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Cleveland Clinic Hospitals Lead Way on Quality-of-Care Measures

Sep 23, 2011

STARTING IN OCTOBER 2012, Medicare will reimburse hospitals based on quality-of-care measures, including how closely hospitals follow best clinical practices and how satisfied patients are with their care. “All institutions now have a heightened awareness of the need to perform better because of Medicare’s pay-for-performance reimbursement that’s coming,” said Michael Hoying, R.Ph., M.S., director of pharmacy for Fairview-Lutheran Hospitals, part of the Cleveland Clinic Hospital System. A New Opportunity for Pharmacists  Among the factors that Medicare will consider in its incentive calculus will be drug-related process-of-care measures for patients with congestive heart failure (CHF)—specifically, the percentage of patients with CHF evaluated for left ventricular systolic (LVS) function and the percent of CHF patients with LVS dysfunction who received an ACE inhibitor or an AR blocker. A year ago, Fairview-Lutheran’s respective scores for this patient population hovered around 93 percent and 86 percent, both below national averages.

Michael Hoying, R.Ph., M.S.

Hoying recognized an opportunity for pharmacists to improve the scores and reach organizational goals of 100 percent compliance. “The pharmacy was not consistently involved with heart failure measures, and we saw that we could do a better job of identifying patients who needed their CHF core measures reviewed.”

In August 2010, Fairview-Lutheran’s night-shift pharmacist began a nightly review of a computer-generated data pool, looking for all patients admitted to the hospital that day with a primary or secondary diagnosis of CHF. For patients with CHF whose most recent echocardiograms showed ejection fractions of less than 40 percent and who had received either an ACE inhibitor or AR blocker, the treatment is documented in the electronic medical record (EMR).For those who had not received drug therapy, the pharmacist checks the EMR to determine if there are valid reasons for why it has not been ordered. If none are found, the patient’s record moves to a follow-up list. Patients for whom a new echocardiogram had been ordered are also placed on the follow-up list.The next morning, a pharmacist reviews the follow-up list and obtains either a medication order for appropriate treatment or documentation of a medication variance. A cardiology nurse practitioner who is part of the daily clinical staff coordinates the final resolution to ensure that the core measures have been met.

“Where we faltered in the past was documenting why an ACE inhibitor wasn’t on board,” said Hoying. “That’s where the pharmacists have really filled a role and made sure that there’s either a good reason why the therapy wasn’t ordered, or have tracked down the physician to get the order if there’s no reason why the patient shouldn’t be receiving the drug.”

Over the next few months, the number of CHF patients screened monthly quadrupled. Fairview-Lutheran reached—and has maintained—100 percent compliance with core CHF measures by the last quarter of 2010.

“At first, managing the list was a little overwhelming,” noted Erin Barnett, Pharm.D., clinical specialist II at Fairview-Lutheran, “but soon we were able to easily integrate the new procedures.”

Connecting Patients and Pharmacists

Last March, Hoying turned to another factor that will weigh heavily in the Medicare incentive calculations: the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) survey. HCAHPS is the first national, standardized, publicly reported survey of patients’ perceptions of their hospital care. The results will count for 30 percent of the Medicare reimbursement score. For the two survey questions about how well patients were informed about new medicines during their stay, Fairview-Lutheran scored poorly.

Hoying initiated a pilot program on one 36-bed unit that increased the number of direct encounters between pharmacists and patients. The goal: improving communications about new drugs.

Prior to pharmacist involvement, overall communication about medications for the unit ranked in the 17th percentile among comparably sized hospitals. For describing what a new medicine was for, it ranked in the 55th percentile, and for describing possible side effects, it ranked near the bottom, in the 2nd percentile.

By the second quarter of 2011, the unit had jumped to the 96th percentile for overall communication about medications, and to the 99th and 90th percentiles, respectively, for the other two measures.

“We’ve had a huge impact,” said Hoying. “I plan to use the data to make the case for greater resources and to start a residency program, which would allow us to expand our coverage to other units.” He’s already added two pharmacists to his staff.

“The story at Fairview-Lutheran demonstrates how pharmacists can really improve patient outcomes as well as their hospital’s ranking,” said David Chen, R.Ph., M.B.A., director of ASHP’s Pharmacy Practice Sections and Section of Pharmacy Practice Managers. “This shows how much they can make a difference.”

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