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Olavo Fernandes BScPhm, ACPR, PharmD , FCSHP

Final Canadian National Delphi Consensus Results - What Are The Appropriate National Clinical Pharmacy Key Performance Indicators (cpKPI) For Canadian Hospital Pharmacists?. Olavo Fernandes BScPhm, ACPR, PharmD , FCSHP Director of Pharmacy- Clinical, University Health Network, Toronto ON

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Olavo Fernandes BScPhm, ACPR, PharmD , FCSHP

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  1. Final Canadian National Delphi Consensus Results - What Are The Appropriate National Clinical Pharmacy Key Performance Indicators (cpKPI) For Canadian Hospital Pharmacists? Olavo Fernandes BScPhm, ACPR, PharmD, FCSHP Director of Pharmacy- Clinical, University Health Network, Toronto ON Assistant Professor (Status)- Leslie Dan Faculty of Pharmacy Sean K. Gorman, BSc(Pharm), ACPR, PharmD Regional Coordinator - Clinical Quality and Research, Pharmacotherapeutic Specialist – Critical Care Interior Health Authority, Clinical Associate Professor – Faculty of Pharmaceutical Sciences, UBC Kent Toombs BSc(Pharm), ACPR Clinical Pharmacy Manager, Capital District Health Authority, Halifax, NS Canadian Hospital Pharmacy Leadership Conference , June 8, 2013

  2. Objectives • To outline the key elements of the national consensus process in developing clinical pharmacy key performance indicators (cpKPI) for hospital pharmacists • including consensus definition, selection criteria for cpKPI,  critical topic/ activity foci and pre-Delphi candidate cpKPI) • To report the final results of the recent national Delphi consensus phase to establish a final suite of cpKPI • To summarize the next phases and communication plans in the national cpKPI process : • exploring interprofessional/ external stakeholder feedback, • national information capture/ measurement systems, • cpKPI knowledge translation kit • practical definition and measurement questions • pan-Canadian communication/ Manuscript publications / posters

  3. Overall Goal of the National cpKPI Collaborative / National Consensus Process To develop a core set of national clinical pharmacy KPI for hospital pharmacists via a systematic national evidence-informed consensus process 3

  4. Key Performance Indicators (KPI) • What is it? • “Quantifiable measures that reflect the critical success factors of an organization” 1 • Quantitative measures of quality • Why is it important? • Elevate professional accountability & transparency • Serve to improve quality of care 1. Doucette D, Millen B. Should Key Performance Indicators for Clinical Pharmacy Services Be Mandatory, Can J Hosp Pharm2011; 64(1):55-57. 4

  5. Rationale for clinical pharmacy KPI (cpKPI) • GAP: currently NO established national or international consensus on what constitutes a KPI for clinical pharmacy services • Rationale: To advance practice toward desired evidence-informed patient outcomes • cpKPI will serve to better define minimum standards and permit benchmark comparisons within and between organizations

  6. National cpKPI CollaborativeDefinition of cpKPI Five pillars/ characteristics of cpKPI: Reflect a desired quality practice and A metric with a link to direct patient care and Link to evidence of impact on meaningful patient outcomes and A pharmacy/ pharmacist sensitive metric Feasible to measure Clinical metric would have to fulfill all 5 pillars to qualify as a candidate cpKPI

  7. Hierarchy of Study Outcomes (AHRQ) • Level 1: Clinical and QoL outcomes • Morbidity, mortality, adverse events • Level 2 : Surrogate outcomes • I.e. blood glucose, blood pressure, cholesterol • Level 3: Measureable variables with an indirect or unestablished connection to target outcome • I.e. medication disease state knowledge • Level 4: Indirect variables • I.e. patient satisfaction, “potential adverse events”

  8. Should Align with Local Consensus or Guidelines for Prioritization of Hospital Pharmacist Activities 6 Domains • Pharmaceutical care patient care process • Operational patient care supporting activities • Drug information • Teaching/Education/Learning • Research • Service (clinical and pharmacy committees) *Extracted from UHN Pharmacist Pyramid-Prioritization of Pharmacist Activities Draft

  9. Front-line Staff/Leaders CSHP 2015/ CPhA Blueprint Literature: 1.Evidence 2.Process Optimal National cpKPI Peer Hospital Best Practices Pharmacy Leadership Information Gathering - Prior to Consensus Building

  10. Proposed Timeline CSHP endorsed concept Pre-Delphi Delphi Post-Delphi KPIWG formed Delphi Process Information Gathering May 2011 Dec’12-Mar’13 We are here Aug 2011 Feb 2013 Survey Development Consensus Meeting

