Research Paper JPHSR 2010, 1: 75–84 © 2010 The Authors Journal compilation © 2010 Royal Pharmaceutical Society of Great Britain Received August 13, 2009 Accepted January 18, 2010 DOI 10.1111/j.1759-8893.2010.00001.x ISSN 1759-8885
Key performance indicators for clinical pharmacy services in New Zealand public hospitals: stakeholder perspectives
jphs_1
75..84
Jerome Ng and Jeff Harrison School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
Abstract Objective To identify a set of measurable key performance indicators (KPIs) demonstrating hospital clinical pharmacy’s contribution to patient care that can be used for benchmarking in the New Zealand setting. Methods Data sources were key stakeholders from public hospitals in each of the 21 District Health Boards in New Zealand. Surveys with selected KPIs thought to represent clinical pharmacy’s contribution to patient care were sent to the Chief Pharmacist, Chief Medical Officer, Director of Nursing, senior management team and Quality and Risk Manager of each District Health Board, who were asked to rate each KPI based on relevance to clinical pharmacy’s contribution to patient care and ease of measurement in their organisation. Mailed survey data were ranked and analysed using Microsoft Excel and SPSS. Key findings The response rate was 43%. The top two ranked KPIs were concerning chart review and medication reconciliation. Only three of 52 KPIs were rated ‘easily’ measurable. No statistically significant differences were seen between professional groups or hospital sizes. Conclusions The top ranked KPIs reflected the pharmacist’s central role in improving the individual patient’s medicines use. Measurability appeared to be a major issue due to resource constraints. This study has provided the platform for future nationwide hospital clinical pharmacy KPIs. Keywords benchmark; clinical pharmacy; hospital; performance; performance measures; pharmacist interventions
Introduction
Correspondence: Jerome Ng, School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, New Zealand. E-mail:
[email protected]
The incidence, costs and consequences of medication errors are well described in the literature.[1–3] As a result of this, there has been an increasing focus on the safe and quality use of medicines on an international level. In New Zealand this has been reflected in the creation of several national initiatives and groups[4,5] (see the homepages of the Safe Medication Management Programme, www.safemedication.org.nz/, and The Quality and Safe Use of Medicines Group, www.safeuseofmedicines.co.nz/). Hospital clinical pharmacy, although well established in New Zealand for some time, has responded to this need by increasing the diversity of services provided. Data from the international literature support these new services, demonstrating clear benefits from targeting this important facet of care.[6–8] Clinical pharmacy is a specialty field of pharmacy which has moved away from the traditional tasks of compounding and distributing medicines, to more cognitive clinical aspects focusing on patient-centred care[9] and optimising medication-related outcomes for patients throughout the medication-management process.[10] The clinical pharmacist now routinely participates in both multidisciplinary and specialty ward rounds, with the explicit aim of reviewing and optimising the appropriateness of medications prescribed and providing patient education. Pharmacists are also core members of many hospital qualityimprovement and medication safety projects.[11,12] Despite this, clinical pharmacy struggles to be recognised by both the public and other professions. In part this may be due to the reliance on qualitative, subjective and informal means of communicating the specialty’s contribution to patient care.[13,14] To date there is no evidence of adoption of any recommended performance measures or key performance indicators (KPIs) for clinical pharmacy. Likewise, there is no evidence of standardised
75
76
Journal of Pharmaceutical Health Services Research
measures for benchmarking practices between organisations nationally or internationally. The lack of ability to collect data on a national or international level compounds this inability to use data for benchmarking.[13–17] The concept of clinical governance[18] has meant that, just like any other health service, clinical pharmacy must justify its existence and demonstrate its effectiveness and efficiency in a resource-scarce environment. Without the ability to demonstrate its contribution to patient care, robustly and quantitatively, there have been questions as to whether clinical pharmacy services can be justified.[19] KPIs and benchmarking have been widely utilised to measure how well health services meet the goals of assuring quality. Within the health sector and beyond, these are seen as key tools to help improve performance.[20–22] KPIs highlight specific areas, allow monitoring on the effects of improvement practices[23,24] and permit different organisations to compare and learn from successful industry leaders in a process commonly known as benchmarking.[24] The published literature in this area highlights a number of different techniques, tools and systems used to measure clinical pharmacy’s contribution to patient care.[13,25–27] There also appears to be some evidence of benchmarking in specialised areas of clinical pharmacy, for example antimicrobial management.[26,28] However, despite the breadth of literature and study there appears to be no national or international consensus on what constitutes a KPI for clinical pharmacy.[13,29,30] The literature clearly shows that although there has been investigation into KPIs to demonstrate clinical pharmacists’ contribution to care, thus far there has been no universal adoption of any specific set of indicators. Furthermore, despite almost 30years of research there is no study, report or otherwise to give a definitive set of measures that can be used. This study takes the stance that national standardised KPIs need to be established and utilised to allow the New Zealand hospital clinical pharmacy profession to justify the services it provides, ensure provision of quality services and allow for further development. The question thus appears to be deciding which KPIs to adopt. This study utilises a pragmatic approach and aims to establish a potential set of measurable yet relevant – to key stakeholders – KPIs which demonstrate clinical pharmacy’s contribution to patient care in the New Zealand hospital setting.
