Measuring Your Department’s Progress in the Advancement of Pharmacy Practice and Patient Safety CSHP Professional Practice Conference - Jan 2006 Patricia.

Measuring Your Department’s Progress in the Advancement of Pharmacy Practice and Patient

SafetyCSHP Professional Practice Conference - Jan 2006

Patricia Macgregor, Nancy RobertsEditorial Board members

Outline

Overview of the sections of the 2003/04 Hospital Pharmacy in Canada Report (HPCR)

– Using ave. results for all hospital types Specialty Focus of the 2003/04 Report HPCR 2003/04 Indicators and trends Conducting a Self-Operational Review

– Using specific results by hospital size & type Aligning Your Organizations Priorities Testimonials

Hospital Pharmacy in Canada Report (HPCR)

Measuring hospital pharmacy progress Data collection every two years Also known as “Lilly” report

www.lillyhospitalsurvey.ca

Demographics Clinical Pharmacy Services Drug Information and Drug Use Evaluation Drug Distribution Drug Purchasing and Inventory Control Human Resources Medication Safety

HPCR Sections

HPCR Sections continued

Technology Education and Research Pharmacy Staffing and Drug Costs for

Clinical Programs

- Acute Care Hospitals

- Pediatric Hospitals Benchmarking

2003/04 HPCR Report Focus

Medication safety and role of pharmacy leaders Clinical practice, direct patient care, pharmacist

prescribing Incident reporting and reduction strategies Distribution delivery systems Escalating drug costs - utilization issues Human resources – impacts of shortages Technology applications

Demographics

144 hospitals responded Nationally– Inclusion criteria – 100 beds total, 50 acute beds

77% response rate overall 59% of respondents were multi-site facilities,

similar to previous survey

(higher in BC, Prairies and Atlantic)

Clinical Data Captured

Staffing allocations per specialty program Clinical pharmacy activity by type with

occurrence rate Specific clinical activity priority and service

level Methods and types of practice evaluation Prescribing privileges by profession Pharmacist prescribing authority by activity Clinical practice models and seamless care

Clinical Practice Trends

Decentralizing pharmacists may decrease medication errors by 45%.*

Centralized pharmacist -errors/bed 3.15

Centralized with occasional unit visits -errors/bed 1.93 Decentralized pharmacist -errors/bed 1.74

% clinical time unchanged, at 38%, from previous surveys

*(Bond et al. Pharmacotherapy 2002 22 (2):134-47)

Clinical Practice Trends

Beds serviced by pharmaceutical care % 30%

Clinical pharmacist FTEs for outpatients 2.73

Clinical pharmacist FTEs for inpatients 8.3

Pharmacist time in direct patient care % 38%

Pharmacist time in drug distribution % 48%

Pharmacist FTEs dedicated to Drug Info 1.3

Pharmacist FTEs dedicated to DUE 0.7

Number of undergraduate student days 228

Pharmacist Time spend in research % 1%

Figure F-2. Proportion of Time Spent by Pharmacists in Each Category 2003/04

Base: All respondents (144)

Drug Distribution48%

Clinical 38%

Other Non-patient Care8%

Teaching 5%

Research 1%

Outpatient Pharmacist FTE Ratios

Average 0.14 FTE pharmacist/10,000 visits DVT/anticoagulation 2.02 FTE/10,000 visit Infectious disease 2.00 FTE Cardiovascular/lipid 1.67 FTE Diabetes 1.16 FTE Hematology/oncology 1.06 FTE Emerg 0.02 FTE

Inpatient Pharmacist FTE Ratios

Average 0.53 FTE pharmacist/10,000 pt days Adult intensive care 1.53 FTE/10,000day Adult medicine 0.65 FTE Adult rehabilitation 0.55 FTE Adult surgical 0.51 FTE Adult mental health 0.47 FTE Geriatrics 0.36 FTE Pediatric medical 1.27 FTE

Clinical Activities Documentation

# interventions per admission – 0.64– Increase from 0.6 in 2001/02 and 0.53 in 1999/00

Annual interventions per pharm FTE – 645 Still 20% respondents who do document

do not do it in the patient chart Pharmacokinetic documentations on the

increase

Priority Ranking vs Actual Activity

Bond et al – 6 clinical services associated with lower total cost of care

– DUE, drug information, ADE monitoring, Drug protocol management, medical rounds participation,

admission drug histories Yet none was reported by more than 70% of

respondents as being among the top 10 priorities

Participants rated clinical services by priority and by extent offered – striking discrepancy