  11. Key National Process Milestones • National consensus definition – cpKPI (Aug 2011) • National Crude Inventory of candidate cpKPI / metrics (started Jan 2012) • National Information-gathering Process: Workshops/ Information sessions-Front line feedback (Feb 2012- Nov 2012) • Outcome and Process Debates/ Finalized Evidence summary tables (June-July 2012) • A priori consensus cpKPI selection criteria (ideal attributes)– “Slavik 11” (Finalized July 2012) • Key cpKPI Critical Activity / Topic Areas – “Doucette 8” (Finalized August 2012) • Final Pre-Delphi Candidate cpKPI list (October 2012) • Selection of National Delphi Panel members (November 2012) • Delphi Panel Process – Round 1-3 (Dec 21, 2013- Mar 8 2013) • cpKPI Live Meeting (February 5, 2013)

  12. Slavik -11- Consensus Criteria – Ideal Attributes Based on high quality literature evidence (e.g. Observational data vs. RCT vs. systematic review) Relevant impact on clinically important outcomes (e.g. Surrogate versus clinical endpoints, effect size of intervention) Best-suited to pharmacist’s role (e.g. Identifies pharmacist-specific clinical role vs. GP vs. RN) Attributable to direct patient care (e.g. Marker of clinical intervention, not distribution) Specific to pharmaceutical care process (e.g. Related to generally-accepted PC processes) Aligned with professional goals, objectives, practices (e.g. Accreditation Canada ROPs, standards, CSHP Vision 2015, etc.)

  13. Slavik -11- Consensus Criteria – Ideal Attributes Accepted disease-based quality indicator (e.g. ACEI or BB for HF, VTE prophylaxis in hospitalized patients) Feasible to measure (e.g. Reliable measurement systems can/could be put in place) Efficient to measure (E.g. Acceptable time commitment, useable) Valuable quality measure (E.g. Prevalent, impactful problem with practical, proven interventions) Generalizability (E.g. Versatile enough to be applied in large, academic and small community sites)

  14. Delphi panelist priority ranking of consensus cpKPI selection criteria- Final – Mar 2013

  15. Bond et. al. (2007) Observational Study Clinical Pharmacy & Mortality admission drug histories medical rounds participation CPR team participation Kaboli PJ et al. (2006) Systematic Review attendance on patient care rounds patient interviews and assessments medication reconciliation discharge “counselling” (patient medication education) follow-up after discharge RCT Outcome Findings Gillespie U et al. 2009- RCT Integrated Intervention pharmaceutical care Integrated Intervention post-discharge hospital visits (ED + readmissions) emergency department visits drug related readmissions Makowsky MJ et al. 2009- RCT 1. “overall quality score” 2. 3 and 6 month all-cause readmission (hospital or ED visit after index hospital admission) Chisholm-Burns MA et al 2010, systematic review w/ focussed meta-analyses HbA1c , LDL Cholesterol, Blood Pressure Adverse Drug Events Bringing the evidence all together with extrapolation………

  16. Evidence Summary Tables Discussion: specific group suggestions to modify or concur with the follow sections • Strengths and Limitations • Application/Synthesis: How does this study inform the cpKPI selection process  (methods, cpKPI selection criteria, and candidate cpKPI)? • What are the patterns (similarities and differences) compared to other key papers? • Purpose: August- used to refresh and focus outcome evidence for streamlining ; Nov-  Used by Delphi panelists to support ranking and decision making

  17. Levels of Evidence • Observational Studies • Systematic Reviews • Randomized Controlled Trials

  18. PRACTICE QUESTION • Does pharmacist-led comprehensive pharmaceutical care reduce morbidity (& other meaningful patient outcomes) for elderly hospitalized patients?

