HRSAs Patient Safety and Clinical Pharmacy Services Collaborative The 12th Annual 340B Coalition Con

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HRSAs Patient Safety and Clinical Pharmacy
Services CollaborativeThe 12th Annual 340B
Coalition ConferenceJuly 15, 2008

• Denise H. Geolot, Ph.D., R.N.
• Director, Center for Quality
• Department of Health and Human Services
  (HHS)
• Health Resources and Services Administration
  (HRSA)
• Collaborative Co-Director
• Jimmy Mitchell, R.Ph., MPH, MS
• Director, Office of Pharmacy Affairs
• HHS, HRSA
• Collaborative Co-Director

Rebecca Hines, MHS, HHC Director, Prevention and
Special Initiatives Office of Planning and
Evaluation HHS, HRSA Improvement
Co-Advisor Krista M. Scardina, Pharm.D. Program
Management Officer Office of Pharmacy
Affairs HHS, HRSA Improvement Co-Advisor
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What is the Collaborative?

• Improve health outcomes, increase clinical
  pharmacy services, and improve patient safety
• Rapid improvement method
• Leading practices come from the field

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The Challenge

• Increase in multiple chronic conditions
• Aging population - polypharmacy
• ADEs leading cause of death and injury IOM
  Report
• Lack of integration of clinical pharmacy services

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Institute of Medicine Findings on Patient Safety
and Errors

• Medication Errors are Most Common
• Injure 1.5 Million People Annually
• Cost Billions Annually
• for every dollar spent on ambulatory
  medications, another dollar is spent to treat new
  health problems caused by the medication.

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Why a Patient Safety Clinical Pharmacy
Collaborative?

• The Senate Appropriations Committee further
  encourages HRSA to establish a pharmacy
  collaborative to identify and implement best
  practices, which may improve patient care by
  establishing the pharmacist as an integral part
  of a patient-centered, interprofessional health
  care team.
• 2007 2008 Senate Appropriations Committee
  Reports Encourage Pharmacy Collaborative.

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HRSAs Commitment

• Support programs to provide the best and safest
  care in the Nation
• Take previously supported Collaboratives with
  documented improvements to the next level

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HRSA Pharmacy Programs

• Pharmacy services are growing rapidly

1999
8,000 entities
2008
13,000 entities
5 Billion
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PSPC Goals

• Improve Health Outcomes
• Improve Patient Safety
• Increase High Quality, Cost-Effective Pharmacy
  Services

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Patient Safety Pharmacy Collaborative
Patient Safety
Clinical Pharmacy Services
QUALITY
Health Outcomes
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Patient Safety Pharmacy Collaborative
Patient
Optimum Health Outcomes
Integrated Patient Care
Clinical Pharmacy Services
No Adverse Events
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Evolving into the Future

• Were ready to go beyond improvements one disease
  at a time!
• Evidence that system improvements in pharmacy
  will improve overall outcomes for patients
• Target high risk patients across a broad range of
  chronic conditions

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Milestones Weve Come a Long Way FastSpring
2007 Summer 2008

• Study Phase
• Identified High Performers
• Conducted 34 site visits
• Compiled Leading Practices
• Convened Expert Panel
• Engaged Partners
• Leadership Coordinating Council
• Sponsored State Leadership Meeting
• Implementation Phase
• Enrolled Teams
• Faculty Selected

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Support for Collaborative

• HRSA Leadership, Bureaus and Offices
• National Faculty and HRSA Team
• Leadership Coordinating Council of National
  Partner Organizations
• State-Based Organizations

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Who are some of Our National Partners?

• Apexus/Prime Vendor Program NASTAD
• and many others

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Study Phase

• What are the leading practices?
• Where do they come from?

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Site Selection Criteria

• Primary criteria
• Clinical outcomes data - EVIDENCE
• Data demonstrating effectiveness of their patient
  safety and pharmacy services
• Innovative patient safety and pharmacy services
  models
• Implemented in outpatient primary care settings
• Secondary criteria
• Regions which had clusters of 34 organizations
  that met the above criteria
• Regional representation

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Site Visits

• 34 Sites included in the sample
• Site visits with 30 high-performing organizations
  in 7 regions of the country
• Telephone visit with 4 organizations in
  additional regions

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Example High-Performer Outcomes
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Organization Types
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Characteristics of Participating Organizations
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Site Observations
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High Performer

• Joshua Feldmann, RPh, PharmD
• Mercy Family Pharmacy

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• How did we capture the leading practices
• from the sites?