Clinical Practice Models and Evaluation

81% reported clinical practice services NOT offered to some inpatients– Equals 33% of inpatient beds

Pharmaceutical care – 70% reported using - average 30 beds serviced

Only 17% evaluate clinical practice

Prescribing Privileges

Pharmacists 66% Midwives 45% Nurse practitioners 47% Other professionals 20%

Pharmacists Prescribing

Lab tests – 21% Independent dosage adjustments – 23% New therapy – 5% Dependent, dosage adjustment – 46% Dependent, new therapy -13%

Seamless Care-Discharge Information Provided

Medications at discharge 95% Medications discontinued 68% Care Plan 56% Monitoring Values 59% Diagnosis 46%

Drug Information and DUE

DUE– 0.8 FTE pharmacist– 0.5FTE support staff

Drug Information

- 1.3 FTE pharmacists

- 0.4 FTE support staff

Drug Distribution and Delivery

Systems used Order entry Order verification MARs, medication profiles etc Technician check technician IV admixture Oncology Ambulatory services

Distribution Delivery Systems

Traditional delivery some beds 63% Total wardstock 21% Unit dose, >90% beds 31%

Figure D-2. Proportion of Beds Serviced by Drug Distribution System 2003/04

Base: All respondents (144)

Unit Dose51%

Unit Based Automated8%

Traditional32%

Carded Dose6%

Total Wardstock3%

Order Entry

Pharmacists 79% Technicians 78% Nurses 5% Physicians 3%

Pharmacist verify pharmacist OE -41%*Significant increase from 01/02 report - 27%

Medication Administration Records (MARs)

Electronic, on-line documentation 10% Manual 44% Computer generated 56% Allergy status on MAR 56% Cards, tickets (Ontario 4%) 25%

Figure D-4. Technician Activities Checked by other Technicians 2003/04

Base: Respondents reporting that function is performed

82%

82%

77%

70%

66%

59%

58%

51%

41%

32%

30%

17%

13%

Unit Dose Tray Filling Unit Dose Packaging 

Replenishing Automated Cabinets 

Cardiac Arrest Tray Filling 

Traditional Prescriptions (Refills) 

IV Admixture Preparation (Batching) 

Interim Dose Filling 

Extemporaneous Compounding 

IV Admixture Preparation (Patient Specific) 

Traditional Prescriptions (New Orders)

TPN Preparation

Medication Order Entry 

Chemotherapy Preparation 

Activities

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

% of Respondents

Figure D-5. Certification Required 2003/04

Base: Respondents using technician check technician

86%

83%

82%

81%

77%

76%

75%

72%

67%

54%

41%

39%

31%

IV Admixture Preparation (Patient Specific) 

IV Admixture Preparation (Batching) 

Chemotherapy Preparation 

Traditional Prescriptions (New Orders)

TPN Preparation

Interim Dose Filling 

Traditional Prescriptions (Refills) 

Unit Dose Tray Filling 

Medication Order Entry 

Unit Dose Packaging 

Extemporaneous Compounding 

Cardiac Arrest Tray Filling 

Replenishing Automated Cabinets 

Activities

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

% of Respondents

Drug Purchasing and Inventory Control

PMRB reported sales from drugs increased 14.5% in 2003

Since 2001/02 report:– Acute care inpatient drug cost/pt day only

increased 26 cents. (Ave $31.25) – Emerg costs/patient day increased 24%– Ave inventory increased by 10.6%

CIHI - Drugs = 16.2% of total healthcare costs

Figure E-1. Percentage of Drug Expenses by Patient Care Area 2003/04

Base: Respondents who provided relevant drug cost information (82)

Ambulatory (Retail Pharmacy) 3%

Ambulatory (Take Home)3%

Emergency Room8%

Clinic / Medical Day Unit25%

Inpatient Long-Term Care6%

Inpatient Acute Care55%

Human Resources

Paid hours per acute patient day, average unchanged at 0.74

Staffing Ratios– Pharmacist 40%– Technician 46%– Support staff 7%– Management 5%– Residents 2%

Human Resource Shortages

63% of respondents reported vacancies as follows:– Pharmacist vacancies 12.9% – Management 6.9% – Technicians 0.9% – Residency vacancies 13.8%

