

Strategy

Patient

10

Pharmacy Mission

Novant Pharmacy exists to ensure safe, effective, and affordable medication use in our communities, one person at a time.

Pharmacy Vision

Optimal medication management across all dimensions of care, every time.

11

Novant Pharmacy Values

• Compassion– We treat customers as family members, with kindness, patience, empathy and

trespect.

• Personal Excellence– We strive to grow personally and professionally. Honesty and personal

integrity guide all we do. We approach each service opportunity with a positive, flexible attitude.

• Teamwork – We support one another and collaborate in our efforts to better serve our

customers.

• Diversity – We recognize that every person is different, each shaped by unique life

experiences; this enables us to better understand one another and our customers.

Strategic Imperatives

Physician

Quality & Safety Guiding principle in our journey to deliver the most remarkable patient Experience, in every dimension, every time

Integration &

Health InformationTechnology

CommittedCommunities

EngagedEmployees

PhysicianPartners Collaborating to reach our shared vision

Building an environment that attracts the best and the brightest to practice at the top of their license

Providing medication management expertise in transitions of care, hospital to home, provider and ambulatory clinics

Implementing user-friendly, standardized, integrated technology solutions

System FinancialHealth

Partnerships& Affiliations

Integration &Strategic Growth

Best practice. No boundaries. Smart growth.

Advancing Novant Pharmacy and our profession

Maximizing efficiencies and leveraging value propositions

12

Strategic Lever:Integration & Strategic Growth

Goal: Realize “One Novant Pharmacy” with full integration of pharmacy services and economies of scale.

Best practice. No boundaries. Smart growth.

Strategies & Tactics

•Continue effort to consolidate formulary across Novant

•Document, track, and report clinical intervention outcomes and value propositions Consolidate Pharmacy policies and procedures to facilitate standardization and best practice

•Conduct gap analysis of existing pharmacy opportunities within Novant

•Develop and implement a checklist for pharmacist training to ensure optimal patient t tioutcomes every time

•Achieve clinical pharmacist deployment in all service lines

•Expand residency training programs to include PGY2

•Initiate steps in the development of new business opportunities

•Identify sources for grants to expand pharmacy clinical services in all dimensions of care

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Strategic Lever:System Financial Health

Goal: Optimize savings opportunities enterprise‐wide

Maximizing efficiencies and leveraging value propositions

Strategies & Tactics

•Improve 340B drug savings

•Identify and implement cost savings initiatives across the system

•Consolidate all pharmacy services and leverage system‐wide contracting and integrated clinical services to maximize savings

•Investigate pharmacy revenue that is not being captured

•Achieve optimal savings from indigent drug replacement program

ll i l S i /Q ifi li i l i i ki•Fully implement Sentri‐7/Quantifi clinical intervention tracking system

•Develop and implement standardized pricing/charging algorithm for acute care pharmacies

•Identify opportunities for clinical pharmacy services and stakeholders across the system and collaborate to realize vision for one Novant Pharmacy

16

13

The currency of leadership is attention…

In most cases, if you can’t measure it, it’s probably not important…..

Performance Measurement: Benchmarking…

• Strengths:• Allows organization to evaluate your own performance in comparison

to best practice sitesto best practice sites.

• Identifies keys areas of performance excellence

• Identifies areas in need of improvement

• Identifies potential areas for new services

• Concerns:• Must understand who your comparison organizations are

― Finding apples to apples comparisons can be difficult.

• Must understand the details of what’s contained in the data― What are defined as drugs, blood factors, contrast media, IV solutions?

• Understand how acuity adjustment is included ― Is it based on Case Mix Index (CMI) or Pharmacy Intensity Score (PIS)?

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Balanced Scorecard Approach

• What is a Balanced Scorecard?

• This is a tool that translates an organization’s mission and strategy into a comprehensive set of performance measures that provide the framework for a strategic measurement and management system.

Measure of Success

• How would we know that we are meeting our bj ti ?objectives?

• What are we measuring?

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Category Description Goal Jan-11 Feb-11

Strategic Indicators

Employee / Customer

Satisfaction

Excellent place to work (PRC >= 90th percentile) >=40%

Excellent place to work (Int Survey) >=80%

Will Recommend to friends (Int Survey) >=80%

Employee satisfaction w/ Pharmacy (2x/ yr) (Int Survey) >=80%

Nursing satisfaction (2x/ yr) (Int Survey) >=80%

Satisfaction with Rx Management (2x/ yr) (Int Survey) >=80%

Ph i f i (PRC S ) 80%Phys satisfaction (PRC Survey) >=80%

Performance Evaluation Completed on time 100%

Turnover Rate -RPh <8%

Turnover Rate -Technicians <=12%

Turnover Rate -Others <=20%

Documented RPh Interventions 10 per 100 PD

$$ Value of Documented R.Ph Intervention $$$

Interventions Accepted 90%

Monthly Unit Inspections Completed-on site 100%

Quality / Medication

Safety

Monthly Unit Inspections Completed-off site by Rx Qtrly 100%

Monthly Unit Inspections Completed-off site by MD Office 100%

MAK override (Medication Override) <5%

Pyxis Medication Override %-Critical Care <10%

Pyxis Medication Override %-Non-Critical Units <5%

Accuracy of order entry (Nursing Intervention Data?) >98%

Medication Errors ( # of var/100 PD) 1/100

Balanced Pharmacy Scorecard

Service and Access

Pharmacy Order Entry Turn-around time "Total" <=60 mins

Pharmacy Order Entry Turn-around time "Stat" <=30 mins

Educational Program Presented to nursing 4/month

Educational Programs Presented-Medical Staff 4/month

Newsletter 1/month

Community Health Edu Community education participation 1/ Qtr

Financial Viability

IV Waste (dollars only) $

Productivity hours

Productivity dollars

Failure to Supply $ recovery $

Contract vs Invoice Price Compare (capture) $y$$ Spent on Staff development $$

Contract Compliance (Excludes sole source drugs) > 95%

% Overtime of total salary dollars <3%

Pharmacy Drug Cost vs. Budget** (Cost /APD) <100%

Patient Days Baseline

Pharmacy Adjusted Patient Days Baseline

Pharmacy Metrics

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What is a Pharmacy Business Report?