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Key Framing Questions for the Study Phase

• What are the successful practices that high
  performing providers are using?
• What do they look like in practice?
• Who can articulate and project these practices
  with clarity and power?

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The Change Package

• Menu of Promising Action Items for Testing and
  Adapting for Use by Teams in Their Home Settings

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Whats In a Change Package?

• Strategies
• Plans for Achieving an End System-Wide
  Improvement
• Change Concepts
• Approaches Found to Be Useful in Developing
  Specific Ideas for Changes That Lead to an
  Improvement
• Action Steps
• Specific Ideas to Implement Each Change Concept

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What Forms the Basis for the Change Package?

• Existing Research Literature
• Leading Practices of High Performers
• Expert Panel
• Experiences of Collaborative Teams

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Data Analysis

• Qualitative data analysis software
• Themes and strategies coded using inductive
  analysis techniques
• Change Package content updated iteratively
• Nine versions of the Change Package presented by
  the study team
• Each version increased in specificity and clarity

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Strategies What Weve Learned

• Leadership Commitment
• Develop organizational relationships that
  promote safe medication-use systems and optimal
  health outcomes
• Measurable Improvement
• Achieve change using the value and power of
  data- driven improvements
• Integrated Care Delivery
• Build an integrated health care system across
  providers and settings that produces safety and
  optimal health outcomes
• Safe Medication Use Systems
• Develop and operate by safe medication-use
  practices
• Patient-Centered Care
• Build a patient-centered medication-use system

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Strategy
Safe Medication Use Systems
Change Concept
Systematically introduce and institutionalize
safe medication-use practices and monitoring
procedures
Action Items

• Require double-checking when pharmacist is
  unavailable, e.g., develop and utilize policies
  requiring two nurses to verify the right drug
  when nurses access medication storage.
• Do not use medication abbreviations or verbal
  orders.
• Facilitate patient access to prescriptions by
  using strategies that ensure RX pick-up, e.g,
  home delivery, mail service, dispensing window,
  partnership with community pharmacy.

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The Work of the Collaborative

• Create Expectation That Each Team Begins by
  Addressing a Change Concept Under Each Strategy
• Use the Improvement Model (Plan/Do/Study/Act) to
  test specific actions in their environment

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Implementation Phase

• Q How do we spread these leading practices?
• A TEAMS
• with support from FACULTY

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Who Are the Faculty?

• Majority are from leading practice sites from
  study phase
• Mix of leaders, physicians, pharmacists, nurses,
  and others
• Innovators and early adapters
• Voice of the Change Package
• Peer leaders to inspire change by showing the way

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Who Are the Teams?

• Teams of providers
• Multiple organizations within communities
• Defined patient population

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Team Participants

• 91 teams
• Over 300 organizations
• Teams average 3 organizations
• Over 500 participants will participate in the
  Learning Sessions

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Team Participants

• 42 states represented (including HI and PR)
• 7 teams from Massachusetts
• 5 each
• Ohio
• New Jersey
• Louisiana
• All geographic areas represented

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Participating Teams
Hawaii
Puerto Rico
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Team Examples Target Populations
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Team Configuration Examples

• CHC Disproportionate Share Hospital Rural
  Health Clinic Community Pharmacy
• HIV Clinic Critical Access Hospital Womens
  Health Clinic
• Multiple CHCs Disproportionate Share Hospital
  and their associated clinics
• Rural Health Clinic Hospital School/College
  of Pharmacy

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Opportunity or Risk?
Hospital Inpatient
Patient Multiple Conditions
Hospital ED
Primary Care Home(s)
Specialist
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Hospital In Patient
Patient Multiple Conditions
Hospital ED
Primary Care Home(s)
Pharmacy Services
Specialist
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RISK
Hospital In Patient
Patient Multiple Conditions
Hospital ED
Conditions For A Disaster
Primary Care Home(s)
Pharmacy Services
Specialist
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OPPORTUNITY
Patient
Hospital In Patient
Multiple Conditions
Hospital ED
Patient Self- Management
Primary Care Home(s)
Pharmacy Services
ClinicalPharmacy Services
Specialist
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Teams Include

• Clinical pharmacists
• Nurses
• Physicians
• Other primary care clinicians
• QI staff
• Administrators
• Senior Leaders
• More!!