*Concern expressed re reduced student applications

Impact of Human Resource shortages on Patient Care

67% respondents reduced services overall 85% reduced direct patient care 56% reduced implementation of approved

service 52% reduced teaching 38% reduced hours 15% reduced distribution

Medication Incident Reporting and Reduction Strategies

100% use med incident reporting tool 67% implemented strategies to increase

reporting 63% disclosure policy 80% have committee to review med safety

DTC, risk, quality, MAC, Pharm/nursing 51% completed self assessment tool 95% of assessment tools used were ISMP

Medication Safety

Verbal and telephone orders limited 76% Med orders conditional until pharmacist review 52% List of non-acceptable abbreviations 40% High alert medication list identified 38% Conc. electrolytes removed from patient care areas 72% Conc. narcotics removed from patient care areas 47% Standardized heparin concs. 81%

Issues for Patient Safety

Medication safety is related to the extent of pharmacist involvement in direct patient care, yet why is:– Time spent in clinical activity unchanged since

1999 (38%)– Clinical services still NOT provided to some

inpatients (33% inpatient beds)– Specific safety initiatives only partially

implemented– ? Related to pharmacist shortage

Technology

Pharmacy systems with clinical

decision support 40% Automated max. dosage alerts 28% Fully interfaced lab results 25% CPOE 5% Handheld devices 49% Wireless network with handheld 8%

Figure H-1 Functions for which handheld devices are used

Base: Respondents reporting the use of handheld devices (71)

94%

68%

37%

23%

17%

3%

3%

1%

11%

Clinical database consultation

Mail, agenda and task management

Formulary information

Workload data collection

Drug utilization activities

Clinical data entry and upload

Clinical data download from pharmacy records

Clinical data download from health records

Other

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

% of respondents

Bar Code Technology

FDA - USA mandate bar codes at bedside – by May 2006

22% respondents use bar code technology– Up from 11% in 2002

Figure H-2 Uses of Bar Coding

34%

16%

16%

13%

3%

3%

47%

0% 10% 20% 30% 40% 50%

% of respondents

Base: Respondents reporting use of bar coding in medication system (32)

return doses to inventory in the pharmacy

verify drug selection prior to dispensing from the pharmacy

verify stocking of automated dispensing cabinets

verify stocking of unit dose bins

identify the patient during medication administration

verify drug selection prior to patient administration

other

Education and Research

Education - Student training remained a high priority with:– 83% reporting training for under-graduate

pharmacy students– 26% reporting training for pharmacy residents

Research– Sites conducting research decreased to 35% from

43% in 1999/2000 ( may be related to the 13.8% residency position vacancy rate)

Hospital Pharmacy in Canada Annual Report

Analysis of Indicators

Lilly Report User Customizable Benchmarking Report

Paid hours per acute patient day Paid hours per acute patient day by

distribution system Drug costs per acute patient day Drug costs per acute admission Inventory turns IV production per acute patient day Interventions per admission

Drug Costs Per Acute Patient Day

$0

$5

$10

$15

$20

$25

$30

$35

$40

$45

Your hospital Average Average Teaching

Interventions per Admission

00.10.20.30.40.50.60.70.80.9

Your hospital Average Average Teaching

Paid Hours (Budget) per Acute Patient Day by Distribution System

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

96/97 97/98 99/2000 2001/02 2003/04

Your hospital Unit Dose Traditional UD/CIVA Traditional/CIVA

Additional benchmarking tables in the Report

Ave drug costs per day by clinical program Ave paid hours per admixture – CIVA, oncology, per

investigational drug study Ave paid hours for inventory/procurement and for

DUE per $1m drug purchases Ave paid hours per patient day for high acuity

programs e.g bone marrow transplant, neonatal or pediatric ICU

Changes in drug expense by patient care area Total drug costs by patient care area

What’s Next?

How does your Organization shape up in comparison to your peers?