  19. A Comprehensive Pharmacist Intervention to Reduce Morbidity in Patients 80 years or Older Gillespie U et al. Arch Intern Med 2009; 169(9):894-900. • Objectives: • assess the effectiveness of interventions performed by ward-based pharmacists on morbidity and overall use of (secondary) hospital care • Design: • prospective, single centre, unblinded, randomized control trial • patient- unit of randomization, central centre • Setting: 2 acute internal medicine wards (university teaching hospital) in Uppsala, Sweden • Duration: Oct 2005-June 2006 • Patients: • Patients 80 years or older admitted to 2 acute care internal medicine wards • Written informed consent • Sample size calculation : 400 patients

  20. A Comprehensive Pharmacist Intervention to Reduce Morbidity in Patients 80 years or Older Gillespie U et al. Arch Intern Med 2009; 169(9):894-900. • Patients randomized to: • intervention (comprehensive care by hospital pharmacist) • Ward based clinical pharmacists • comprehensive patient interview, BPMH, admission medication reconciliation, • pharmaceutical care drug review (Cipolle method) to identify and resolve DTPs, physician interventions on drug selection, dosages, monitoring…. • Addressed: indication, effectiveness, safety and adherence • DTPs discussed on ward rounds • Patients received education and discharge counselling/ reconciliation • pharmacist discharge letter communicated to primary care physicians by pharmacists • Follow up telephone call 2 months after discharge • control: standard care without pharmacist involvement by physicians and nurses

  21. Results: Major Outcomes Gillespie U et al. Arch Intern Med 2009; 169(9):894-900. • Patients Evaluated (n=368, 182 intervention / 186 control) over a 12 month period Post-Discharge Hospital Visits (ED + readmission) • ↓ 16% intervention group • (quotient 1.88 vs. 2.24, 95% CI 0.72-0.99) Emergency Department Visits: • ↓ 47% intervention group • (quotient 0.35 vs. 0.66, 95% CI 0.37-0.75) Drug Related Readmissions: • ↓ 80% intervention group • (quotient 0.06 vs. 0.32, 95% CI 0.10-0.41) Aside: Balancing Measures- Readmissions Alone and Mortality : - No significant difference

  22. Bond et. al. (2007) Observational Study Clinical Pharmacy & Mortality admission drug histories medical rounds participation CPR team participation Kaboli PJ et al. (2006) Systematic Review attendance on patient care rounds patient interviews and assessments medication reconciliation discharge “counselling” (patient medication education) follow-up after discharge RCT Outcome Findings Gillespie U et al. 2009- RCT Integrated Intervention pharmaceutical care Integrated Intervention post-discharge hospital visits (ED + readmissions) emergency department visits drug related readmissions Makowsky MJ et al. 2009- RCT 1. “overall quality score” 2. 3 and 6 month all-cause readmission (hospital or ED visit after index hospital admission) Chisholm-Burns MA et al 2010, systematic review w/ focussed meta-analyses HbA1c , LDL Cholesterol, Blood Pressure Adverse Drug Events Bringing the evidence all together with extrapolation………

  23. Doucette 8- Consensus Critical Activity / Topic Areas • Pharmaceutical Care – Integrated (DTP assessment/ care plan/ monitoring) • Medication Reconciliation- BPMH/Med History Taking • Medication Reconciliation- Admission Reconciliation • Medication Reconciliation- Discharge Reconciliation • Team (or Patient) Rounds • Discharge Patient Education / Counselling • Post Discharge Follow-Up • Disease or Drug Specific – Best Practice Quality Indicators

  24. Doucette 8- Consensus Critical Activity / Topic Areas • Dot voting: 20 dots per person • Assign proportionately Question: • Will measuring a cpKPI in this “critical activity topic area” be useful to advance clinical pharmacy practice to improve the quality of patient care? • Semchuk-26 Draft Candidate KPI list

  25. DEMOGRAPHICS OF cpKPI DELPHI PANEL

  26. What is your practice setting (check all that apply)? 69% (18) Other= Administration, Pharmacy Association, Oversee multiple sites, Regional Health Authority, Long Term Care and Rehabilitation Centre, District health authority with tertiary and community practice. 35% (9) 27% (7) 27% (7) 23% (6) 12% (3) Communityhospital Teaching hospital Other Clinic Tertiary care hospital Academia

  27. Do you work primarily with pediatrics or adults? Adults 88% (23) 12% (3) Pediatrics

  28. How many years of experience do you have as a licensed Pharmacist? 65% (17) 19% (5) 8% (2) 8% (2) 0% (0) 0-5 years 6-10 years 11-15 years 16-20 years 20+ years

  29. What is your educational background? Other: MBA, BSc (Pharmacology), EXTRA Fellowship (CFHI) Certified Health Executive (CHE), MBA, Post PharmD Residency, Certified Geriatric Pharmacist 100% (26) 54% (14) 54% (14) 23% (6) 19% (5) Residency (ACPR) Masters Degree PharmD Other BScPhm

