Mha Reflection Paper

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PHARMACY PRACTICE

Improving the Quality of Clinical Pharmacy
Services: A Process to Identify and Capture
High-Value “Quality Actions”
Nicole Bruchet, Peter Loewen, and Jane de Lemos

INTRODUCTION

P

atients are harmed and resources wasted because of underuse, overuse, and misuse of medications and treatments.1,2 To improve health services, governments and other key organizations use quality indicators.3,4 These indicators improve quality through 2 main mechanisms. First, the process of

developing quality indicators allows standards, targets, and priorities to be set. Second, quality indicators are used to retrospectively measure and report various aspects of care, providing a framework that increases accountability, allows benchmarking, and identifies areas for improvement.5,6

Despite the widespread use of quality indicators to
improve health services, the pharmacy profession has not widely adopted this concept for quality improvement in the clinical realm. We propose that this concept can be used to redesign the delivery of care. As pharmacists, we need to redefine what we need to be doing, find out whether we are doing it, and then use this information to find areas to improve.

Pharmacists cannot identify and manage all of the drugrelated problems that patients experience or are at risk of experiencing. Rather, the goal should be to maximize patient benefit with available resources. Pharmacists need to identify those drug-related problems for which management or prevention would result in the greatest benefit for as many patients as possible. In other words, they need to prioritize. In this article, we define a new concept that we call “quality actions” and describe a process to identify high-value quality actions for specific patient populations. Measurement consists of documenting whether or not a quality action has been considered or performed. This system will allow pharmacists to identify, measure, and report what they should be doing, which is

fundamental to achieving improvement.

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C J H P – Vol. 64, No. 1 – January–February 2011

BACKGROUND ON QUALITY INDICATORS
AND QUALITY IMPROVEMENT
Quality indicators are defined as measures based on
standards of care that assess a particular health care process or outcome.6 They can be evidenced-based, or, if evidence is
lacking, they can be determined by expert consensus.6 International and national agencies publish and use quality indicators to track performance and identify areas for improvement.3,4 For example, the Joint Commission has published 25 quality

indicators for myocardial infarction, heart failure, pneumonia, and surgical care,3 and the US National Quality Forum has
developed more than 200 quality indicators.7 If an intervention is associated with evidence of improved outcomes, setting a
corresponding evidence-based standard (or process) that can be measured should lead to improvement in the process and its
outcomes.8,9
The link between process and outcome is important.
Many quality indicators focus on processes of care rather than on clinical outcomes because process indicators are usually
more appropriate for generating improvements in quality.10 The reasons for this are critical but frequently misunderstood.
Consider the following example. High-quality randomized
controlled trials (RCTs) have shown that angiotensin-converting enzyme (ACE) inhibitor therapy reduces mortality among
patients with systolic dysfunction.11 On this basis, a health care system might implement a process to ensure that “all patients with systolic dysfunction should receive ACE inhibitor therapy (assuming no contraindications)”. The corresponding quality indicator would be “the proportion of patients with systolic dysfunction who have no...
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