Conducting a Self-Operational Review

Leadership and Management

Bar Code Technology

HPCR 03/04 (n= 144) Your Hospital

201 – 500 Beds

Over 500 Beds

Teaching Status

% with some level of Bar-coding implemented

21% 39% 41%

Leadership and Management

Uses of Bar Code Technology (Numbers too small to break down by site size)

HPRC 03/04 ( n=32) Your Hospital

All Hospitals

Returning doses to Inventory 34%

Verify drug, stock, dispense 16%

Verify unit dose bin stocking 13%

Verify drug prior to patient admin 3%

Leadership and Management

Computerized Provider Order Entry - CPOE

HPCR

2003/04 (n = 144)

Your Hospital

201 – 500 Beds

Over 500 Beds

Teaching Status

Operational CPOE

Sites (%) with approved plan to implement CPOE

1%

15%

13%

26%

11%

25%

Leadership and Management

Clinical Decision Support

HPCR

2003/04 (n = 144)Your Hospital

201-500 beds

Over 500 Beds

Teaching Status

Pharmacy systems with clinical decision

34% 42% 32%

Automated Max dosage Alerts

31% 26% 38%

Fully Interfaced Lab results

29% 24% 20%

Trend Table 1 - Human Resource Shortages

Type Vacancy (%)

Pharmacist 12.9%

Technician 6.9%

Residents 0.9%

Management 13.8%

Human Resources

TechniciansCertification programs for technician checking functions

HPCR

2003/04 ( n = 144)

Your Hospital

All Hospitals

Respondents (%) with technician certification

Respondents (%) with fully implemented re-certification program (36/102)

71%

35%

Trend Table 2- Direct Patient Care/Clinical Pharmacy Services

Your

Hospital

201-500 beds

Over 500 beds

Teach

Beds serviced by pharmaceutical care %

27 33 35

Clinical pharmacist FTEs for outpatients

1.89 4.83 4.32

Clinical pharmacist FTEs for inpatients

5.4 15.8 12.7

Pharmacist time in direct patient care %

38 44 38

Pharmacist time in drug distribution %

49 41 38

Trend Table 3 - Direct Patient Care/Clinical Pharmacy Services

Your

Hospital

201-500 beds

Over 500 beds

Teach

Pharmacist FTEs dedicated to DUE

0.7 0.8 0.8

Number of undergraduate student days

153 474 404

Pharmacist FTEs dedicated to Drug information

0.9 1.6 1.5

Pharmacist Time spend in research %

1% 2% 2%

Direct Patient Care/Clinical Pharmacy Services

Targeted Inpatient Clinical Practice Sites

HPCR 03/04

(n = 100)

Your Hospital

201- 500

Beds

Over 500 Beds

Teaching Status

Gen Medicine

Other acute

Adult Surgical

Adult ICU

Haem-Onc

1.9 FTE

1.5

1.2

0.6

0.5

5.8 FTE

4.0

3.1

2.5

1.8

5.0 FTE

3.9

2.8

2.0

1.5

Direct Patient Care/Clinical Pharmacy Services

Targeted Inpatient Clinical Practice Sites

HPCR 03/04

(n = 100)

Your Hospital

201- 500

Beds

Over 500 Beds

Teaching Status

Adult Mental Health

Geriatrics

Obs/Gyn

Pediatric medical

Pediatric ICU

Pediatric haem-onc

0.5 FTE

0.5

0.5

1.1

1.5

1.7

1.0 FTE

0.8

0.4

0.5

0.8

0.8

0.8 FTE

0.6

0.6

1.3

1.2

1.3

Direct Patient Care/Clinical Pharmacy Services

Targeted Outpatient Clinical Activities

HPCR 03/04

(n=102)

Your

Hospital

Bed Size

201 - 500

Bed size

Over 500

Teaching Status

Haem-onc

Renal/Dialysis

Infect-Dis

ER

DVT/Anticoag

Cardiovas/lipid

Diabetes

0.82 FTE

0.71

0.67

0.54

0.51

0.13

0.22

1.79 FTE

1.14

1.33

1.10

1.16

0.52

0.59

1.57 FTE

0.82

1.12

1.02

1.20

0.66

0.52

Direct Patient Care/Clinical Pharmacy Services

Seamless Care – Discharge information provided

HPRS 03/04

(n=41)

Your Hospital

201-500 Beds

Over 500 Beds

Teaching Status

Medication list at Discharge

100% 93% 100%

Meds discontinued 54 73 86

Care Plan 69 47 55

Monitoring Values 54 67 68

Diagnosis 38 53 55

Drug Use Management

Drug Information

Hand-held devices supplied to physicians and other professionals for clinical activities

HPCR

2003/04 ( n = 144)