• Pharmacy business report is a tool used by Ph L d t i t ksome Pharmacy Leaders to communicate key

information on key Pharmacy performance activities, strategic initiatives, and medication use opportunities to targeted audiences within their organization.

Things to consider when developing a Pharmacy report

• Associate the report with the department’s d I tit ti ’ l d bj tiand Institution’s goals and objectives.

• Provide executive summary

• Include relevant information and examples.

• Organize the report in easy to follow format

• Share report with executives including nursing and physicians

• Be sure to share with your pharmacy team

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Things to consider when developing a Pharmacy report

• Use the Pharmacy report as an educational and marketing tool to the pharmacy team seniormarketing tool to the pharmacy team, senior administration, and other healthcare teams.

• Include the improvements and projects that the Pharmacy has accomplished.

• Avoid the use of questionable information that may invite scrutiny and additional questionsinvite scrutiny and additional questions.

• Ask for feedback from Pharmacy employees and mangers when compiling the report.

Communicating Pharmacy Performance:Pharmacy Business Review

2nd Quarter 2011July 2011

Submitted byMi h l N diMichael Nnadi

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90‐Day GoalsExecutive Summary

1. Pharmacy operational expense is below budget in 2nd quarter by $1.45Mand YTD June, $3.05M

2. Drug savings for the 2nd quarter is $1.05M and YTD June, $1.8M. Key factorscontributing to savings include:contributing to savings include:‐Clinical intervention, formulary management, & collaboration with providers, $517K‐Indigent drug recovery program, $172K‐340 B drug program, contract, and inventory management, $1.15M

3. Clinical pharmacy services accomplishments includes ongoing formulary standardization, developing order sets, therapeutic substitution, nursing, provider & students education, formulary, and related cost avoidance/ savings

d f d l h d l h3. Medication safety and quality remains the guiding principles in pharmacy transformation efforts. We continue to see downward trend in medication and patient overrides compared to previous reports

4. Average pharmacy productivity remains high at 104%. Workload has increased by 1.5%.

Results

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Total Savings:

$$12,933,926

Forsyth Medical CenterPharmacy Scorecard

For the Month Ending July 31, 2011 PY QTD QTD QTD Flex Budge

QTD Variance Over (Under) Flex Budget July Flex Budget

Variance Over (Under) Flex

Budget

Percent Change -

Flex Budget

Patient RevenueInpatient 14 817 826$ 13 723 171$ 15 884 950$ (2 161 779)$ 13 723 171$ 15 884 950$ (2 161 779)$ 13 6%

Current Month

Inpatient 14,817,826$ 13,723,171$ 15,884,950$ (2,161,779)$ 13,723,171$ 15,884,950$ (2,161,779)$ -13.6% Outpatient 3,930,669$ 3,933,457$ 3,769,058$ 164,399$ 3,933,457$ 3,769,058$ 164,399$ 4.4%

Total Patient Revenue 18,748,495$ 17,656,627$ 19,654,007$ (1,997,380)$ 17,656,627$ 19,654,007$ (1,997,380)$ -10.2%

Operating Expenses Salaries & Wages 952,270$ 950,078$ 867,781$ 82,297$ 950,078$ 925,444$ 24,634$ 2.7% Medical\Surgical Supplies 130,432$ 114,157$ 119,925$ (5,768)$ 114,157$ 119,925$ (5,768)$ -4.8% Drugs 2,215,046$ 1,953,770$ 2,135,377$ (181,607)$ 1,953,770$ 2,135,377$ (181,607)$ -8.5%

-$ -$ Total Operating Expenses 3,701,034$ 3,375,209$ 3,498,051$ (122,842)$ 3,375,209$ 3,498,051$ (122,842)$ -3.5%

Key Expenses Overtime Salaries 126,772$ 142,835$ -$ 142,835$ 142,835$ -$ 142,835$ 0.0% Office Supplies 5,410$ 1,821$ 4,699$ (2,878)$ 1,821$ 4,699$ (2,878)$ -61.2% Travel and Conference 249$ 155$ 2,083$ (1,928)$ 155$ 2,083$ (1,928)$ -92.5% Mileage 163$ 61$ 313$ (251)$ 61$ 313$ (251)$ -80.4%

Dietary Expenses 76$ 245$ 262$ (17)$ 245$ 262$ (17)$ -6 5% Dietary Expenses 76$ 245$ 262$ (17)$ 245$ 262$ (17)$ -6.5%

Total Key Expenses 132,670$ 145,117$ 7,356$ 137,761$ 145,117$ 7,356$ 137,761$ 1872.7%

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Forsyth Medical CenterPharmacy Scorecard

