Description of pharmacist-led quality improvement huddles in the patient-centered medical home model

Abstract

Objectives:

This case study describes the implementation of pharmacist-led quality improvement team huddles in the patient-centered medical home clinic model. The purpose of these huddles is to have an impact on clinic-based quality metrics.

Setting:

Pharmacists embedded into primary care clinics at 2 separate health centers, within a large academic medical center, were funded by the clinics to lead their quality improvement (QI) team huddles.

Practice description:

Huddle team members vary depending on the practice sites and can include physicians, pharmacists, advanced practice providers, nurses, administrative managers, social workers, and medical assistants. These huddles are typically held every 1–2 weeks for 15–20 minutes. Small rapid plan-do-check-act cycles allow the process to be quickly assessed and altered if needed. The quality metric that the team focused on changed based on clinic goals. Two case studies showcase successful examples of quality improvement initiatives that had a significant impact on the individual clinic-based metrics.

Innovation:

The 2 case studies focus on pharmacist-led quality team huddles for controlled substance and asthma action plan metrics. The clinical pharmacists involved were pivotal to organizing and helping incorporate new processes within their clinics sites.

Results:

The work of the team huddles brought the clinics from a nonreimbursable status to reimbursable for these metrics.

Discussion:

Because pharmacists in the ambulatory care setting focus on chronic care disease management and QI, they are in an excellent position to lead team huddles focused on QI and registry management. By establishing interdisciplinary QI team huddles led by clinical pharmacists, these clinics were able to increase revenue for the clinic in the way of increasing pay-for-performance measures.

Conclusion:

Pharmacist-led quality improvement team huddles can have a positive impact on quality metrics, population health, and reimbursement.

The Institute for Healthcare Improvement (IHI) suggests the use of team huddles within the clinic setting as a way to improve overall clinic flow, communication, and safety.¹ The use of team huddles allows clinic members to contribute to improving care while also helping them to further understand each discipline’s role.¹ Daily team huddles in the ambulatory care setting typically are set at a predetermined time and involve care team members reviewing the patient schedule for the day to determine clinic needs.¹

Team huddle activities have been described in a variety of health care settings. In the Veterans Affairs health system, daily team huddle activities included planning for upcoming patient visits, discussing patients with complex needs, reviewing the day’s workflow and communication needs, and clarifying the role of each huddle team member.² Research has found that daily patient care team huddles in 3 different health care settings—general medicine clinic, inpatient surgical unit, and pediatric hospital—enhanced relationships within the patient care team, increased safety, and created time in the day for conversations regarding patient care.³ In a health system associated with the University of Rochester, NY, team huddle experiences were incorporated into their affiliated primary care residency programs.³ These huddles, which consisted of check-in and check-out staff, medical assistants (MAs), nurses, nurse practitioners (NPs), advanced practice providers, medical residents, faculty doctors, pharmacists, behavioral scientists, therapists, and social workers, emphasized improving patient care through teamwork.⁴

In primary care, the patient-centered medical home (PCMH) model aims to provide collaborative patient-centered and evidence-based care to patients.⁵ According to the U.S. Department of Health and Human Services, PCMHs have 5 key functions: 1) comprehensive care, 2) care that is patient centered, 3) care that is coordinated, 4) accessibility of services, and 5) quality and safety, which includes quality improvement (QI) activities.⁶ The use of interdisciplinary teams when providing this care has been shown to help meet the needs of patients and enhance QI efforts.⁷ Combining regular interdisciplinary team huddles and the PCMH model, through the use of chronic care quality team huddles, can improve clinic functions and patient care.

It has been well established in the literature that clinical pharmacists, as valued members of the PCMH team, have a positive impact on care received in the ambulatory care setting.^8–10 Ambulatory care clinical pharmacists have improved quality of care to patients in the areas of lowering low-density lipoprotein and controlling blood pressure and glycemia.^8,11 As such, the pharmacist is in a place to have a significant impact on quality metrics that affect pay-for-performance measures.

When it comes to focusing on QI within health care, plan-do-check-act (PDCA) cycles are a widely used tool. They are a means for performing continuous improvement within a project by frequently assessing and adjusting a process until the desired outcome is achieved.¹² To our knowledge, this is the first description of a QI huddle led by a pharmacist in a primary care PCMH clinic setting to improve both clinic and patient outcomes.

Objectives

This report focuses on the implementation of the pharmacist-led QI huddles, reasons for their initiation, and barriers to and facilitators of their implementation. Examples of 2 successful QI initiatives, controlled substance metrics and asthma action plans (AAPs), are described in case study format with the use of the PDCA framework.

Setting

Our institution is a large academic medical center that houses 14 PCMH-based clinics with a combination of both family medicine and internal medicine practices. Our team is composed of 11 clinical pharmacists and 2 postgraduate year 2 ambulatory care residents providing clinical pharmacy services to all 14 PCMH clinics to varying degrees. Clinical pharmacists spend as little as 1 day a week to as much as 4 days a week in clinics. Currently, the clinics fund 100% of the clinical pharmacist time while they are in the clinic. A total of 6 clinics in our practice fund an extra half-day of clinical pharmacist time specifically to focus on quality work and lead the QI team huddles.

