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Continuous Quality Improvement Quality Care Pharmacy Program - A Brief Re-Cap The Quality Care Pharmacy Program is an integrated system of performance standards and supporting tools and processes. It was developed to assist individual pharmacies, and Community Pharmacy as an industry, to meet the evolving needs and expectations of customers and patients, and to compete successfully in an increasingly challenging business environment. The strong feedback from pharmacies that have implemented the Quality Care Pharmacy Program is that it has helped them achieve a higher standard of: • service for customers; • professional care for patients; • morale and teamwork among pharmacy staff; and • business performance in the pharmacy. Importantly, following the Wilkinson and Galbally competition policy reviews of pharmacy legislation, Australian governments have accepted that the Quality Care Pharmacy Program is a key plank in demonstrating significant public benefit justifying retention of the current pharmacy ownership and scheduling arrangements. In addition, the references to the Program in the Third Community Pharmacy Agreement clearly indicates that the Federal Government understands the important role that the Program is playing in delivering better health outcomes to consumers.
The Next Step – Continuous Quality Improvement We can all take satisfaction in what has been achieved over the last couple of years, but there is no room for complacency. The mantra of competition policy is unlikely to go away in the foreseeable future, and Community Pharmacy has only won would could be described as round one of a much longer fight with respect to the retention of current ownership and scheduling arrangements. While the Quality Care Pharmacy Program provides a solid platform for success, it is also inevitable that customer needs and expectations, and the competitive environment, will change over time. And almost certainly, customer expectations will get higher, and the business environment will become more challenging. The Pharmacy Guild of Australia has now conducted two annual reviews on the Program. These updates help to ensure that the Program remains relevant to the general needs of consumers and pharmacy managers and staff, but we can’t really expect that an industry-wide system like QCPP will specifically address all of the issues faced by individual pharmacies.
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That’s why we see the next step in improving consumer health outcomes, customer satisfaction and business performance being driven by individual pharmacies, in the form of the implementation of Continuous Quality Improvement. What is Continuous Quality Improvement? Continuous Quality Improvement (CQI) is a broad business/management term, generally used to describe the process of systematically reviewing and improving existing operational processes. When we use the term CQI in relation to the Quality Care Pharmacy Program, however, we apply a more Community Pharmacy focussed definition: “CQI describes the process of demonstrating a commitment to the ongoing improvement of customer outcomes and business profitability, through the systematic review and enhancement of the pharmacy’s Quality Care Pharmacy Program standards, and their continuous improvement over time” Some of the key things to note about this definition are: •
CQI is a systematic process – best results will be achieved through a disciplined and ongoing approach, rather than an unplanned, ad-hoc or reactive approach.
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CQI is about ongoing improvement -- it isn’t something you can do once and then safely forget about.
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The focus is on customer outcomes and/or business profitability – when you get right down to it, these are the core issues for any business. If what you are doing isn’t contributing directly to one or both of these factors, you should be asking yourself why you are doing it at all.
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The Quality Care Pharmacy Program provides the starting point – QCPP doesn’t pretend to cover every aspect of pharmacy operations, and you should always be thinking about what you can do to improve these other aspects of the business. For the purpose of maintaining QCPP accreditation however, you will be asked to undertake some CQI initiatives that clearly represent an improvement/extension to the existing Program in your pharmacy.
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Continuous Quality Improvement and Industry Commitment CQI will form part of the ethos of Community Pharmacy in coming years. In other parts of the pharmacy channel, be it manufacturing or wholesaling, CQI is already part of every day operations in the mindset of staff. The Quality Care Pharmacy Program Advisory Board, which represents the key stakeholders of the Program, has committed to develop and adapt programs over coming years to assist pharmacies to implement CQI. From the University sector, through to post-graduate continuing professional development programs put on by our Professional Associations and assistance given by the pharmacy brands, all will assist in the development of CQI for Community Pharmacy. Thank you for your continuing commitment to Community Pharmacy. CQI and QCPP Accreditation The expectations of the Quality Care Pharmacy Program in relation to Continuous Quality Improvement is that from 1 October 2001 each accredited pharmacy will: 1. implement and monitor improvements against a minimum of eight existing Standards 2. submit a brief report outlining the initiatives undertaken using the templates provided in the self-assessment documentation. This should be submitted with annual self-assessment documentation requirements. Furthermore, the Quality Care Pharmacy Program recognises that Continuous Quality Improvement can occur in a number of different contexts, all of which enable proprietors to achieve the philosophical objective of CQI. Accordingly, the QCPP Policy Committee believes that participation in nominated activities throughout the year should provide credit against the QCPP CQI reporting requirement. Participation in specific activities will enable a pharmacy to claim a credit against the CQI requirement. For a list of these activities and the QCPP CQI credit points available visit the QCPP website at: www.qcpp.com/qcpp_cqi_credit_point_activities.htm or contact the QCP Division on 1300 363 340. CQI Implementation – Suggestions for Action The remainder of this document provides a series of suggestions illustrating actions that could be undertaken by a pharmacy with respect to CQI obligations established under the Quality Care Pharmacy Program. These suggestions are
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provided as thought-starters only. We have not attempted to outline a CQI action for every standard (indeed, for some standards it may be hard to identify a genuine CQI action), and it certainly not an exhaustive list of the actions that could be taken. Your pharmacy has total freedom to identify and implement any initiatives that you believe would represent a genuine CQI initiative in support of the existing Quality Care Pharmacy Program. Completion of the annual ‘Pharmacy CQI Report’ will provide the basic ‘evidence’ as to whether the actions taken in your pharmacy represent genuine CQI initiatives. You should contact the QCPP helpline on 1300 063 340 if you require additional information on identifying and implementing appropriate CQI initiatives in your pharmacy.
