Elsevier

Research in Social and Administrative Pharmacy

Original Research

Keeping the "continuous" in continuous quality improvement: Exploring perceived outcomes of CQI program use in community pharmacy

Abstract

Background

Given the significant potential of continuous quality improvement (CQI) programs in enhancing overall levels of patient safety, community pharmacies in North America are under increasing pressure to have a formal and documented CQI program in place. However, while such initiatives may seem great on paper, in practice the outcomes of such programs to community pharmacy practice remain unclear.

Objective

To explore the perceived outcomes identified by community pharmacies that adopted and actively used a standardized (i.e., common across pharmacies) CQI program for at least 1 year and to develop a framework for how such outcomes were achieved.

Methods

A multi-site study of SafetyNET-Rx, a standardized and technologically sophisticated (e.g., online reporting of medication errors to a national database) CQI program, involving community pharmacies in Nova Scotia, Canada, was performed. During the summer and fall of 2011, 22 interviews were conducted with the CQI facilitators in 12 Nova Scotia community pharmacies; equally split between independent/banners and corporate chains. Of the CQI facilitators, 14 were pharmacists, while the remaining eight were pharmacy technicians. Thematic analysis following the procedures presented by Braun and Clarke was adopted to identify and explore the major outcomes.

Results

Results of the thematic analysis highlighted a number of perceived outcomes from the use of a standardized CQI program in community pharmacies, specifically: (1) perceived reduction in the number of medication errors that were occurring in the pharmacy, (2) increased awareness/confidence of individual actions related to dispensing, (3) increased understanding of the dispensing and related processes/workflow, (4) increased openness to talking about medication errors among pharmacy staff, and (5) quality and safety becoming more entrenched in the workflow (e.g., staff is more aware of their roles and responsibilities in patient safety and confident that the dispensing processes are safe and reliable). In achieving such outcomes, pharmacies had to balance customizing the CQI program to address a number of operational challenges, with ensuring that the core standardized components remained in place.

Conclusions

This research identified the perceived outcomes of CQI program use by CQI facilitators. Additionally, the findings are incorporated into a framework for CQI implementation that can be used by pharmacy managers, corporate head offices, and regulatory authorities to leverage greater CQI adoption and success.

Introduction

Community pharmacies are often faced with the task of quickly dispensing a large number of prescriptions, while at the same time ensuring that such activities are performed accurately and safely. Despite recent technological advances in e-prescribing and pharmacy automation, pharmacy practice remains very much a high volume manual process and thus very prone to quality-related events (QREs).1 Quality-related events, defined as "any departure from the appropriate dispensing of a prescribed medication that is or is not corrected prior to the delivery and/or administration of the medication"2 such as incorrect drug, dosage, quantity, or patient, may have significant negative implications to the patient, staff member, and pharmacy. However, despite their potentially disastrous outcomes, QREs often highlight broader process or system flaws and as such represent excellent learning opportunities. Through systematically examining such errors, root causes can be found and process changes made to reduce the likelihood of similar errors occurring again. When pharmacies proactively and continuously examine their processes for the potential sources of QREs, the result, referred to as continuous quality improvement, has the potential to significantly reduce the sources of QREs and ultimately enhance patient safety.

Continuous quality improvement (CQI) is a management approach focused on continually and systematically examining an organization's work processes in order to identify and address the root causes of poor quality (including errors, waste, and inefficiencies) and improve organizational performance (including financial, customer satisfaction, and safety) overtime. To achieve such outcomes, CQI emphasizes, among other things, an evolutionary approach to quality improvement, employee empowerment, teamwork, and the use of scientific methods to identify and address quality issues and plan and implement subsequent changes.3, 4

Given the significant potential of CQI programs in reducing the sources of QREs and enhancing overall levels of patient safety,5 many pharmacy regulatory authorities in North America now require community pharmacies to have a formal and documented CQI program in place.6 However, there currently exists a large degree of variation as to what such CQI programs look like, ranging from simple manual in-pharmacy programs to standardized CQI programs (e.g., common across a large number of pharmacies) that leverage the latest in information technology to enable the rapid and broad communication and analysis of QREs.

These latter CQI programs are especially important as they allow for enhanced QRE reporting and learning to occur. Specifically, standardized CQI programs enable community pharmacies to: (1) widely and rapidly communicate QRE details (e.g., contributing factors, outcomes) across multiple pharmacies, even if they are business competitors, (2) deploy a turn-key CQI program that is most likely based on best practices and compliant with regulatory standards of practice, (3) identify severe or common QREs occurring elsewhere and proactively make changes to prevent similar scenarios from happen to them, and (4) engage staff working at multiple pharmacies (e.g., relief pharmacists) in QRE reporting and learning, as such staff only need to know one CQI process.7

Standardized CQI programs, therefore, not only have the potential to improve safety within the individual pharmacy, but also to enhance the safety of pharmacy practice across the jurisdiction. However, while standardized CQI programs may seem great on paper, in practice, their implications to community pharmacies remain unclear. As a result, it remains largely unknown within a community pharmacy context as to the positive outcomes of such programs that pharmacy managers, corporate head offices, and regulatory authorities can use to leverage broad-based support and ensure that standardized CQI programs, despite operational challenges, are used on a continual basis. Subsequently, this research explores the perceived outcomes obtained by community pharmacies that adopted and actively used a standardized CQI program (i.e., common across pharmacies) for 12–24 months. The specific objectives of this study are as follows:

•

To identify the perceived outcomes of standardized CQI program use by community pharmacies;

•

To develop a framework outlining how community pharmacies achieved such outcomes.

Section snippets

SafetyNET-Rx CQI program

To explore the perceived outcomes of standardized CQI program use, a single CQI program was chosen to better account for issues related to program complexity, technological sophistication, and program completeness. Subsequently, this research focused on the SafetyNET-Rx CQI program.7 As illustrated in Fig. 1, SafetyNET-Rx is a Nova Scotia, Canada based CQI program designed to provide pharmacy staff with the processes, tools, training, and support needed to: (1) better report QREs; (2) identify

Results

During the summer and fall of 2011, 22 interviews were conducted with CQI facilitators in 12 Nova Scotia community pharmacies. Data saturation was found after 10 pharmacies (i.e., 19 interviews) with interviews conducted in 2 additional pharmacies (i.e., 3 interviews) to ensure findings and equal pharmacy representation. Specifically, of the 12 pharmacies represented by participants, 6 were independent/banner pharmacies and 6 were part of large pharmacy chains. A total of seven different

Discussion

Continuous quality improvement programs such as SafetyNET-Rx emphasize a systems approach to quality improvement, where the focus shifts from assigning blame to individuals to examining the entire pharmacy system in order to determine contributing system flaws and QRE root causes. The design of the system can enhance safety by having procedures and attributes that make errors more visible, leading to a higher probability that these errors can be intercepted prior to causing harm to the patient.9

Conclusion

Standardized CQI programs provide the needed resources to enable pharmacy staff to learn from QREs and plan, implement, and assess changes to help reduce the likelihood of similar errors happening again. Additionally, as these programs are designed to rapidly communicate QRE contributing factors and outcomes across pharmacies, the potential for enhanced learning is significantly greater than isolated in-pharmacy programs. Standardized CQI programs do, however, require that community pharmacies

Acknowledgments

The authors would like to thank the Nova Scotia College of Pharmacists and Institute for Safe Medication Practices Canada for their in-kind support of the SafetyNET-Rx CQI program.

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