For the Month Ending July 31, 2011 PY QTD QTD QTD Flex Budget

QTD Variance Over (Under) Flex Budget July Flex Budget

Variance Over (Under) Flex

Budget

Percent Change -

Flex Budget

Current Month

Inpatient StatisticsFacility Admissions w/ NBs 3,630 3,509 3,509 - 3,509 3,509 - 0.0%Facility Discharges w/o NBs 3,355 3,260 3,260 - 3,260 3,260 - 0.0%Facility Patient Days w/o NBs 19,334 18,078 18,078 - 18,078 18,078 - 0.0%Pharmacy SRC 1,794 1,721 1,721 - 1,721 1,721 - 0.0%Salaries & Wages per Admission 262$ 271$ 247$ 23$ 271$ 264$ 7$ 2.7%Salaries & Wages per Discharge 284$ 291$ 266$ 25$ 291$ 284$ 8$ 2.7%S l i & W P ti t D 49$ 53$ 48$ 5$ 53$ 51$ 1$ 2 7%Salaries & Wages per Patient Day 49$ 53$ 48$ 5$ 53$ 51$ 1$ 2.7%Med/Surg Supplies per Admission 36$ 33$ 34$ (2)$ 33$ 34$ (2)$ -4.8%Med/Surg Supplies per Discharge 39$ 35$ 37$ (2)$ 35$ 37$ (2)$ -4.8%Med/Surg Supplies per Patient Day 7$ 6$ 7$ (0)$ 6$ 7$ (0)$ -4.8%Drug Cost per Admission 610$ 557$ 609$ (52)$ 557$ 609$ (52)$ -8.5%Drug Cost per Discharge 660$ 599$ 655$ (56)$ 599$ 655$ (56)$ -8.5%Drug Cost per Patient Day 115$ 108$ 118$ (10)$ 108$ 118$ (10)$ -8.5%Total Operating Exp per Admission 1,020$ 962$ 997$ (35)$ 962$ 997$ (35)$ -3.5%Total Operating Exp per Discharge 1,103$ 1,035$ 1,073$ (38)$ 1,035$ 1,073$ (38)$ -3.5%Total Operating Exp per Patient Day 191$ 187$ 193$ (7)$ 187$ 193$ (7)$ -3.5%

Adjusted Discharge StatisticsAdjusted Discharges 5,126 4,875 5,002 (127) 4,875 5,002 (127) -2.5%Pharmacy Adjusted Discharges 4,245 4,194 4,034 161 4,194 4,034 161 4.0%Pharmacy Revenue per Pharmacy AD 4,417$ 4,210$ 4,873$ (663)$ 4,210$ 4,873$ (663)$ -13.6%Salaries & Wages per Pharmacy AD 224$ 227$ 215$ 11$ 227$ 229$ (3)$ -1.3%Med/Surg Supplies per Pharmacy AD 31$ 27$ 30$ (3)$ 27$ 30$ (3)$ -8.5%D C t Ph AD 522$ 466$ 529$ (64)$ 466$ 529$ (64)$ 12 0%Drug Cost per Pharmacy AD 522$ 466$ 529$ (64)$ 466$ 529$ (64)$ -12.0%Total Operating Exp per Pharmacy AD 872$ 805$ 867$ (63)$ 805$ 867$ (63)$ -7.2%

Adjusted Patient Day StatisticsAdjusted Patient Days 29,541 27,035 27,738 (703) 27,035 27,738 (703) -2.5%Pharmacy Adjusted Patient Day 24,463 23,260 22,367 892 23,260 22,367 892 4.0%Salaries & Wages per Pharmacy APD 39$ 41$ 39$ 2$ 41$ 41$ (1)$ -1.3%Med/Surg Supplies per Pharmacy APD 5$ 5$ 5$ (0)$ 5$ 5$ (0)$ -8.5%Drug Cost per Pharmacy APD 91$ 84$ 95$ (11)$ 84$ 95$ (11)$ -12.0%Total Operating Exp per Pharmacy APD 151$ 145$ 156$ (11)$ 145$ 156$ (11)$ -7.2%

340B Drug Program Contribution to Savings June YTD

NH Facility Jan-June 2011y

FMC $1,820,238TMC $69,460

Brunswick $110,167

Presbyterian $1,980,683$3,980,549

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Additional Cost Savings Initiatives in 2nd Qtr

2nd Quarter Corporate Initiatives

Pyxis expenses avoided $600,000Conversion of Ferrlecit to Nulecit $177,867Restoration of contract Price for Eraxis $53,915Euflexxa $182,000T t l S i $1 013 782Total Savings $1,013,782

Annualized savingsCorporate pharmacy savings initiatives

YTD June 2011

Facility Sum of soft cost saved Sum of hard cost saved

Forsyth Medical Center $ 1,790,569.00 $ 344,930.00

Cost savings from Clinical Pharmacists’ activity June YTD

Medical Park Hospital $ 360,043.00 $ 24,454.00

Presbyterian Hospital - Charlotte $ 1,415,932.00 $ 126,157.00

Presbyterian Hospital - Huntersville $ 90,542.00 $ 3,949.00

Presbyterian Hospital - Matthews $ 128,949.00 $ 4,274.00

Presbyterian Orthopaedic Hospital $ 39,088.00 $ 105.00

Thomasville Medical Center $ 106,230.00 $ 11,924.00

Brunswick Community Hospital $ 4,814.00 $ 1,437.00

Grand Total $ 3,936,167.00 $ 517,230.00

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Cost Savings per Hospital

Jan ‐ Jun 2011

$2,000,000

Cost Savings from Pharmacists’ Clinical Initiatives FY 2011

$800,000

$1,000,000

$1,200,000

$1,400,000

$1,600,000

$1,800,000

Sum of softcostsaved

Sum of hardcostsaved

$0

$200,000

$400,000

$600,000

Forsyth Medical

Center

Medical Park

Hospital

Presbyterian

Hospital ‐

Charlotte

Presbyterian

Hospital ‐

Huntersvil le

Presbyterian

Hospital ‐

Matthews

Presbyterian

Orthopaedic

Hospital

Thomasvi lle

Medical Center

Brunswick

Community

Hospital

Number of Interventions per Intervention Class

Jan ‐ Jun 2011

20646

20,000

25,000

11408

4212 4194

2171922 915 442 442 337 292 183 181 128 20

5,000

10,000

15,000

Total

442 442 337 292 183 181 128 200

Pharmacokinetics

Therapeutic

Anticoagulation NU

LL

Drug Information

Antibiotic Stewardship

Targeted Drug Program

Renal Dosing

Medication Events

IV to PO

Education/Training

Allergy Conflict Resolved

Investigational Drugs

*Not specified

(blank)

