WOUND CARE BENCHMARKING IN

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1 WOUND CARE BENCHMARKING IN COMMUNITY PHARMACY PILOTING A METHOD OF QA INDICATOR DEVELOPMENT Project conducted by Therapeutics Research Unit, University of Queensland, Princess Alexandra Hospital in conjunction with the Department of Pharmacy Practice, Monash University and the Australian Institute of Pharmacy Management October 2003 Revised January 2004 This project was funded by the Australian Government Department of Health and Ageing as part of the Third Community Pharmacy Agreement through the Third Community Pharmacy Agreement Research and Development Grants (CPA R&D Grants) Program managed by the Pharmacy Guild of Australia ISBN

2 PREFACE We are grateful to the Third Community Pharmacy Agreement Research and Development Grants (CPA R&D Grants) Program for giving us the opportunity to explore issues of measurement and service quality in community pharmacy. This preliminary work has shown that it is possible to develop rulers for measuring the services provided by community pharmacies. The study has also identified a number of needs for wound care and emphasised the challenge before community pharmacy to measure the health outcomes of the services provided. We wish to acknowledge the contributions of the Expert Panel to this project. Panel members gave freely of their time and expertise. Thanks are also due to the owners and staff of the pharmacies taking part in the pilot study. They too, were generous with their time and assistance, at a time when they were coping with the largest recall of pharmaceutical products Australia has ever seen. We would also like to thank Bruce Annabel, from Johnston Rorke Pharmacy Services, who generously provided data on the financial performance of some pharmacies in the wound care category. Julie Stokes Michael Roberts Sheree Cross John Chapman Greg Duncan i

3 EXECUTIVE SUMMARY AIMS This project sought to define a set of quality service indicators to assist community pharmacists with self-assessment of their provision of a quality wound care service. This project also sought to relate these indicators to the current practice of wound care provision in community pharmacies so that pharmacies could identify areas for improvement as part of a continuous quality improvement process. DESCRIPTION OF THE PROJECT The overall study methodology is summarised in Figure. 1. Establish expert panel Advise on: Likely stakeholder contributions: Brainstorm possible indicators Current pharmacy wound care practices & data availability Feasibility of applying draft indicators as part of pharmacy practice Quality issues of concern to, and methods to collect data from consumers & other health professionals Specific aspects of quality wound care (what indicates quality-in-fact?) Outcome assessment eg. Improved wound healing Secondary sources of dressing use/sales data Alternative strategies to facilitate data collection eg. Point-of-sale or dispensing computer Dissemination of results & implementation within political framework Develop draft indicators from: Literature Current studies Expert consultation Consider method of measurement and data capture Pilot indicators - (June-Oct 2002) 15 pharmacies - purposive, nonrandom sample Include pharmacies with known high quality service Multidisciplinary expert panel to: Review draft indicators and methods of measurement/data capture for relevance & feasibility consider possible standards for level of compliance with indicators Pharmacies to run indicator program Capture data required for indicators Gain any consumer consent required Repeat data collection as required Include audit and test-retest Examples of possible indicators: Rate of wound healing assessed through patient follow-up Pharmacist & pharmacy staff knowledge about wound care & wound type recognition Ongoing specific staff training/education Ratios of wound care products stocked or sold (eg. interactive vs passive dressings) Number of referrals for wound care products/advice to & from other health professionals Patient satisfaction Possible methodologies include guided self-audit process, consumer survey, secondary data collection from wholesalers Evaluation of indicators and indicator development methodology for feasibility, practicality, generalisability and cost effectiveness Analysis of: Indicator data comparing between high, moderate and basic quality services Pilot pharmacy feedback on process Feedback results of pilot to expert panel Revise indicator set for dissemination and inclusion in QCPP program Figure 1 Overall study methodology In brief, the set of quality service indicators for a quality wound care service by community pharmacists were developed as follows: A multidisciplinary expert panel was formed to develop the indicators. The panel consisted of representatives from community pharmacies and staff, consumers, general practitioners, vascular medicine, community nurses, podiatrists, consumers organisations e.g. Diabetes Australia, wound care product manufacturers and medical researchers (Chapter 4) This panel used published literature, current studies, manufacturer data and expert advice to develop a best practice wound care flow chart for community pharmacy and a resulting set of draft indicators (Chapter 5) Assessment of the indicators was undertaken in a pilot study of 14 community pharmacies (Chapter 6.2). The following sets of data were collected: characteristics, stock holdings, sales and wound service care provision reported by the community pharmacy independent audit of pharmacy wound care section by a pharmacy researcher ii