Methods This was an observational study by way of survey. The survey tool was developed to identify key stakeholders’ perceptions on the relevance and measurability of currently recommended KPIs by major hospital pharmacy/non-pharmacy organisations and as identified in the literature. Relevance was defined as ‘the ability of the KPI to reflect the clinical pharmacy service or clinical pharmacist’s impact on individual patient care’ and measurability was defined as ‘the ease of data collection of the KPI within the organisation’. Respondents were asked to rate each KPI based on these two dimensions using a five-point Likert scale ranging from not relevant (1) to extremely relevant (5) and not easily at all (1) to extremely easily (5) respectively.
2010; 1: 75–84
KPIs were formulated by way of the Delphi process by three pharmacists with experience in academia, management and clinical care. The list was generated by attaining KPIs, performance measures and tools/models as suggested by major clinical pharmacy-related organisations (G. Hall, personal communication),[12,31] non-pharmacy specific organisations involved with the quality and safe use of medicines[32–36] and the literature. There were 105 indicators identified originally from the literature. The primary objectives by the Delphi group were to standardise and consolidate the KPIs. Similar KPIs were amalgamated and KPIs deemed not to reflect standard practice were removed. Where there were aspects of clinical pharmacy services that were not included in existing frameworks these were discussed and, where appropriate, an indicator was suggested. Following the Delphi process the number of KPIs was reduced to 71. The Delphi group also gave a brief descriptor of each indicator; these were used to generate a consensus descriptor for each KPI. The Chief Medical Officer (CMO), Director of Nursing (DON), Chief Pharmacist (CP), Quality and Risk Manager (QRM) and senior management team member directly accountable for pharmacy services (SMT) were chosen as respondents for this study as they were the key decisionmakers involved with medicines’ management in the hospital setting, influencing resource allocation and the hospital’s strategic direction. In addition, any KPIs that were adopted would most likely report to this select group of staff so it made sense that the surveys should encompass the end users’ perspectives. The draft survey was pre-tested with a convenience sample of one local hospital consisting of one staff member from each respective discipline: medical, nursing, pharmacy, quality improvement and senior management. Pilot respondents were not included in the study analysis. Face validity and differences between the Delphi process and convenience sample group were not tested. The stakeholder groups found that the initial survey was quite lengthy in nature, contained KPIs that could not have been totally attributable to pharmacy services alone (e.g. patient mortality rate, average length of stay) and were unclear of the differences between some of the KPIs (e.g. no. of medication errors compared with ‘prescribing errors: identification and resolution of unintentional departure from recommended prescribing practices per patient bed day’). Following recommendations and discussion between the stakeholder group participants and study investigators, the KPIs were further consolidated, resulting in a total of 52 KPIs. The surveys were then posted to the staff occupying those positions in the main hospital of each of the 21 District Health Boards (DHBs) of New Zealand (n = 105 total possible respondents; this number was later reduced to 103 because one of the positions was vacant and another was held by a single staff member with a dual role). Data analysis was performed with SPSS version 15.0 (SPSS Inc., Chicago, IL, USA) and Microsoft Excel 2007 (Microsoft Corporation, Seattle, WA, USA). Multivariate analysis of variance (MANOVA) was utilised to test for differences in KPI ratings for relevance and measurability between two variables: hospital size (i.e. tertiary care versus secondary care) and professional groups. The a priori level of significance was