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QUALITY IMPROVEMENTMedication Safety Event Reporting

• Pharmacy is engaged in several improvement projects including medication error reduction: MAC patient overrides

QUALITY IMPROVEMENTMedication Safety Event Reporting

Patient OverridesAll Facilities By Month

January, 2009 - June, 2011

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00% FMC

MPH

TMC

PHC

PHM

POH

PHH

BCH

KMC

0.00%

1.00%

Janu

ary

Febr

uary

March

April

May

June

July

Augus

t

Septembe

r

Octob

er

Novem

ber

Decem

ber

Janu

ary

Febr

uary

March

April

May

June

July

Augus

t

Septembe

r

Octob

er

Novem

ber

Decem

ber

Janu

ary

Febr

uary

March

April

May

June

Override data is higher for October, 2010 due to MAC system outage on 10/21/10 and 10/22/10 and use of the recovery process.

• Pharmacy is engaged in several improvement projects including medication error reduction: MAC patient overrides

25

Operational Performance

Medication Turn Around Time: 2nd Quarter 2011 (average)

Goal BCH FMC MPH TMC KMC PHC PHH PHM POH RRMC

Routine

<=45 mins 27.47 56 20.27 51.89 33.51 28.1 16.6 35.56 30.83 4.7

Stat<=15 mins 17.76 14.47 13.37 18.3 12.86 6.93 10.43 20.66 18.76 3.13

• Pharmacy service access: Turn Around Time (TAT)

90-Day GoalsPharmacy productivity remains high for the second Quarter of 2011

Dept # FacilityHour Productivity (Includes

Orientation and Education)48706 BCH Pharmacy 95.50%

4706 FMC Pharmacy 109 60%4706 FMC Pharmacy 109.60%

6706 MPH Pharmacy 122.60%

3706 PHC Pharmacy 95.40%

2706 PHH Pharmacy 97.90%

5706 PHM Pharmacy 94.40%

9706 POH Pharmacy 84.80%

109706 PWH Pharmacy 107.90%

66706 RRMC Pharmacy 112.10%

8706 TMC Pharmacy 108.80%

118706 KMC Pharmacy 127.90%

113706 Franklin 83.7%

114706 Upstate 115.2%

Total 104.38 %

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90-Day GoalsPharmacy Workload Continues to increase

Productivity: Orders Processed YTD

NH FacilityPrior Year

YTDCurrent

Year YTD Var (%) Variance

BCH 87,058 87,911 0.98% 853

Franklin N/A 62,423

FMC 1,096,039 1,124,607 2.61% 28,568

MPH 84,113 88,333 5.02% 4,220

TMC 84,668 98,006 15.75% 13,338

KMC N/A 23,930 100%

PHH 184,345 177,345 -3.80% -7,000

PHC 1,023,644 974,399 -4.81% -49,245

PHM 248,684 251,649 1.19% 2,965PHM 248,684 251,649 1.19% 2,965

POH 109,970 103,783 -5.63% -6,187

PWH 245,500 252,900 3.01% 7,400

RRMC 298,338 332,466 11.44% 34,128

Upstate N/A 137,543

Total: 3,462,359 3,515,329 1.53%

Lessons Learned

There is always opportunity for Therapeutic Intervention because all patients receive medications

Hospital Pharmacy is a continuously evolving practice with anHospital Pharmacy is a continuously evolving practice with an increasing emphasis on direct patient care.

Yet hospital pharmacy departments are often perceived as a “pharmaceutical materials management department” with our clinical focus being a secondary function.

Pharmacy Leaders must define and demonstrate the broad values that we deliver to our patients and institutions throughthat we deliver to our patients and institutions through measurement

27

Lessons Learned

Demonstrate your ability to create a strategic direction for your department with a clear vision of the journey

Communicate your vision for Pharmacy Practice to your teamCommunicate your vision for Pharmacy Practice to your team, nursing, physicians, and administration

Demonstrate your ability to “understand your business better than anyone else" and how it performs in comparison to others

Market your department and profession to all who will listen


Breakout Small Group Discussions #1

‐ Approx. 20 minutes

‐ Share examples of strategic plans

‐ Identify common key elements

‐ Lessons learned

‐ Prepare summary to present

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Measurement of a Pharmacy Measurement of a Pharmacy Clinical Practice Model and

Dashboard Development

Clinical Practice Model and

Dashboard Development


Director System, Pharmacy Clinical Services


Director System, Pharmacy Clinical Services

29

Overview

Why we need Clinical Metrics and Dashboards

Examples of Dashboards:

– Clinical Service Intervention

– Hospital Interventions

– Regional Interventions

– Financial Impact– Financial Impact

– Clinical Outcomes

Conclusions

Role of the Pharmacist in Hospitals

• Reviewing individual patients’ medication orders for safety d ff ti d t ki ti ti i di t dand effectiveness and taking corrective action as indicated

• Collaboratively managing medication therapy for individual patients.

• Educating patients and caregivers about medications and their use.

• Leading continuous improvements in the medication use processprocess.

• Leading the interdisciplinary and collaborative development of mediation use policies and procedures.

30

How Common Are these Services?

2007 ASHP Survey:

Only 38% of hospitals overall have service specific pharmacists review therapy.

– 72% at hospitals greater than 400 beds

– 26% at hospitals 200 beds or less

Only 24% of hospitals have pharmacists reviewing medication therapy for 75% or morereviewing medication therapy for 75% or more of patients.

*2010 Survey: pharmacist redeployed to units in last 3 yrs 23.5%

Am J Health‐Syst Pharm—Vol 64 Mar 1, 2007 Am J Health‐Syst Pharm—Vol 67 Apr 1, 2010

Clinical Involvement

Patient

Why Are Pharmacy Clinical Service So Variable?