4 an assessment of service quality by an independent mystery shopper a consumer telephone survey semi-structured interviews with pharmacies after pilot study data collection The potential quality indicators were then evaluated against an independent measure of service quality in the pharmacies (Chapter 6.3). The performance of the indicators as part of a self-audit or benchmarking process was studied for feasibility, practicality, generalisability and cost-effectiveness. KEY FINDINGS 1. Participating community pharmacy characteristics. 14 community pharmacies of a possible 35 screened participated in this study, the majority of those failing to do so citing timing and staffing issues (Chapter 7.1). 2. Need for wound care products in pharmacy. The pharmacies in this study saw a median of one wound care customer a day (excludes sprains, strains and sports injuries). Cuts and grazes were the most common wounds (35%) followed by stitches and surgical wounds (20%), burns (15%) and leg ulcers or pressure sores (12%) (8.1.7). Wound care products represented less than 2% of turnover for 70% of the pharmacies surveyed. The percentage of turnover from wound care at the sites in the study ranged from less than 1% (45% of sites) to more than 5% (9% of sites) with a median level at 1-2% ( ). Higher turnover was associated with greater sales of advanced dressings (Figure 8.24). 3. Space used for wound care in pharmacy. Total linear metres of shelving taken up by dressings was a median of 5.4m for smaller pharmacies (less than 200m 2 ) and 10.0m for larger pharmacies (>200m 2 ) with wound care products (not first aid, tapes and bandages) occupying a median of 64% and 50% of this shelving respectively (Table 8.1). The sizes, shapes and bulk of these products created difficulties for pharmacies in merchandising this pharmacy category ( and 7.3). 4. Wound Care services by pharmacy assistants. Wound care services in community pharmacy are generally provided by pharmacy assistants, with pharmacists being consulted for about one quarter of wound care customers (9.3.3.) in pharmacies providing the level of wound care service commonly seen in community pharmacy. Pharmacy assistants have a lack of confidence in dealing with wound care customers particularly in situations where their lack of knowledge is highlighted (7.3 and 7.4). Pharmacy assistants with better knowledge are better able to influence customers (8.1.3) and better pharmacy assistant knowledge is also associated with better service quality (8.3.4 and Table 1). 5. Customer satisfaction with wound care service. From the limited number of subjects recruited to the customer survey, the majority of customers rated the pharmacies as excellent in meeting their overall wound care needs (5 of 9) (Table 8.20) and based on customer recall, advice was given in 55% of these transactions, in 1 case, written information. More than 60% of pharmacies had written information on wound care available for their customers but the customer survey suggests that this written information is not routinely provided. 6. Pharmacists perceptions inconsistent with practice. Proprietors estimates or impressions of characteristics of their wound care service are not always a good reflection of the actual characteristics e.g. types of wound seen, staff training, how often the pharmacist is consulted, referral rates and service quality (sections , and 8.1.7). Prospective data such as a customer log or objective information such as a staff training registered would provide more reliable information about the service. iii