  30. DOUCETTE 8 – 20 Dot Voting RESULTS

  31. Doucette 8- Consensus Critical Activity / Topic Areas • Pharmaceutical Care – Integrated (DTP assessment/ care plan/ monitoring) • Medication Reconciliation- BPMH/Med History Taking • Medication Reconciliation- Admission Reconciliation • Medication Reconciliation- Discharge Reconciliation • Interprofessional (team) patient care rounds • Discharge Patient Education / Counselling • Post Discharge Follow-Up • Disease or Drug Specific – Best Practice Quality Indicators • Used to create “Semchuk 26” candidate cpKPI list

  32. Grape Analogy: BUNDLES AND CRITICAL ELEMENTS

  33. Modified Delphi Process Methodology • A Delphi technique is a structured process commonly used to develop consensus healthcare quality indicators • It was developed to minimize influence from more vocal group members, and utilizes surveys or questionnaires instead of discussion. • frequently used with expert panels to generate consensus on healthcare issues • To arrive at consensus, a modified Delphi technique will be used. • This ‘modified” technique is an iterative process that builds consensus using three rounds of anonymous panelist ratings with a live/tcon meeting

  34. Delphi Rounds • Standardized Orientation • Audio PowerPoint + Mandatory Pre-Reading • Round 1 • Demographic Information; Panelist ranks Semchuk 26 cpKPI, For each Slavik 11 and Overall Ranking, Suggest new cpKPI • Round 2 • Review R1 aggregate summary/ report card for each cpKPI • Frequency Graphs Summary • Review anonymous qualitative comments • Panelist re-ranks all cpKPI • Live Meeting – Debate and Discussion to inform individual rankings • identify meet other panelists for the first time • Round 3 • Review Feb 5 Live Minutes , R2 summaries (as above), Final Rankings

  35. Delphi Rounds • Individual cpKPI ratings • Opportunity to suggest additional candidate cpKPI (round 1 only to allow panel feedback) • Ranking of priority of “Doucette 8” Critical Activities and “Slavik 11” Selection Criteria • Combining cpKPI, Creating New cpKPI by modifying working (ie cpKPI 27, 28, 30) • Threshold for consensus consideration: • 75% of panelists assign a rating of 7-9 on the 9 point Likertscale • MAGIC NUMBER = 20

  36. Round 1 Qualitative Panelist Discussion Themes • Qualitative discussion themes while comparing cpKPI included: • Varying degrees of sensitivity to pharmacists’ contribution • Varying degrees of feasibility of measurement • Varying degrees of generalizability across practice areas (i.e.. psychiatry, surgery) as well as across different types of hospitals (i.e. urban versus rural) • Inter-relationships between: medication reconciliation cpKPIs; discharge/ inpatient counsellingcpKPIs

  37. Round 1 – 3 New cpKPI Submitted by Panelists • cpKPI #27: combined pharmacist admission Med Rec + BPMH Number (or proportion) of patients who receive formal documented admission medication reconciliation by a pharmacist (includes a pharmacist-BPMH OR pharmacist-BPMH-review as part of reconciliation as well as resolution of identified discrepancies). • cpKPI #28: Proactive bundle; Number (or proportion) of patients receiving “proactive comprehensive, direct patient care by a pharmacist in collaboration with the health care team” (Makowsky Collaborate RCT Bundle). • cpKPI #29: Time on Ward Committed decentralized clinical pharmacist time per patient day per patient service.

  38. Live Feb 5: Meeting Issues and Controversies How to optimally handle process of care vs. disease/drug-specific indicators? High Value Action “DTP resolved” as a subset Grape Theory: Bundles and Critical Elements Number vs. proportion A priori Suite properties “High Risk vs. All Patients”

  39. Final Delphi Results Round 3 Final Rankings 8 cpKPI have officially met consensus 6/8 Doucette Categories represented with combos

  40. How do the final national clinical pharmacy key performance indicators align with national consensus selection criteria?

  41. National cpKPI CollaborativeNext Steps 7 Post-Delphi Phases cpKPI knowledge translation kit- practical getting started kit Final 8 cpKPI-specific measurement summaries, background, 7 step change management framework Final 8 : Practical Outstanding Questions Wording, outstanding questions, practical definitions, practical measurement issues Exploring external stakeholder feedback Interprofessional : physicians, nurses, Ministry of Health, pharmacists- US, UK, NZ, Aus, patients, hospital administrators National information capture systems / measurement systems (“apps”) Pan-Canadian Communication of Final Delphi Results 2 Manuscript Publications/ 7 Conference Abstracts Formal “Pilot” Sites

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