ProcurementAnd Storage(Turns, Line Items)

Drug Distribution(Doses Billed, TAT)

Order Processing(Orders Processed, TAT)

(No Standard Metric)

31

Pharmacy Resource Council Strategic Plan Framework

PH&S Mission, Vision & Values

We will succeed as “One Ministry Committed to Excellence”

Foundation

System Strategy

PRC Vision:Enhancing quality of life through safe & effective medication use

PRC Outcomes:• Utilize a standardized system to demonstrate the value of clinical pharmacy• 100% of CMS clinical quality indicators met relative to pharmaceutical care• Implement technology solutions to eliminate preventable medication adverse events• Pharmacist will review the therapy of 100% of patients with complex & high-risk medication

regimens • Achieve system-wide target of 90% compliance with market share contracts• Develop & adopt a standardized training and competency assessment program at least

biannually with 100% compliance• Compliance with regulatory requirements

PRC Strategic Priorities:Attract and retain the best workforce

Leverage System Wide Capabilities

Tactics: (specific Steps to Achieve Individual Strategies)

Leverage Technology

Enhance Quality & Scope of Pharmacy Clinical Services

Operating Commitments

PeopleCentered

Mission Inspired

Service Oriented

QualityFocused

FinanciallyResponsible

(specific Steps to Achieve Individual Strategies)

• Participate in and develop education programs.

• Develop HR strategy

• Career advancement

• Implement proven technology applications

• Coordinate and enhance pharmacy informatics resource

• Standardize technology

• System wide reporting tool

• Benchmark internally and externally

• Implement standard practice model

• Direct patient care

• Communicate success

• Develop Common Metrics / Benchmarking Program

• Regional P&T Process

• Shared services / resources

• Identify and share best practice

Steps In the Process

Develop Shared Need/Common Vision

D fi Obj tiDefine Objective

Develop Metrics

Initiate Pilot

Estimate ROI (Resources / Return)

Implement andMeasureImplement and Measure

Spread and Adopt

Build Upon Success

32

Shared Need / Common Vision

di ib i d d lDrug‐distribution‐centered model– Engaged with medication delivery. – Clinical role reactive to order processing.

Clinical‐pharmacist‐centered model– Engaged with medical team, but not medication use and delivery process.

P ti t t d i t t d d lPatient‐centered integrated model– Engaged with medical team and complete medication use process.

Woods, M. Practice Model Challenge. Am J Health‐Syst Pharm. 2009; 66.

PH&S “Standard” Practice ModelPH&S “Standard” Practice Model

Unit or Service‐based Clinical Staff

Defined (Specialized) Clinical Services (as much as possible)

Systematic review of medication therapy (e.g. profile review)

Prospective Involvement in Medication Therapy Decision– Rounding

– Collaborative Practice AgreementsCollaborative Practice Agreements

Efficient and Effective Distribution– Maximize Technician Resource/automation

– Centralized Order Entry

Maximize Involvement in Education – Pharmacy practice (interns, clerkships, residents)

– Other patient care team members

Documentation– Internal to pharmacyp y

– In medical record

Clinical Decision Support

Standards of Care / Protocols

Competency Standards (e.g. credentialing, training)

Professionalism (e.g. society involvement, scholarly work, etc.)

33

Initial Pilot

• Providence Sacred Heart Medical Center

• 623 bed tertiary care center

• Implementation of clinical documentation program.

• Performance Report• Trend interventions

h l• Pharmacy supply expense

• Benchmark data

Intervention Definition and ValueLEGEND: Primary Interventions – Teal Secondary Interventions – Gold Undefined - Purple

Intervention Type Primary – Teal Secondary - Gold

Intervention Class

Soft Costs Saved

Hard Costs Saved

RVU 1° 2° Quick Time Taken Description Notes/Example

*Not specified *Not specified 0 0 0 Y Y N 0 Default when no intervention type is selected. No values are applied

Prevention of an ADE that would likely have been i d d ti t MORBIDITY Ch

ADE Prevention Minor Safety 220 0 20 N Y N 20

serious and caused patient MORBIDITY. Changes in therapy occurred as a result of clinical skills and not just a computer notice (i.e. duplicate therapy, a llergy, or drug interaction notice). Must document enough information to be able to verify upon audit/review.

Example: Elderly patient sedation changed from Ambien to reduce risk of falls.

ADE Prevention Major Safety 2200 0 30 N Y N 20

Prevention of an ADE that would likely have been serious and could have resulted in MORTALITY. Changes in therapy occurred as a result of clinical skills and not just a computer notice (i.e. duplicate therapy, allergy, or drug interaction notice). Must document enough information to be able to verify upon audit/review. Use ADE Prevention Major when a history of anaphylaxis with medication ordered changed to a safer alternative.

Examples: A Category X medication is ordered for a pregnant patient (this kind of warning does not appear during order entry). Heparin is ordered for a patient with an active GI b leed.

Allergy Review Safety 0 0 15 Y N N 15 Use for identifying a llergy issues needing fo llow-up

Allergy Avoided Safety 220 0 20 N Y N 20

Use this intervention only if a therapy change was made by pharmacy to avoid an allergy. Use ADE Prevention Major when a history of anaphylaxis with medication ordered changed to a safer a lternative.

Allergy Clarified Safety 110 0 20 N Y N 20 Use this to specify types of reaction to a drug/food allergy or to clarify if patient has allergies.

Patient has allergy to penicillin. RPh verifies with patient that penicillin causes shortness of breath and hives.