5 7. Need for standard operating procedures. Availability of written policies or procedures in areas such as products kept, advice to customers on product use, staff training, skills, knowledge and resource maintenance, and referral to other health professionals to support wound care services was low ( ). The level of documentation of the wound care services e.g. wound history, wound follow-up and monitoring, was also low. There is a need for independent tools, guidelines and protocols to help pharmacy staff consult the pharmacist where appropriate, initiate referral, to guide customers on appropriate product selection and to offer advice on the appropriate use of products (7.3 and 7.4). 8. Rural pharmacies have a greater need for support. There is some evidence that the demands on rural pharmacies for wound care services are greater than on an average metropolitan community pharmacy since there are fewer alternative service providers, as evidenced by the broader stock range carried (Figure 8.5) and greater levels of more advanced dressings (Table 8.3). These pharmacies also find it more difficult to access training for staff and pharmacists find it more difficult to find locum cover for training courses in the city (7.3). 9. Need to increase use of advanced dressings. Only 35% of products sold were more advanced dressings but the median appropriateness rating of dressings sold was equivalent to Limited potential to help healing (8.1.7). Pharmacies carry large quantities of passive and first aid dressings (and associated tapes and bandages), often therapeutically equivalent dressings, and these dressings represent 65% of sales (8.1.5 and 8.1.7). As part of improving wound care, pharmacies need to increase the proportion of more advanced dressings sold to have a greater impact on wound healing. 10. Influential role of manufacturers. Wound care product manufactures exert a strong influence on the merchandising display ( ), product range carried ( ) and as providers or information and training ( and 7.3). 11. Need for wound care training for pharmacy staff. Pharmacy assistants reported influencing customer product selection in 61% of cases but the appropriateness of products sold was often low. Wound care education currency and quality varied greatly between pharmacies (9.3.1). Currently, some pharmacy assistants have difficulty accessing training and those that receive training report that the content is sometimes over our heads and does not seem to have relevance in the way that they carry out their work (7.3). There is also a need for pharmacist wound care training - in 1/3 of pharmacies, pharmacists had received no wound care training in the last 2 years and pharmacist wound care knowledge was associated with service quality measures (Table 1). 12. Independent measures of service quality (9.4). Lack of information seeking or advice as assessed by a mystery shopper was a major limitation in current community pharmacy wound care practice. In general, adequate wound care resourcing was perceived by the independent auditor but a customer log suggested that the products selected were inappropriate. Expressed in terms of a combined quality scores, pharmacies could be categorised as being: a. in urgent need of improvement, b. offering a basic service, c. providing an intermediate service and d. advanced service, the latter being met by a single site. Various indicators could be related to quality measures as shown in Table 1. Data collection for practice improvement purposes is generally outside usual practice as illustrated by the limitations of point-of-sale systems for this purpose and the difficulty in capturing the outcomes of wound care in community pharmacy, although the need was recognised by participants. iv