Your Hospital

201-500 Beds

Over 500 Beds

Teaching Status

Respondents (%) supplying hand-held devices for clinical activities

51% 63% 61%

Trend Table 4 - Handheld Device Use

HPCR 2003/04 Your Hospital

201-500 Beds

Over 500 Beds

Teaching Status

Clinical data Base Consult 94% 96% 100%

Mail, Calendar, tasks 60 75 71

Formulary info 34 38 32

Workload 17 25 24

DUE 17 17 24

Clinical Data Entry 3% - only 5 sites total

Drug Distribution

Medication Administration Records (MARs)

HPCR

2003/04 (n = 144)

Your Hospital

Bed Size

201 - 500

Over 500 Beds

Teaching Status

Electronic, on-line 12% 13% 14%

Hard copy, computer

generated MARs

54% 61% 50%

Manual 40% 45% 36%

Cards, Tickets

Yes (≥90%)

9% 13% 9%

Allergy on Mar 56% 63% 57%

Drug Distribution

Parenteral Drugs

HPCR

2003/04 (n = 65)

Your Hospital

Bed Size

201 - 500

Over 500 beds

Teaching Status

Average No. of admixtures per acute patient day

1.00 1.07 1.37

Drug Distribution

Order EntryHPCR 03/04 (n = 144) Your

Hospital201-500 Beds

Over 500 Beds

Teaching Status

Pharmacists only 76% 82% 77%

Technicians 76% 87% 82%

Nurses 1% 8% 5%

Physicians 3% 4% 6%

Trend Table 5 – Medication Safety and Quality Improvement

HPCR 03/04 (n=144) Your Hospital

201 – 500 Beds

Over 500 Beds

Teaching Status

% completing medication safety Self-Assessment

49% 61% 61%

Strategies to increase error reporting

75% 71% 71%

Disclosure policy 65% 71% 75%

Committee review med safety 78% 87% 91%

Use ISMP assessment tool 97% 87% 91%

Drug Costs

HPCR

2003/04 ( n = 144)

Your Hospital

201- 500

Beds

Over 500 Beds

Teaching Status

Average Total

($1,000,000s)

5.3 17.3 14.7

% increase in Costs 13.3 10.7 11.6

Aligning Your Organizations Priorities

Supporting your Priorities

Canadian Society of Hospital Pharmacists (CSHP) Standards, Statements and Guidelines - www.cshp.ca

Canadian Council on Health Services Accreditation (CCHSA) – New Patient Safety Standards effective 2006 – www.cchsa.ca

Institute for Safe Medication Practices (ISMP) – Canada - www.ismp-canada.org

Supporting your Priorities Cont’d…

Canadian Patient Safety Institute - www.patientsafetyinstitute.ca

Safer Healthcare Now Initiatives - www.saferhealthcarenow.ca

American Society of Health System Pharmacists – www.ashp.org

Institute for Healthcare Improvement (IHI) -www.ihi.org

Institute of Medicine (IOM) - www.iom.edu

Supporting your Priorities Cont’d…

Last but not least…… Hospital Pharmacy in Canada Report –

www.lillyhospitalsurvey.ca – extensive inventory of references at the end of each section of the document.

Hospital Pharmacy in Canada Annual Report

Analysis of Indicators

Paid Hours (Budget) per Acute Patient Day by Distribution System

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

96/97 97/98 99/2000 2001/02 2003/04

Your hospital Unit Dose Traditional UD/CIVA Traditional/CIVA

Drug Costs Per Acute Patient Day

$0

$5

$10

$15

$20

$25

$30

$35

$40

$45

Your hospital Average Average Teaching

Drug Costs per Acute Admission

$-

$50

$100

$150

$200

$250

$300

$350

Your hospital Average Average Teaching

Inventory Turns

02468

101214

93/9

494

/95

95/9

696

/97

97/9

8

99/2

000

2001

/02

2003

/04

Your hospital Average Average Teaching

I.V. Production Per Acute Patient Day

0.00

0.25

0.50

0.75

1.00

1.25

1.50

1.75

2.00

Your hospital Average Average Teaching

Interventions per Admission

00.10.20.30.40.50.60.70.80.9

Your hospital Average Average Teaching

Paid Hours (Budget) Per Acute Patient Day

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

93/94 94/95 95/96 96/97 97/98 99/2000 2001/02 2003/04

Your hospital Average Average Teaching

Using the Data - Testimonials

“…it takes 17 years for a new piece of science/evidence to be propagated through the system.” (IOM Report)

Contact Information

Patricia Macgregor - [email protected] Nancy Roberts – [email protected]

THANK-YOU - MERCI