34

Example: Service Line Pharmacy Savings Report

E x p e n s e s & C o s t S a v in g In it ia tiv e s p e r P h a rm a c y S e rv ic e L in e

S U R G IC A L S E R V IC E S 2 W e e k P e r io d S ta rt in g 7 /2 5 /2 0 0 4 Y e a r T o D a teS ta rt in g 6 /1 3 /0 4

E X P E N S E SS a la ry E x p e n s e 4 ,0 0 8 .0 0$ 1 5 ,0 7 8 .4 0$

C O S T S A V IN G IN IT IA T IV E S # o f In te rv e n tio n s 2 w k to ta l Y e a r T o D a teC h a n g e s M a d e in T h e ra p y

A lle rg y A v o id e d 2 1 8 2 .1 6$ 1 8 2 .1 6$ M e d O rd e r C la r if ic a tio n 3 1 2 ,8 2 3 .4 8$ 5 ,2 8 2 .6 4$ C o n s u lt 7 -$ M e d D C 'D b y R P h 1 5 1 ,3 6 6 .2 0$ 2 ,9 1 4 .5 6$ D o s e A d ju s te d 2 1 1 ,9 1 2 .6 8$ 4 ,4 6 2 .9 2$ D u p lic a te D C 'D 1 9 1 .0 8$ 2 7 3 .2 4$ D V T P ro p h y la x is b y R P h 0 -$ -$ E p o g e n U s e A v o id e d 0 -$ F o rm u la ry S u b 6 3 2 4 .0 0$ 5 9 4 .0 0$ In te ra c tio n A v o id e d 0 -$ 9 1 .0 8$ M e d C h a n g e d 0 -$ 1 8 2 .1 6$ A d ju s t fo r R e n a l F x 8 7 2 8 .6 4$ 1 ,9 1 2 .6 8$ R o u te C h a n g e d 1 6 5 6 0 .9 6$ 1 ,1 2 1 .9 2$ g $ ,$M e d S ta r te d 1 5 1 ,3 6 6 .2 0$ 2 ,3 6 8 .0 8$

O th e r In it ia t iv e sN /V -$ R o u tin e O rd e r ( ite m c o s t) -$ M is c C o s t S a v in g s -$

T O T A L C O S T S A V IN G S 9 ,3 5 5 .4 0$ 1 9 ,3 8 5 .4 4$

N E T S A V IN G S /L O S S 5 ,3 4 7 .4 0$ 4 ,3 0 7 .0 4$

Initial Service Financial Report

Expenses & Cost Saving Initiatives All Pharmacy Service Lines

2 weeks starting YTD2 weeks starting YTD7/25/2004 Starting 6/13/04Salary Expense Dollars Saved Profit/Loss Salary Expense Dollars Saved Profit/Loss

ED/OR 3,235$ 2,509$ ($726) 12,352$ 10,489$ ($1,863)ICU 6,165$ 5,340$ ($825) 21,814$ 24,092$ $2,278Peds 3,598$ 9,202$ $5,604 29,992$ 22,280$ ($7,712)NICU 3,598$ 4,977$ $1,379 10,456$ 9,928$ ($527)Peds Onc 3,923$ 8,065$ $4,141 13,366$ 18,736$ $5,370Surg 4,008$ 9,355$ $5,347 15,078$ 19,385$ $4,307Neur/Nephro 4,884$ 2,799$ ($2,085) 15,645$ 11,016$ ($4,629)Cardiology 4,070$ 7,075$ $3,005 14,815$ 12,988$ ($1,827)gy ,$ ,$ $ , ,$ ,$ ($ , )Oncology 4,070$ 5,042$ $972 14,815$ 11,509$ ($3,306)CTT 4,070$ 9,480$ $5,410 15,954$ 14,006$ ($1,949)Psych 3,253$ 2,256$ ($997) 12,044$ 5,953$ ($6,091)IMR 1,712$ 783$ ($929) 6,847$ 783$ ($6,064)

Total 46,586$ 66,883$ 20,297$ 183,178$ 161,165$ ($22,013)

35

Report from 12/12/2004

Expenses & Cost Saving Initiatives All Pharmacy Service Lines

2 weeks starting YTD2 weeks starting YTD12/12/2004 Starting 6/13/04Salary Expense Cost Saving Iniatives NET SAVINGS/LOSS Salary Expense Cost Saving Iniatives NET SAVINGS/LOSS

ED/OR 2,931$ 5,927$ $2,996 44,587$ 55,353$ $10,766ICU 4,885$ 6,410$ $1,525 78,654$ 150,632$ $71,978Peds 2,687$ 14,406$ $11,719 49,459$ 138,032$ $88,573NICU 1,647$ 3,481$ $1,834 47,117$ 55,364$ $8,247Peds Onc 3,354$ 7,926$ $4,572 53,708$ 107,795$ $54,087Surg 4,264$ 12,155$ $7,891 64,257$ 116,590$ $52,333Neur/Nephro 4,393$ 6,783$ $2,390 65,220$ 65,481$ $261C di l 3 903$ 7 419$ $3 516 59 742$ 68 275$ $8 533Cardiology 3,903$ 7,419$ $3,516 59,742$ 68,275$ $8,533Oncology 3,903$ 4,873$ $970 59,742$ 78,035$ $18,293CTT 3,908$ 16,319$ $12,411 62,312$ 99,278$ $36,966Psych 2,606$ 2,476$ ($130) 43,936$ 32,741$ ($11,195)IMR 1,224$ 308$ ($916) 23,474$ 27,494$ $4,020