6 13. Effectiveness. The expert panel methodology was effective in identifying potential indicators. Of the indicators collected, all were feasible and practical for the majority of sites except for the customer recruitment for the customer survey and the sales/purchases history data and took a median of less than 4 hours of pharmacy time to collate. Some of the measures based on proprietor estimates were less reliable than prospectively collected more objective measures. Indicators also suggest quality improvement actions. Individual pharmacies reported that, by and large, their participation in the pilot as a data collection exercise was beneficial, often in ways unanticipated by the researchers. The costeffectiveness of using the indicators depends on pharmacies making improvements to services provided and any flow-on effects on wound healing or prevention of complications. Focusing on wound care can be financially worthwhile for individual pharmacies, since the average gross profit margins for this category in a sample of 21 pharmacies was 38% compared to 29-30% commonly seen for the dispensary (data provided by Johnston Rorke Pharmacy Services) (9.8.1). Table 1 Relationship between indicators and any quality measure Related to quality measures Not related to quality measures QCPP accreditation (R) space, facility & display only Rural versus metropolitan (A) but trends Size of business entity as indicated by: favour rural if exclude advanced sites* Opening hours (R) Physical size of pharmacy (A) No. prescriptions filled/week (R) No. EFT Pharmacists (R) No. pharmacists employed (R) Extent of use of manufacturers displays No. EFT Pharmacy assistants (R) (A) (audit aspects not service experience or technical quality) Total linear metres of dressing shelving In banner group (A) (yes=poor mystery shopper result)* (A) and linear metres of shelving for first Providing dressings to other organisations (R) aid (A) Signage for the wound care area (A) Availability of written information on Linear metres of shelving for wound care dressings (A) wound care for customers to take away and percentage of dressing shelves for wound care (not (R) first aid) products (A) Wound care referrals by pharmacy to Attention to merchandising other than the use of other health professionals (R & L) manufacturers displays (A) Wound history taking (R) Wound care referral to pharmacy from other health Monitoring and follow-up of wound professionals (R) healing (R) Maintenance of patient wound care records (R) Existence of wound care Extent of pharmacy assistant influence on purchase (L) policies/procedures whether written or Frequency of pharmacist consultation in a wound care unwritten (R) service episode (L) Proportion of opening hours a wound care No. pharmacy assistants with wound care training (R) trained assistant was on duty (R) Pharmacy assistant & pharmacist knowledge scores (Q) Presence of wound assessment Presence of product selection information resources (R) information resources (R) Percentage of patients seeking wound care who had Stock range and stock level of passive burns (R & L) and stitches/surgical wounds (L) (negative and first aid dressings (A), hydrogels and relationship) hydrocolloids Percentage of dressings sold not passive or first aid dressings, tapes or bandages (L) especially hydrogels, hydrocolloids and alginates Higher percentage of turnover from wound care (R) Overall stock range and stock level (A) and stock range and level of more specialised dressings Key for source of data: R=reported by proprietor; A=recorded at independent audit; L=recorded by staff on the customer log; Q=quiz; *=needs further investigation 14. Involving community pharmacies in research. Strategies were identified to overcome barriers to community pharmacies participating in research. The relevance of the project to their practice and the use of research mentors were enablers of this pharmacy research. v

7 CONCLUSIONS Currently, pharmacies act passively (by a passive supply of passive dressings). Their opportunity is to become active by selling of active dressings to meet individual customer needs. The recognition by the pharmacists that this research was valuable suggests there is a possibility that the opportunity could be seized by those pharmacies wishing to invest more in direct patient care. RECOMMENDATIONS Given that future wound care products are likely to emphasize the presence of active medicinal substances, pharmacy has an opportunity to become a dominant supplier in this niche market, the following recommendations relate to improving current services and building capacity to fill a wound care niche. 1. Education of pharmacists and pharmacy assistants in wound care practice must be a priority if community pharmacy wishes to remain as a credible service provider of wound care advice and products. This education should be at a level and delivered in a way that is relevant to practice. 2. Benchmarking indicators for outcomes of community pharmacy wound care practices should be integrated into pharmacy IT systems as part of an ongoing quality assurance process and to provide evidence on which to base future government negotiations. 3. Benchmarking indicator methodology developed here should be translated into other areas of professional community pharmacy practice. 4. Non-company based simple tools should be provided to community pharmacies to assist in wound care product selection. 5. Protocols and resource booklets need to be developed to enable community pharmacies to better refer and network with local healthcare providers. 6. There is a need to better support rural community pharmacies in enhancing their wound care service. 7. Manufacturers need to pack dressings in sizes more suitable for sale in community pharmacy (e.g. pharmacy packs with 1-3 units/pack). 8. Self-selection by the customer would be facilitated by having basic written instructions for use of more advanced dressings available in the wound care section and by displaying simple visual aids to help customers select the best product or give non-brand specific choices for treatment. 9. There is an opportunity to develop wound care as a specialty practice by: a. A focus on service delivery (stock range and staff knowledge better addressed) including staff interventions e.g. assistance selection and best use of dressings, customer follow-up of wound healing. b. appropriate merchandising for self-selection (since customers will still self-select, especially if the pharmacy is busy). 10. Benchmarking indicators could be used to inform future Guild-government agreements so that these organisations could coordinate the collection and analysis of indicators longitudinally. 11. The critical success factors for research in community pharmacy should be recognised and supported by pharmacy organisations. Research projects conducted in community pharmacies should address the critical success factors such as mentoring and this should be allowed and expected as part of the costing of these projects. vi