PDSA Worksheet - ASHP Media



MTM Quality Improvement Case: MTM clinic

You have established a Medication Therapy Management Clinic in your organization. Key aspects used for the justification of your MTM clinic as part of your organizations patient- centered medical home project with your largest payer were reducing adverse drug events, in particular resulting in hospitalization and improvement of chronic medication adherence. The reimbursement structure for your organization in the patient-centered medical home project is incentivized if your organization achieves a 5% improvement over your baseline entering into the contract.

Reviewing data from your organization provided by the payer shows the following baseline drug-related problems leading to hospitalization:

1. insulin induced hypoglycemia

2. beta-blocker induced bradycardia and syncope

Reviewing the Medication Possession Ratios (MPRs) of chronic medications in your clinic population (patients on medications for diabetes, hypertension, heart failure, hyperlipidemia, and depression) shows the average MPR of 70%.

The quality improvement team for your patient-centered home makes the decision to initially tackle the beta-blocker drug-related problem. This problem requires monitoring heart rates on all patients taking beta-blockers by the MTM practitioners. This would be doable in your current process with little interruption in your current process for both providers and patients. The team approves a collaborative practice process where the MTM pharmacist may reduce the beta-blocker dose when heart rates are below 60 BPM with 2-week follow up after all dose adjustments for continued bradycardia or any deterioration in conditions the beta-blocker may be used for. Review of the quality measure data bases does not reveal a specific measure for this objective.

Adherence is a major focus of your clinic. Review of the adherence literature shows that multiple adherence intervention addressed to the individual needs of the patient achieves the best patient outcomes. The MTM clinic will provide pill box fills, assistance in access, medication education, medication reconciliation, and frequent medication monitoring for adherence services. The team is confident based on the adherence literature that adherence rates measured by MPR should increase to 90%. Because adherence services are currently built into your processes, this also is a doable plan for your clinic. Review of the quality measure data bases shows an adherence measure that you can use.

National Quality Forum Endorsed adherence measure 0542: Medication Possession Ratio (MPR) for chronic medications for individuals over 18 years of age. (endorsed 8/2009)

You complete the PDSA worksheet as follows:

PDSA Worksheet

Plan to Develop or Improve MTM Services

|Aims - What are the one or two high level goals you have for your program? |Aim 1. Reduce adverse drug events in the population served. |

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| |Aim 2. Improve and maintain medication adherence. |

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|Strategies – What are the strategies you intend to pursue for achieving your |Strategy 1. Target medication(s) that are most frequently associated with ADE associated hospitalizations. |

|aims? | |

| |Strategy 2. Staff training in identifying and resolving ADEs. |

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| |Strategy 3. Document adherence of chronic medications for the top 5 disease states at each visit. |

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| |Strategy 4. Consistent methods utilized by MTM staff to measure adherence. |

|Objectives – For each goal what are your desired objectives / outcomes? |Aim 1. |

| |O1: Reduce the incidence of beta-blocker bradycardia resulting in hospitalization |

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| |O2: Measure pulse rate at each visit for beta-blockers in 90% of patients |

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| |O3: Measure cost avoidance of number of MTM visits to decrease hospitalizations |

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| |Aim 2. |

| |O1: Increase Medication Possession Ratios for chronic medications to 90% |

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| |O2: Measure type of services provided to improve adherence |

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| |O3: Measure workload (visit length) per type of service(s) provided |

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|Key Performance Measures – For each objective how will you measure success? |Measures |

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|A1-O1: | |

| |Number of patients hospitalized due to beta-blocker bradycardia compared to number of patients on beta-blockers with and without |

| |bradycardia over 12 months. |

| |(patient outcome measure) |

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|A1-O2: |Sample 25% of charts for patients on beta-blockers with heart rate measurement to patients on beta-blockers with a standard of 90%|

| |or greater. (process measure) |

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| |Cost associated with number of MTM visits in non-hospitalized patients on beta-blockers compared to cost associated with number of|

|A1-O3: |MTM visits in hospitalized patients on beta-blockers plus cost of hospitalization. (financial measure) |

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| |Medication possession ratio of chronic medications in patients 18 yrs or older (with hypertension, heart failure, diabetes, |

| |hyperlipidemia, and depression seen in MTM clinic). (patient outcome measure) |

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|A2-O1: | |

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| |Number and type of adherence services provided to patients with hypertension, heart failure, diabetes, hyperlipidemia, and/or |

| |depression seen in the MTM clinic. (process measure) |

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|A2-O2: |Length of visit per type and number of adherence services provided in MTM clinic. |

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|A2-O3: | |

Quality Measure Feasibility Checklist

|Question |Yes/No |Value |Comments |

|Number of patients hospitalized due to beta-blocker bradycardia compared to number of patients | |Yes = 1 | |

|on beta- blockers with and without bradycardia over 12 months. | |No = 0 | |

|Is the data readily available to collect? |yes |1 | |

|Is the data being collected during the process of care? |yes |1 |Where in the process? – patient visit |

|Will collecting data significantly disrupt the efficiency of providing care? |no |0 | |

|If yes, is it acceptable disruption? | | | |

|Will the data be collected on the entire population? |no |0 |If not, which group? Patients on beta-blockers |

|Are you able to collect the data electronically? |yes |1 |Vital sign fields |

|Do you have the resources to collect the data? |yes |1 | |

|Do you have the time to collect the data? |yes |1 | |

|Will the data provide you timely information? |yes |1 | |

|Are there problems with accuracy for your data? |no |0 | |

|Will the collection of data be costly? |no |0 | |

|Does the data need to be case-mix adjusted or risk stratified? |no |0 | |

|(i.e., adjusted for vulnerable populations, disparate populations, or other added complexities) | | | |

|Will the information provide you information to improve? |yes |1 | |

|Is the ability to change what you are measuring under your control? |yes |1 | |

|Do norms, benchmarks, or standards exist? |no |0 | |

Optimal measure = 10−12 Acceptable measure = 5−10 Difficult measure = < 5 TOTAL: 7

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