Total 39,705$ 88,483$ $48,778 649,946$ 995,070$ $345,124

Cost Savings Documented Increased

Overall Pharmacy Clinical Service Profit/Loss

120000

20000

40000

60000

80000

100000

Dolla

rs

Conversion date

0

7/11

/2004

7/18

/2004

7/25

/2004

8/1/

2004

8/8/

2004

8/15

/2004

8/22

/2004

8/29

/2004

9/5/

2004

9/12

/2004

9/19

/2004

9/26

/2004

10/3/

2004

10/10

/200

4

10/17

/200

4

10/24

/200

4

10/31

/200

4

11/7/

2004

11/14

/200

4

11/21

/200

4

11/28

/200

4

2 Week Starting Date

Salary Expense Dollars Saved via Interventions/Projects

36

Drug Expense vs. Budget Improved

Drugs and Biotech Budget vs. Purchased

600000

800000

1000000

1200000

1400000

Dol

lars

PPI

0

200000

400000

Jan-03

Feb-03

Mar-03

Apr-03

May-03

Jun-03

Jul-03

Aug-03

Sep-03

Oct-03

Nov-03

Dec-03

Jan-04

Feb-04

Mar-04

Apr-04

May-04

Jun-04

Jul-04

Aug-04

Sep-04

Oct-04

Nov-04

Dec-04

Jan-05

Feb-05

Mar-05

Apr-05

May-05

Jun-05

Jul-05

Aug-05

Sep-05

Drug & Biotech Purchased Drug & Biotech Budget Linear (Drug & Biotech Purchased)

Result: Support from Administration

“The value of our model is clear both from a knowledge transfer standpoint which improves quality and also for expense controls”

Mike Wilson, President, SHMC

37

Next Step: Duplicate Results(Implement and Measure)

HFH: converted from “target drug” modelHFH: converted from target drug model

– Added 3.2 total additional F.T.E.

– Established 3 clinical services (200 beds)

SPH: “unit based order entry” model

– Centralized order review – Pyxis Connect®

– Implemented operational efficiencies– Implemented operational efficiencies• Phone tree, tech check tech, triage RPh, etc.

Documentation using clinical intervention software

Comparison of Documented Changes in Therarpy by Pharmacist 9-06 vs 9-07

800

900

1000

Warfarin Education Done

Warfarin Dosed by Pharmacist

TPN Change

Tikosyn Processed

Therapeutic duplication avoided

Sentri 7 Initiated Intervention

Sedation Protocol Change

Renal Dose Change

Count of Intervention

InterventionResults: Documentation Increased

200

300

400

500

600

700

Num

ber o

f int

erve

ntio

ns

POM Processed

PK evaluation-Vancomycin

PK evaluation-Other

PK evaluation-AG

Pain Consult or Service Change in Tx

Pain Consult Change in Tx

Non-form Changed

Lab Value Review/Change in Tx

IV-to-PO Change

IV to PO Change

IV Drug compatibility Done

Insulin Protocol Change

Indication Clarified Leading to Change

0

100

09/05 09/06 09/07 09/05 09/06 09/07

Holy Family St Patrick

Hospital/Month/Year

Education - Patient Completed

Education - Group

Duration of Therapy Changed

Drug Tx Consultation Completed

Drug Interaction Avoided

Drug Information

Dose Per Pharmacist Completed

Dose Changed AdultHospital Month/Year

38

Results: Cost Avoidance Increased

Dollars Saved

11.27

19.11

26.36

9.19

23.17

28.59

5

10

15

20

25

30

Prior to practicemodelPeriod followingpractice model

Dollars Saved Per Pt. Day

0

5

HFH HFH HFH SPH SPH SPH

Hospital / Year

9/05 9/059/06 9/069/07 9/07

Drug Expense Per Adjusted Patient Day

$60 00

$70.00

$80.00

$90.00

$10.00

$20.00

$30.00

$40.00

$50.00

$60.00

SPH $1.9 M

PHFH $2.6 M

$0.00

2005 2006 2007 2008 2009

Saint Patrick Hospital Providence Holy Family Hospital

SPH 5% Inflation HFH 5% Inflation

39

Pharmacy Supply and Labor Expense Trend Compared to Peer Hospitals

Result: More Endorsements

“I fully support the implementation of the pharmacy clinical practice model as it delivers a significant return on investment both financially and on improving quality of care”

Tom Corley, President, HFH

40

Next Step: Spread and Adopt

Approval for system wide initiative.

– Business Case

– Software Purchase

– System, Region, Service Area, Site Support

– Staffing resources• Regional Director Pharmacy Clinical Services

I l t Ph D t ti dImplement Pharmacy Documentation and Clinical Decision Support Tool

Develop Metrics to Benchmark Clinical Services

Metric Development

Core data sourcesCore data sources

– Census

– CMI

– Clinical FTE (from evaluation sheets)

– Intervention Data

• Gross intervention savings documented

41

Region HospitalLicensed

beds

Average Daily

Census Q1 2009

CMAA Daily

Average 2008

Total Staff RPh

F.T.E.

Occupied Beds Per

F.T.E.

CMAA Daily

Average Per Staff

R.Ph. F.T.E.

*Clinical F.T.E. 2006

*Clinical F.T.E. 2009

Clinical F.T.E. / 100

CMAA Daily Average 2008

Occupied Beds Per Clinical

F.T.E.

CMAA Daily Average Per

Clinical F.T.E.