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Professional Services Standard PDE-3 Patient Counselling Area MTP-3 Dispensary Assistants
Possible CQI Action(s) Develop and implement a system for monitoring customer satisfaction with respect to the patient counselling area, and make appropriate improvements in response. If your pharmacy does not currently use a Dispensary Assistant, consider up-skilling a staff member for this role. If necessary, conduct a study designed to quantify the financial impact of doing so. Develop and implement a system for identifying any additional training needs of Dispensary Assistants, based on your observance of the performance of their duties over time. Develop and implement a system for working with individual Dispensary Assistants to identify areas where, with appropriate supervision and/or additional training, their existing role/responsibilities could potentially be extended.
SER-1
Develop and implement a system for monitoring and improving the proportion of pharmacist time spent in Pharmacist Accessibility direct contact with customers (as distinct from and Advice activities that could more appropriately be conducted by a Dispensary Assistant). Develop and implement a system designed to identify developments in relation to a series of common health ailments or concerns (asthma, diabetes, high blood pressure etc.) and pro-actively communicating these to customers. SER-3 Patient Medication Profile SER-4 Brand Substitution
Develop and implement a system for regular (at least annual) clarification with patients of their existing medication profile, and updating as necessary. Develop and implement a system for identifying developments in relation to appropriate brand substitution (e.g. the introduction of a new generic drug), and conveying this information to all relevant pharmacy staff.
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Professional Services (cont.) Standard SER-5 Non-Prescription Items
SER-9 Medical Advice Referrals POP-1 Resource Management
POP-2 Professional Practice – Customer Care and Advice
POP-3 Professional Practice – Indirect Supply
POP-7 Rights and Needs of Customers
Possible CQI Action(s) Develop and implement a system for identifying regular prescribers who routinely write nonprescription items on prescription, and (sensitively) raising this matter with them on the basis of reducing the cost applicable to their patients. Develop and implement a system for following up with the relevant medical practitioner with respect to clinical interventions in relation to drug therapy, and updating the patient medication profile as necessary. Develop and implement a system designed to monitor patients’ ability to access a pharmacist for consultation on non-prescription medicines, and implement appropriate changes to resourcing and/or workflow practices in response. Develop and implement a system for routinely evaluating the performance of pharmacy staff in relation to provision of advice and appropriate selection of pharmacy medicines, including the identification and provision of any necessary training or coaching. Develop and implement a system for confirming that instructions/advice provided to the patient’s agent has been accurately relayed and understood by the patient, and providing additional counselling as necessary. Develop and implement a system for routinely evaluating the performance of pharmacy staff in relation to respectful care of customers, and the provision of any necessary training or coaching.
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Professional Services (cont.) Standard PPS-1 Health Promotion
Possible CQI Action(s) Develop and implement a system designed to ensure regular review and updating of the educational material provided in the pharmacy. Identify the health promotion materials that are most/least selected by customers, and adjust the pharmacy’s stock/display accordingly. Develop a calendar of health topics for communication to customers, and develop appropriate materials and activities by pharmacy staff in support. Develop and implement a system designed to encourage and collect feedback from consumers and health professionals after each health education/promotion activity conducted in the pharmacy (e.g. by distributing surveys or feedback forms), analyse the responses and make appropriate changes to future health promotion activities.
PPS-2 Dispensing
Develop and implement a system of regular (at least monthly) random self-audit to assess timeliness of supply (e.g. for every third prescription received, record the time of receipt and time of supply). Develop and implement a system for recording the total number of items dispensed per day, and analyze this information to identify trends (e.g. how busy the pharmacy usually is on pension days, before school holidays etc.). Use this information to make appropriate decisions in relation to staffing levels, workflow etc.
