1. Measuring Your Department’s Progress in the Advancement of Pharmacy Practice and Patient Safety CSHP Professional Practice Conference - Jan 2006 Patricia Macgregor, Nancy Roberts Editorial Board members

2. 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

3. Hospital Pharmacy in Canada Report (HPCR) Measuring hospital pharmacy progress Data collection every two years Also known as “Lilly” report www.lillyhospitalsurvey.ca

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

5. HPCR Sections continued Technology Education and Research Pharmacy Staffing and Drug Costs for Clinical Programs - Acute Care Hospitals - Pediatric Hospitals Benchmarking

6. 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

7. 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)

8. 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

9. 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)

10. Clinical Practice Trends Beds serviced by pharmaceutical care %30% Clinical pharmacist FTEs for outpatients2.73 Clinical pharmacist FTEs for inpatients8.3 Pharmacist time in direct patient care %38% Pharmacist time in drug distribution %48% Pharmacist FTEs dedicated to Drug Info1.3 Pharmacist FTEs dedicated to DUE0.7 Number of undergraduate student days228 Pharmacist Time spend in research %1%

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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Prescribing Privileges Pharmacists 66% Midwives 45% Nurse practitioners 47% Other professionals 20%

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

19. Seamless Care-Discharge Information Provided Medications at discharge 95% Medications discontinued 68% Care Plan 56% Monitoring Values 59% Diagnosis 46%

20. Drug Information and DUE DUE – 0.8 FTE pharmacist – 0.5FTE support staff Drug Information - 1.3 FTE pharmacists - 0.4 FTE support staff

21. Drug Distribution and Delivery Systems used Order entry Order verification MARs, medication profiles etc Technician check technician IV admixture Oncology Ambulatory services

22. Distribution Delivery Systems Traditional delivery some beds 63% Total wardstock 21% Unit dose, >90% beds 31%

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

24. Order Entry Pharmacists 79% Technicians 78% Nurses 5% Physicians 3% Pharmacist verify pharmacist OE -41% *Significant increase from 01/02 report - 27%

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

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

27. Figure D-5. Certification Required 2003/04

28. 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

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

30. 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%

31. 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

32. 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

33. 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

34. Medication Safety Verbal and telephone orders limited76% 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%

35. 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

36. 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%

37. Figure H-1 Functions for which handheld devices are used

38. Bar Code Technology FDA - USA mandate bar codes at bedside – by May 2006 22% respondents use bar code technology – Up from 11% in 2002

39. Figure H-2 Uses of Bar Coding

40. 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)

41. Hospital Pharmacy in Canada Annual Report Analysis of Indicators

42. 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

46. 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

47. What’s Next? How does your Organization shape up in comparison to your peers?

48. Conducting a Self-Operational Review

49. 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%

50. 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 Inventory34% Verify drug, stock, dispense16% Verify unit dose bin stocking13% Verify drug prior to patient admin 3%

51. 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%

52. 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%

53. Leadership and Management Pharmacy Pharmacists time spent in Drug Distribution versus Clinical Activities HPCR 2003/04 (n=144) Your Hospital Bed Size 201 - 500 Bed Size >500 Teaching Status Pharmacists time (%) spent in Drug Distribution 49%41%38%

54. Trend Table 1 - Human Resource Shortages TypeVacancy (%) Pharmacist12.9% Technician 6.9% Residents 0.9% Management13.8%

55. Human Resources Technicians Certification 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%

56. Trend Table 2- Direct Patient Care/Clinical Pharmacy Services Your Hospital 201- 500 beds Over 500 beds Teach Beds serviced by pharmaceutical care % 273335 Clinical pharmacist FTEs for outpatients 1.894.834.32 Clinical pharmacist FTEs for inpatients 5.415.812.7 Pharmacist time in direct patient care % 384438 Pharmacist time in drug distribution % 494138

57. Trend Table 3 - Direct Patient Care/Clinical Pharmacy Services Your Hospital 201- 500 beds Over 500 beds Teach Pharmacist FTEs dedicated to DUE 0.70.8 Number of undergraduate student days 153474404 Pharmacist FTEs dedicated to Drug information 0.91.61.5 Pharmacist Time spend in research % 1%2%

58. 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

59. 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 1.1 1.5 1.7 1.0 FTE 0.8 0.4 0.5 0.8 0.8 FTE 0.6 1.3 1.2 1.3

60. 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

61. 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 547386 Care Plan 694755 Monitoring Values 546768 Diagnosis 385355

62. 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%

63. Trend Table 4 - Handheld Device Use HPCR 2003/04Your Hospital 201- 500 Beds Over 500 Beds Teaching Status Clinical data Base Consult94%96%100% Mail, Calendar, tasks607571 Formulary info343832 Workload172524 DUE17 24 Clinical Data Entry3% - only 5 sites total

64. Drug Distribution Medication Administration Records (MARs) HPCR 2003/04 (n = 144) Your Hospital Bed Size 201 - 500 Over 500 Beds Teaching Status Electronic, on-line12%13%14% Hard copy, computer generated MARs 54%61%50% Manual40%45%36% Cards, Tickets Yes (≥90%) 9%13%9% Allergy on Mar56%63%57%

65. 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 1.001.071.37

66. Drug Distribution Order Entry HPCR 03/04 (n = 144)Your Hospital 201- 500 Beds Over 500 Beds Teaching Status Pharmacists only76%82%77% Technicians76%87%82% Nurses1%8%5% Physicians3%4%6%

67. 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% Strategies to increase error reporting 75%71% Disclosure policy65%71%75% Committee review med safety78%87%91% Use ISMP assessment tool97%87%91%

68. Drug Costs HPCR 2003/04 ( n = 144) Your Hospital 201- 500 Beds Over 500 Beds Teaching Status Average Total ($1,000,000s) 5.317.314.7 % increase in Costs13.310.711.6

69. Aligning Your Organizations Priorities

70. 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

71. Supporting your Priorities Cont’d… Canadian Patient Safety Institute - www.patientsafetyinstitute.ca www.patientsafetyinstitute.ca Safer Healthcare Now Initiatives - www.saferhealthcarenow.ca 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

72. 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. www.lillyhospitalsurvey.ca

73. Hospital Pharmacy in Canada Annual Report Analysis of Indicators

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

82. Contact Information Patricia Macgregor - pmacgregor@tsh.topmacgregor@tsh.to Nancy Roberts – narobert2@serha.canarobert2@serha.ca THANK-YOU - MERCI