Pharmacist-led QI team huddles at the PCMH sites within our academic medical center aim to improve chronic care disease quality metrics, pay-for-performance measures, and clinic workflow. A QI team huddle often has several disciplines present, including, but not limited to, physicians, nurses, pharmacists, medical and office assistants, care navigators, panel managers, and health care managers. Before the initiation of the huddles, the clinical pharmacist met with each discipline involved in the huddle to describe the reason for the initiation of the huddles, each person’s role in the huddle, initial focus areas for the huddle, and the process of the PDCA cycle used in the huddle. These huddles are held every 1 to 2 weeks for 15–20 minutes. Huddles are kept short to allow all disciplines to participate despite busy schedules and clinic workflow. Small rapid cycles of the PDCA cycle are used to allow the process to be quickly assessed and altered if needed. Huddles focus on a specific metric or topic until the processes and metrics have improved to an acceptable level as defined by the team or institution. Once their goal is achieved, the team collaboratively decides on their next process and metric for improvement. A 3-month rotation of huddle participants is used within the physician, nurse, and MA groups to allow more members of the clinic team to participate. These participants were initially suggested by the pharmacist in charge of the huddle, and then input from clinic administration finalized which health disciplines would be involved. Each physician, nurse, and MA within the practice is expected to participate in the huddle on a rotating schedule. Each member of the huddle is responsible to take new process changes back to their group for implementation.

Practice description and innovation

Health Center A

General information

In 2011, Health Center A adopted clinical pharmacist-led QI team huddles. The purpose of huddles at this site was to foster processes that improve quality metrics (e.g., blood pressure, diabetes, heart disease, and controlled substance metrics), patient flow, and clinic issues. The huddles consisted of a multidisciplinary team including the clinical pharmacist, panel manager, MA, physician, nurse, and various office administration representatives (MA lead, outpatient office assistant lead, clinic assistant manager, clinic manager).

Case study: controlled substance registry

At baseline, Health Center A was not meeting quality goals for their controlled substance (CS) registry. Patients were on the CS registry if 1 of the following criteria were met: 1) a new prescription for Schedule II, III, IV opioid with quantity 150 or more; 2) a renewal for a Schedule II opioid with quantity more than 30; 3) a renewal for a fentanyl patch with quantity 10 or more; 4) a renewal for a Schedule III or IV opioid with quantity 90 or more and more than 2 refills; 5) a new prescription for a benzodiazepine with quantity more than 90; or 6) a renewal for a benzodiazepine with quantity 90 or more and more than 2 refills. The CS registry consists of metrics in obtaining comprehensive drug screening laboratory tests, controlled substance agreements, and state prescription drug monitoring program (PDMP) reports. Initial data collected from the electronic medical record (EMR) system showed low compliance rates for all 3 of these CS quality metrics (Table 1). These low scores compromised not only patient care but also clinic reimbursement and funding because this is a pay-for-performance measure within the institution.

Table 1.

Controlled substance registry data

Time frame	Drug comprehensive screening (institution goal: 55%)	Controlled substance agreement (institution goal: 75%)	PDMP screening compliance (institution goal: 75%)
December 2010	21%	28%	10%
July 2010–June 2011	34%	39%	52%
July 2011–April 2012	33%	34%	66%
July 2012–June 2013	60%	76%	88%
July 2013–June 2014	62%	80%	87%
July 2014–June 2015	61%	74%	93%
July 2015–December 2016	75%	86%	97%

Abbreviation used: PDMP, prescription drug monitoring program.

The clinical pharmacist–led QI huddle team met, on average, once weekly for 15–20 minutes and used quick PDCA cycles to develop a process that both worked for the clinic structure and benefited the patients. The baseline practice model was a nurse-driven CS program used to help monitor patients on the CS registry, but this required modification. Much of this program focused on CS prescription preparation and pick-up. If a patient was due for a required annual comprehensive drug screen (urine drug screen [UDS]), a nurse attempted to have the patient provide a urine sample at the time of his or her next CS prescription pick-up by sending the patient to the laboratory. During follow-up appointments, the physicians were responsible for having the patient complete and sign his or her required annual CS agreement outlining expectations and agreement to not obtain CS medications from any other providers. Once completed, the CS agreement was scanned into the EMR and was available to view within 1 week. Finally, clinic staff, mainly medical assistants, would run the PDMP reports for the physicians as time allowed, although no formal process was in place for who would perform this task and when it would be completed.

UDS collection was the first metric selected for QI, which included all patients on the CS registry. The team decided that rather than sending the patient to the laboratory for a urine sample, this would be collected at the clinic point of care. Once that was implemented, the MAs recorded the number of patients who were able to provide a urine sample. These numbers were captured weekly and reported at the next team huddle meeting until the process was deemed to be successful, with the majority of the weeks observed having 100% of patients due for urine screening leaving a urine sample (Table 2).