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Professional Services (cont.) Standard PPS-3 Dose Administration Aids
Possible CQI Action(s) Develop and implement a system for the ongoing assessment of wastage (i.e. filled DAAs that are returned with unused medicines), and develop and implement appropriate procedures for improvement in this area. Develop and implement a system for working with individual Dispensary Assistants to identify areas where, with appropriate supervision and/or additional training, their existing role/responsibilities in relation to DAAs could potentially be extended.
PPS-4 Patient Counselling
Identify categories of individuals who may be considered ‘high-risk’ or ‘at-risk’ (e.g. visually impaired people, new customers, people whose first language is not English, people on medication for asthma or diabetes), and develop and implement incremental pharmacy procedures in relation to counselling such patients. Identify any existing drugs requiring special warning labels, and develop and implement a system for ensuring that appropriate special warning labels are always used in relation to these products. In addition, develop and implement a system for identifying a similar need in relation to new product introductions. Develop and implement a system for identifying developments in relation to identified drug interactions or contraindications, and for providing this information to any other pharmacists working in the pharmacy.
PPS-5 Compounding
PPS-7 Comprehensive Medication Review
Develop and implement a system for ensuring that the pharmacy maintains appropriate levels of stock/ingredients required for compounding, based on examination of demand patterns. Develop and implement a system designed to regularly collect and review feedback from patients, carers, medical practitioners and other health care professionals in relation to the pharmacy’s Comprehensive Medication Review service, and make appropriate improvements.
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Professional Services (cont.) Standard PPS-8 Comprehensive Pharmaceutical Care
PPS-9 Drug Information Service
Possible CQI Action(s) Develop and implement a system designed to regularly collect and review feedback from patients, carers, medical practitioners and other health care professionals in relation to the pharmacy’s Comprehensive Pharmaceutical Care service, and make appropriate improvements. Develop and implement a system designed to facilitate appropriate quality improvements based on the analysis of the record of requests and consultations with respect to key indicators such as : • Types and numbers of inquiries received (e.g. subject, inquirer) and type of response provided (e.g. on the spot, after consulting references, or extensive research required). • Usual or average response time. • Audit trail — ease of tracing original inquiry in cases where follow-up information is required. Develop and implement a system for obtaining feedback in relation to written reports requested and/or supplied, and making appropriate quality improvements in response to comments received from the enquirer.
PPS-10 Liaison Pharmacy
Publish a collaborative article in a local newspaper and/or create a newsletter. Develop and implement a system for regularly assessing the performance of the Liaison Pharmacy service, and make appropriate improvements.
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Professional Services (cont.) Standard PPS-11 Pharmacy Services to Residential Care Facilities
Possible CQI Action(s) Develop and implement a system for regularly assessing the performance of the service to the residential care facility, and make appropriate improvements. This should include a mechanism for obtaining feedback from residents, facility staff and other members of the medication advisory committee. Review and/or develop policies for the facility in collaboration with members of the medication advisory committee on medication-related issues (e.g. selfadministration of medicines by residents, the use of ‘prn’ medicines etc.).
PPS-12 Distance Dispensing
PPS-13 Internet Pharmacy
PPS-14 Domiciliary Medication Management Review COL-1 Accepting Temperature Sensitive Products COL- 4 Dispensing Temperature Sensitive Products
Develop and implement a system for regularly assessing the performance of the Distance Dispensing service. This should include a mechanism for recording any verbal feedback offered by customers, and for pro-actively seeking feedback from patients of the service. Develop and implement a system for regularly assessing the performance of the Internet Pharmacy service. This should include a mechanism for recording any verbal feedback offered by customers, and for pro-actively seeking feedback from patients of the service Develop and implement a system for regularly assessing the performance of the DMMR service. This should include a mechanism for recording any verbal feedback offered by customers, and for proactively seeking feedback from patients of the service Monitor the incident log to check performance of suppliers in this regard. Discuss solutions to noncompliance with the supplier if performance is unacceptable. Develop and implement a system designed to identify patients at ‘high risk’ of correct maintenance of the temperature control guidelines appropriate to their dispensed medication, and for following up with these patients to verify that the products have been transported and subsequently stored in an appropriate manner.
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Retail Skills Standard APP-1 Pharmacy Appearance APP-2 Quality Care Pharmacy Branding
APP-3 Pharmacist and Staff Appearance ACC-2 Communication ACC-4 Pharmacy Visibility STO-1
Possible CQI Action(s) Develop a schedule of upgrade of fixture/fittings replacement, and document in the pharmacy financial plan (e.g. replace carpet in 2003.) Develop and implement a local area marketing campaign centred on the pharmacy’s status as a QCPP accredited pharmacy and the QCP logo. Extend the usage of the QCP logo to include all pharmacy communications to customers (e.g. stationery, signage, business cards, ads etc.). Develop with staff a policy of wearing the cosmetics and fragrances sold by the pharmacy. Negotiate a subsidy with suppliers to facilitate. Incorporate telephone training into the staff training plan. Develop and implement an initiative designed to enhance the visibility of the pharmacy ((e.g. installing additional exterior lighting). Arrange for at least one staff member to undertake visual display training.