WA/MT PSHMC 623 452 181 26.03 17.4 7.0 12 12 6.6 37.7 15

PSPH 390 255 107 19.8 12.9 5.4 0 6.2 5.8 41.1 17

PRMCE 372 292 151 25 11.7 6.0 0 5.3 3.5 55.1 28

PHFH 272 110 66 10.99 10.0 6.0 1 3.4 5.2 32.4 19

SPH 231 109 78 16.6 6.6 4.7 2.4 4.5 5.8 24.2 17

OR PSVMC 523 386 206 35 11.0 5.9 9.6 9.6 4.7 40.2 21

PPMC 483 287 158 27.45 10.5 5.8 1.6 7.4 4.7 38.8 21

PSJMC 360 263 94 21 12.5 4.5 0 2.4 2.6 109.6 39

LCOMT 315 104 97 11.6 10.0 8.4 2 4.8 4.9 21.7 20

CA Tarzana 245 175 15 9 19.4 1.7 1 1 6.7 175.0 15

LCOM SP 231 105 32 4.7 22.3 6.8 0 0.7 2.2 150.0 46

PHCH 206 193 72 13 14.8 5.5 0 2 2.8 96.5 36

AK PAMC 364 248 106 28 8.9 3.8 7.95 7.95 7.5 31.2 13

1363 248.17 5.5 37.55 67.25 20

MM

OO

3000

3500

4000

4500

AA

BB

CCDD

FF

HH

II

KK

LL

NN

EE

JJ

1000

1500

2000

2500

3000

$ Sa

ved

per C

MA

GG

0

500

0 10 20 30 40 50

CMAA per Clin FTE

42

Statistical Correlation

No Statistical Correlation

43

Pharmacy Clinical Intervention Metrics

“High Impact” interventions:Adverse drug event prevented allergy avoided medication dosed byAdverse drug event prevented, allergy avoided, medication dosed by pharmacy, pain consult, pharmacokinetic consult, antibiotic change, chemo dose change, TPN changed, renal dose adjustment, stress ulcer prophylaxis added, warfarin dose adjustment. Target: 15‐20 per 100 CMAA

Cost avoidance:

Estimated cost‐avoidance associated with the documented medication interventions by pharmacy. The values are provided by Solicient based on hard and soft dollar savings results in the literature evaluating the impact of the interventions. Target: $30 ‐ $75 per CMAA

Pharmacy ClinicalPharmacy Clinical Documentation Report

First thru Fourth Quarter 2010

Steve Pickette, Pharm D, BCPSDirector System Pharmacy Clinical Services

44

PHRMH

PMMC

PMH

PNMC

PPMC

PSVMC

PSH

PWFM

C

Current Outcome (through 1st Qtr)

Clinical Pharmacy Model Implementation

Implementation of clinical pharmacy practice model to minimize the risks, decrease the

costs, and improve the outcomes associated with drug therapy at 5 PHSOR facilities

a Centralized order entry

Clinical Pharmacy Practice Model Initiative

Oregon

a. Centralized order entry

b. Pharmacist in clinical units/areas

c. Systematic medication therapy review, i.e. dosing, affordability, patient education

Milestones

1Q2011

Complete gap analysis for all 8 ministries

2Q2011

Establish baselines for clinical intervention metrics

Develop action plans for implementation

Evaluate progress based on intervention metrics (see graphs and interventions tab)

3Q2011

Implement action plans

Meeting metrics for high impact interventions ? (see graphs and interventions tab)

4Q2011

Report process and outcome measures

Meeting metrics for high impact interventions ?

Report year end results

45

$25.00

$30.00

$35.00

INTERVENTION DASHBOARD DOLLARS SAVED PER CMAA BY REGION

$5.00

$10.00

$15.00

$20.00

$0.00

Q1/

2011

Q2/

2011

Q1/

2011

Q2/

2011

Q1/

2011

Q2/

2011

Q1/

2011

Q2/

2011

AK CA OR WA/MT

47

Other Results: Patient Outcomes

Readmission Rate (Pilot vs. Control)

CHF 20% l– CHF: 20% lower

– AMI: 20% lower

– AMI/CHF on Warfarin: 35% lower

Length of Stay (Pilot vs. Control)

– Overall: 1.45 day difference in mean LOSOverall: 1.45 day difference in mean LOS

• Statistically significant (p=0.001)

– ICU: 1.27 day difference in mean LOS

30 Day Readmission Rate: AMI/CHF Patients on Warfarin

‐‐‐‐: Never implemented

‐‐‐‐: Fully implemented

___: Not yet implemented

N=3,940

48

Outcomes: Significant Difference in Length of Stay

Implementation : Pilot Control

n=643,832

Clinical Pharmacy Metrics

Monitor pharmacist impact on patient careQ t l i f th b f d t d– Quarterly review of the number of documented pharmacist interventions

• High Impact: pilot results 15‐20/100 CMAA

• Total Intervention Count: 30‐35/100 CMAA

– Cost avoidance per acuity adjusted admit• Pilot group: $75 ‐ $133 per CMAAg p p

– Annual review of patient outcomes• 30 day readmission rate for AMI/CHF patients on warfarin: pilot results 15%

49

Lessons Learned

ROI can be developed in support of clinical h ti d lpharmacy practice model

Measurements of clinical and financial impact must be utilized to ensure ongoing support for staffing

Must move from “would like to do” beyondMust move from would like to do beyond “should do” and get to “need to do” status, e.g. regulatory requirement


Breakout Small Group Discussions # 2

‐ Approx. 20 minutes

‐ Share examples of dashboards

‐ Identify common key elements

‐ Lessons learned

‐ Prepare summary to present

50

Sixteenth Annual ASHP Conference

for Leaders in Health-System Pharmacy REFERENCES

2008 ASHP Pharmacy Staffing Survey Results.

A Perez, F Doloresco, JM Ho0ffman et al. Economic Evaluations of Clinical Pharmacy Services: 2001-2005 Pharmacotherapy 2008;28(11):285e–323e.

CA Bond, CL Raehl,. Clinical Pharmacy Services, Pharmacy Staffing, and Hospital Mortality Rates. Pharmacotherapy Vol. 27, No 4, 2007.

CA Pedersen, PJ Schneider, DJ Scheckelhoff. ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing – 2010 Am J Health-Syst Pharm. 2011;68.

MA Chisholm-Burns, JS Graff Zivin, JK Lee et. al. Economic effects of pharmacists on health outcomes in the United States: A systematic review. Am J Health-Syst Pharm. 2010;67:1624-34.

SG Pickette, L Muncey, D Wham Implementation of a standard pharmacy clinical practice model in a multihospital system Am J Health-Syst Pharm. 2010;67:751-6.

SS Rough, M McDaniel, JR Rinehart Effective use of workload and productivity monitoring tools in health-system pharmacy, part 1 Am J Health-Syst Pharm. 2010;67:300-11.

Woods, Mark T; Practice Model Challenge. Am J Health-Syst Pharm. 2009;66.

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