Development of Clinical Pharmacy Productivity Metrics

Development of Productivity Metrics

Manual Data Collection

Initial efforts to track productivity tied to clinical pharmacy activities began in 2008. Early measures incorporated the number of orders verified relative to the number of hours worked (analogous to traditional input metrics) and the total number of interventions completed by the decentralized clinical pharmacists. Interventions included order clarification or confirmation, identification of duplicate or unnecessary therapy, therapeutic consultation, antibiotic regimen change, nonformulary-to-formulary conversion, i.v.-to-oral conversion, automatic substitution, monitoring of renally dosed medication, profile review, and provision of general continuity of care. The data for the two metrics were obtained through EMR reports generated by pharmacy administrators via Epic-Care Ambulatory EMR (Epic System Corporation, Verona, WI) and the manual collection of completed interventions routinely conducted by the clinical pharmacy staff. Reports were generated in the Clarity reporting system provided by Epic and extracted into an Excel database, version 2007 (Microsoft Corporation, Redmond, WA) for data analysis, data graphing, and generation of final reports.

Through manual data collection, pharmacists electronically documented their interventions and the amount of time spent completing them. Because of the amount of time required for manual tracking of these data, pharmacy administrators believed that interventions were grossly underreported and began to explore alternative methods for the automated capture of interventions through automated reports.

Manual Tracking of Interventions

In January 2009, administrators revised the expectation for documenting interventions. Manual tracking became optional, and an order-discontinuation report generated from the EMR was added to the monthly intervention data to more accurately account for decentralized clinical pharmacist interventions related to discontinued orders.

The order-discontinuation report was an automated report that tracked all discontinued orders by pharmacy staff. The report allowed analysis by pharmacist and type of discontinuation (e.g., dosing adjustment, change in therapy, drug–drug interaction) often encountered after a clinical pharmacy intervention. For each discontinued order, a reason for discontinuation (e.g., renal dosing adjustment, i.v.-to-oral conversion) must be selected from a drop-down box in the EMR. This requirement allowed report generation and analysis of interventions performed by decentralized clinical pharmacy staff. The discontinuation report was also designed for analysis of decentralized-pharmacist-initiated discontinuations by admission rate and frequency of occurrence.

In January 2010, pharmacy staff (the clinical pharmacy manager, the pharmacy department's quality data coordinator, and decentralized clinical pharmacy staff) worked with information technology (IT) staff in a series of inperson meetings to identify additional clinical activities amenable to electronic capture in the EMR to enhance existing measures of clinical pharmacists' productivity. Measurable clinical activities amenable to electronic capture and reporting were identified based on the current electronic reporting capabilities. Once the activities were identified and a variables list was generated, methods to extract the variables from the EMR were developed by IT staff. All participants helped to identify measurable clinical activities.

Developing Weighted Metrics

Through consensus, clinical staff developed a weighted metric for each variable to quantify measured activities by the amount of time spent and cognitive skill required (Table 2). Consensus was defined as agreement among the clinical pharmacy manager and decentralized clinical pharmacists. Each staff member was sent a list of variables and asked to provide comment and feedback, from which the variables list was generated and finalized. The process was repeated until all members agreed. Overall response from the pharmacy staff was collaborative and positive. The staff recognized the importance of productivity measures in relation to workload assignments and worked diligently to meet the challenge of developing the tool.

It is understood that variability exists among these metrics depending on the specific patient. An overall measure was assigned to each type of activity on the basis of the average amount of time and effort spent on each activity. Because pharmacists' area assignments are based on overall patient acuity and because pharmacists are cross-trained in all patient care areas, we believed that overall weighting was as balanced as possible. Planned comparisons among clinical pharmacy staff were within the same assignment areas rather than between areas. Decentralized clinical pharmacists were asked to weigh each activity relative to other activities on the basis of the average time and cognitive skill required to complete a specific intervention.

Because patient profile review is required for all inpatients at the hospital and the subsequent generation of a relevant progress note is time-consuming and requires a higher level of clinical expertise, this variable had the greatest weight. A patient profile review requires extensive evaluation of the appropriateness of therapy (e.g., drug, dose, route, schedule), drug interactions (e.g., drug–drug, drug–disease, drug–food), relevant laboratory test values, allergies, i.v.-to-oral conversion, i.v. administration rates and dosing, formulary adherence, home medication use, deep venous thrombosis or gastrointestinal prophylaxis, and any other notable drug-related issues that require the follow-up or intervention of a pharmacist.

Progress notes are similarly weighted and may include warfarin consultation, renal dosing protocol, clozapine dosing (initial and follow-up), methadone consultation, narcotic-conversion assistance, phenytoin and valproate level monitoring, post surgical deep venous thrombosis pro-phylaxis review, medication reconcilliation, and pharmacokinetics calculations (initial and follow-up).

Additional decentralized clinical pharmacist responsibilities include management of patients' medication lists, which may involve new-order verification, order discontinuation, and new-order entry based on oral orders. New-order verification was weighted a 1 because it is a basic function of clinical responsibility. Any additional interventions that occurred during order verification were accounted for in other metrics (e.g., discontinuation of a medication due to a dosage adjustment). Entry of oral orders was weighted a 2 because it requires interdisciplinary communication and usually includes pharmacists' involvement in rounds or provider consultation. Discontinued orders were also weighted a 2 because they represent interventions in maintaining patients' medication profiles.

Reporting of unexpected medication events was weighted a 4 because of the time required to determine the potential cause of the medication error, incorporation of the appropriate changes to the patient's profile, need for staff contact and potential further interaction or intervention, and completion of required documentation. Emergency resuscitation code attendance is a critical function of the decentralized pharmacy staff, and every attempt is made to attend all emergency resuscitation codes called when decentralized pharmacists are on duty. Pharmacists' attendance is recorded manually by the provider assigned to document the code situation. Code attendance was weighed as half of the duration of the code (in minutes) in an attempt to standardize the effort and time spent relative to other clinical pharmacist responsibilities.

Table 1. Demographic Characteristics of the Pharmacy Department at Regions Hospital ^a
Characteristic	Year
2010	2009	2008
No. admissions per year	27,271	24,477	24,507
Average daily patient census	372	316	322
Institutional expense budget that is pharmacy-related, %	5.5	5.5	6.0
Total no. inpatient pharmacist FTEs	28.50	28.03	28.51
No. adjusted patient days per pharmacist FTEs	4,239	4,117	4,127
No. doses dispensed per pharmacist FTE	82,853	81,313	78,634
No. orders processed per pharmacist FTE	32,704	30,957	25,059
No. admissions per pharmacist FTEs	958	873	860

Table 2. Decentralized Clinical Pharmacy Productivity Metrics ^a
Metric	Weighted Value
Orders verified in EMR	1
Orders entered into EMR (oral)	2
Orders discontinued	2
Patient profile review	5
Progress notes	5
Unexpected medication event reporting	4
Emergency resuscitation code attendance	Duration (minutes) divided by 2

Table 3. Decentralized Clinical Pharmacy Interventions Per Month and Year
Year	Mean Interventions/Month	Total Interventions/Year
2008	842	10,104
2009	8,705	104,460
2010	9,078	108,936

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