Feature Displays Develop and implement some form of pharmacy incentive based on encouraging your staff to design, build and maintain a significant feature display. STO-2 Pharmacy Layout STO-3 Fixtures and Fittings STO-5 Pharmacy Stock
Upgrade an area of the pharmacy that you have identified as under-performing for layout-associated reasons. Undertake an upgrade of pharmacy fittings and fixtures, designed to increase customer safety and/or the financial performance of the pharmacy. Develop and implement a system for routinely (at least monthly) monitoring the financial performance of all areas of the pharmacy, and make relevant adjustments to layout, display, stock etc.
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Retail Skills (cont.) Standard STO-6 Supporting Information
STO-7 Stock Pricing STO-8 Stock Weight
Possible CQI Action(s) Introduce a significant information-related initiative to the pharmacy, such as the Pharmacy Self Care program, computerised information kiosks, health information database software etc. Develop and introduce a system for regularly confirming that all scanned prices match the shelf price displayed. Develop and implement a system for recording stockouts, and making appropriate adjustments to stock holdings. Develop and implement a system for analysing departmental stock levels in relation to turnover and profitability.
STO-11 Special Offer Merchandise
STO-12 Sensitive Merchandise STO-13 New Products
If a banner group pharmacy, develop and implement a system that ensures all staff are made aware of any catalogue items that are not stocked/unavailable, and the pharmacy has agreed on a specific course of action if a customer enquires about such an item. Incorporate training in this area into the staff training plan of all relevant staff members. Develop and implement a program that ensures that pharmacy staff are regularly and directly trained/briefed by relevant sales representatives. Develop and implement a system for regular review (say, weekly for the first three months, for a product that could be expected to be a relatively frequent seller) of the performance of all new products, with a focus on identifying reasons for poor sales performance, and taking remedial action as necessary.
STO-15 Durable Medical Equipment and Other Aids
Develop and implement a system for gathering information on the latest developments in this area, and communicating this to all relevant staff.
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Retail Skills (cont.) Standard STO-17 Non-Cash Payment Options STO-19 Ordering Stock STO-22 Clearance/Quit Goods
Possible CQI Action(s) Develop and implement a system for recording issues associated with the various non-cash payment options (cheques, credit cards, customer accounts etc.), and routinely reviewing the pharmacy’s policies in this area. Develop and implement a system for routinely recording out of stocks and borrows, and make appropriate adjustments to the pharmacy’s ordering procedures. Liaise with other retailers in the local area, and introduce a ‘market day’ concept for the clearance of marked down goods.
Business Management Standard CFP-1 to CFP-4 Managing Sales Managing Productivity Managing Costs Managing Cashflow STA-3 and STA -4 Pharmacy Orientation / Induction Training STA-6 Staff Levels STA-10 Recognition and Rewards STA-13 Employment and Termination
Possible CQI Action(s) Develop and implement a system for regular (at least weekly) communication with staff in relation to the pharmacy’s financial performance, and developing initiatives for improvement.
Develop and implement a system for debriefing of all staff who complete the pharmacy induction/training program, and making appropriate improvements for the future. Develop and implement a system for the ongoing identification of customer traffic patterns, and take appropriate action to ensure the pharmacy has sufficient staff to cope with customer demand. Develop and implement a system to determine the ongoing effectiveness of the pharmacy’s approach to recognition and rewards, and adjust policy if necessary. Develop and implement a system for monitoring changes in relevant legislation, communicating this to relevant staff, and updating all relevant pharmacy tools and procedures in this area.
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Loss Prevention Standard SEC-3 Shoplifting SEC-4 Employee Theft
SEC-6 Payment Fraud SAF-2 Emergency Procedures
Possible CQI Action(s) Develop and implement a system for ongoing analysis of stock losses due to shoplifting, and developing and implementing procedures to minimise this loss. Develop and implement a system for reducing the opportunity for staff theft, by relating actions undertaken back to a specific employee (e.g. individual cash register pin numbers, security access codes). Develop and implement a system to monitor pharmacy losses due to payment fraud, and take appropriate remedial action (e.g. change policies, retrain staff, counsel specific staff members etc.). Develop a business contingency plan for major loss or damage in the pharmacy (fire, flood, bomb etc.).