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What Will Teams Do?

• Commit to Collaborative aims
• Commit time and effort
• Designate consistent members to attend all 4
  Learning Sessions and support travel
• Measure and track progress
• Share activities and results
• Align with team around continuity of care
• Bring their organizations senior leader(s) to a
  designated Learning Session

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Team Example

• Tracey Cole, RPh
• Pharmacy Director
• Holyoke Health Center

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How Does the PSPC Create Improvements?

• 16 month rapid learning model
• Focused on improving health outcomes
• Led by an expert faculty and national leaders
• Creates community of learning
• Learning Sessions and Action Periods are venues
  for change
• Improvements are tracked and shared for mutual
  benefit

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Learning Collaborative Process
Enroll Participants
Select Topic
Prework
Identify Change Concepts
P
P
P
D
A
A
D
A
D
S
S
S
Planning Group
LS 1
LS 2
AP1
AP2
AP3
LS 3
LS 4
LS 4
Supports Listserv Site Visits
Filming Conference Calls Rapid
Sharing Team Reporting Web
site Leadership Coordinating Council
PDSAPlan, Do, Study, Act LS Learning
Session APAction Period
Adapted from IHI Breakthrough Series
Collaboratives IHI.org
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PDSA Rapid Improvement Technique
Rapid Testing!!
Plan
Do
Act
Study
By Tuesday we will
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Repeated Use of the PDSA Cycle
Changes That Result in Improvement
Where we want to end up
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Repeated Use of the PDSA Cycle
Changes That Result in Improvement
Where we want to end up
Hunches Theories Ideas
Where we start
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Repeated Use of the PDSA Cycle
Changes That Result in Improvement
DATA
We build a bridge with data and action.
Hunches Theories Ideas
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Repeated Use of the PDSA Cycle
Changes That Result in Improvement
DATA
Implementation of Change
Wide-Scale Tests of Change
Follow-up Tests
Hunches Theories Ideas
Very Small Scale Test
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Repeated Use of the PDSA Cycle
Changes That Result in Improvement
Rapid Testing!!
DATA
Implementation of Change
Wide-Scale Tests of Change
Follow-up Tests
Hunches Theories Ideas
By Tuesday we will
Very Small Scale Test
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Key Benefits of Team Participation in the PSPC

• Its the Right Thing to Do for the Patients We
  Serve
• Safer
• More and improved Clinical Pharmacy Services
• Improved Health Outcomes
• Reduces and Manages Risk
• Builds on and Takes Prior Experience to a New
  Level
• Works across organizations in a community
• Goes beyond improvements in one disease state

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Key Benefits of Team Participation in the PSPC

• Gain expertise in creating linkages and
  partnerships across organizations using
  patient-centered approach
• Exposure to Cutting Edge People and Methods on
  Quality Improvement, Leadership Change
  Management
• Chance to Be A Part of a Major National Movement
  in a Rewarding All Teach, All Learn Environment
• Access to expert faculty and technical assistance
  to develop and test high leverage changes

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The Work of the Collaborative

• Teams are Major Locus of Change
• Change Package is Recipe Book for Change
• Strategies Change Concepts Action Items
• Plan Do Study Act cycles for creating
  change
• Introduced and Led by a Faculty of Their Peers
• Drawn from the field
• Articulate leading practices that get results

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What to Remember..

• Improve health outcomes, increase clinical
  pharmacy services, and improve patient safety
• Rapid Improvement Approach
• Leading practices from field

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Timeline

• July 2008 Faculty Meeting
• August 2008 Learning Session 1
• Fall 2008 Action Period 1
• December 2008 Learning Session 2
• Winter 2008-09 Action Period 2
• Spring 2009 Learning Session 3
• Summer 2009 Action Period 3
• Fall 2009 Learning Session 4
• Improved Patient Outcomes!

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PSPC Information

• HRSA Website
• www.hrsa.gov/patientsafety
• Questions?
• patientsafety_at_hrsa.gov
• HRSA Knowledge Management System
• www.healthdisparities.net