Quality assurance in the pharmacy

Quality improvement is not optional. Medicare Part D requires participating pharmacies to implement a continuous quality improvement (CQI) program. So do a growing number of third-party payers in the private sector and a growing number of state pharmacy boards.

“Part D is one more entity pushing you to do the right thing,“ said Ken Baker, a pharmacist, attorney, and frequent contributor to Drug Topics. “The first problem is demonstrating that you are actively doing something and proving that what you are doing improves quality. The second problem is proving that you are doing it every single day, every single script.”

The road map to improving quality is probably familiar: measure quality, usually in terms of medication errors; determine what causes the errors; implement changes to reduce errors; measure; and repeat.

“No pharmacy, no pharmacist, wants an error. That’s the bottom line,” said Tara Modisett, vice president, quality initiatives, National Alliance of State Pharmacy Associations (NASPA). “Forget Part D, the third-party contracts, the pharmacy boards, the public pressure. Pharmacists want to make sure errors never, ever, reach the patient. That’s the primary focus.”

Most pharmacies have some sort of CQI process in place, said Eric Luecht, pharmacy area manager, Cigna Medical Group, Phoenix, Ariz. But CQI is too often an informal effort that happens sporadically. If quality improvement isn’t continuous, it isn’t improving.

“You need to look for the near misses, errors that didn’t reach the patient,” Modisett said. “You may fix one combination of factors that led to an error, but 3 weeks later, another combination of factors is going to create another problem. You need a systematic approach.”

There are at least two ways to approach CQI, Baker said. One is a system that routinely monitors pharmacy processes from prescription intake to patient counseling. Another is an automated device to check every prescription.

The device is already available, Baker said. It’s a countertop unit known as Pass Rx, manufactured by Centice Corporation (see Drug Topics, March 2010). At $20,000, the device is not inexpensive, but it can identify and verify more than 23,000 oral solid formulations in about 6 seconds.

“It’s that final check that every pharmacy and every script needs,” Baker said. “You don’t have to use a device like this, but if you don’t, the problem is remembering to do a visual check on every script and proving that you’ve done it on every script. PassRx gives you quality data showing what you’ve done, where your errors occur, how you’ve changed over time, and how you compare to other pharmacies.”

Pharmacies can also consider a systems approach, such as the one that Baker created when he was vice president and general counsel at Pharmacists Mutual Insurance Company. His original program was purchased by NASPA, reworked, and launched as Pharmacy Quality Commitment (PQC). PQC is being marketed by state pharmacy associations nationwide for $300 the first year and $200 every succeeding year.

PQC is a pharmacy safety net, Modisett said. It is a series of checklists, measurement tools, and best practices that help track and trap errors before they reach the patient. Data collected using PQC are protected from discovery under the Patient Safety and Quality Improvement Act of 2005. Pharmacies can collect detailed data about the quality of their operations, including near misses, and use the data to improve quality without worrying about it appearing in court.

“Licensing PQC meant that we didn’t have to reinvent a program on our own,” Luecht said. “I like that it stresses the steps you can take to avoid errors. It focuses on the positive message that it is more efficient, less expensive, and less dangerous to fill every script correctly the first time. Improving quality has reduced costs, improved outcomes, lowered stress levels in the pharmacy, and increased patient satisfaction.”