Table 2.

Urine drug screens offered and completed

Date (week of)	Number of drug screens offered	Number of drug screens completeda
6/08/12	6	6
6/13/12	13	12
6/22/12	4	4
6/29/12	6	4
7/13/12	8	6
7/16/12	11	11
7/23/12	7	6
8/10/12	3	3

^aReasons for urine drug screen noncompletion include patient refusal, age of patient, and physician declining need for it.

Regarding the CS agreement, the process was not changed, but more provider education was delivered focusing on the importance of having signed agreements reviewed with the patient and scanned into the EMR. This provider education was delivered through e-mails and during monthly provider meetings.

The process for obtaining PDMP reports was also targeted as an area for improvement, which again included all of the patients in the CS registry. In an effort to streamline this process, the clinic panel managers were assigned the task of running the reports due for annual review and providing them to the physicians. This process occurred over a few months. By November 2012, all CS registry PDMP data had been obtained, and the process was deemed to be a success. This process continues yearly to help keep the clinic in compliance with PDMP requirements.

The largest focus revolved around the nursing CS program. By improving this program, the aims were for more patients to be enrolled, and thus monitored closely, and to improve the efficiency of the program for patients. The new process goals were to: 1) extend the pick-up hours for the patients and their families; 2) have the outpatient office assistants give out due prescriptions; 3) create a log book or signature process to document who was picking up the prescription; and 4) transfer the prescriptions to a new location near the outpatient office assistants for ease of patient pick-up. A workflow for each new process was created and finalized over 6 to 7 months (Appendix 1). Scripts were also created for the office assistants to use when talking with patients, especially around when UDS testing was needed for patients not seen by their physicians within the past 4–6 months (Appendix 2). The office assistants were notified via the EMR to schedule an appointment for the patient at the time of prescription pick-up. Finally, with implementation of this process, the clinical pharmacist provided each physician a list of his or her patients currently on CS and had the opportunity to enroll any patients, not previously enrolled, in the nursing CS program.

The clinical pharmacist was responsible for overseeing the huddle, writing and revising the new CS processes steps based on the group feedback, providing input into the CS process as a whole, and assigning homework for subsequent PDCA cycles. The clinical pharmacist was also involved in researching the requirements needed to improve the institutions’ CS quality metrics and in tracking data to report improvement to the group during and after the process changes.

This process began in May 2012 and ended in January 2013, with huddles occurring weekly, although some huddles were canceled owing to schedule conflicts of some key members. In the end, it was determined that the new process changes were effective and were able to help the clinic improve its CS registry metrics and CS process clinic flow. Health Center A’s clinic was able to move from being one of the lower-scoring clinics (out of 14 PCMH clinics in the institution) for CS quality metrics to being one of the best within the ambulatory care system and exceeding all institution CS metric goals (Table 1). The PDMP and UDS collection processes continue to be in place today, and improvement seen in metrics has persisted. Currently, the process for CS prescriptions has changed owing to the requirement of electronically submitted prescriptions for CS within the institution.

Health Center B

General information

Health Center B brought a clinical pharmacist into the quality process in 2010 through the facilitation and leadership of weekly 15-minute pharmacist-led QI team huddles. These team huddles included a clinical pharmacist lead, physicians, MAs, nurses, administration, nutrition (adult only), and a panel manager.

Case study: asthma action plans

At Health Center B, the clinical pharmacist facilitated both adult and pediatric chronic care team quality huddles with very similar structure to those in Health Center A. In general, the active issues varied between the 2 groups, with a large portion of the adult huddles devoted to improving processes and performance for adult diabetes quality metrics. The pediatric huddle, on the other hand, had a more diverse agenda, even with the limited number of quality metrics that fell under their purview. The clinical pharmacist and both groups recognized the potential to gain efficiencies by having both huddles work on a common process and metric or by sharing processes developed by one huddle with the other group. In the first few years of the huddles, however, no opportunity to capitalize on shared efficiencies presented itself.

In year 3, the pediatric huddle decided to focus on the development of a process for ensuring that patients with asthma had a current asthma action plan (AAP) and the plan was reviewed with the patient and documented in the EMR. Completing these plans in a brief physician visit was difficult and often not prioritized among the other concerns covered in the visit. MAs were already queuing up a paper template for the plan, but completion rates were low. Given that pediatric patients with asthma are high resource, there was consensus among the physician group that compliance with this process would both improve the performance on this quality metric and provide meaningful improvement to patient care.

The pediatric huddle group decided to take a different approach to tackling this problem, asking the MAs, panel managers, pharmacist, and physicians all to look at modifying and optimizing their portions of the process for AAPs. Figure 1 describes the process implemented to increase AAP completion within the clinic. A substantial increase in the metric for AAP completion was noted for the pediatric clinic, which moved Health Center B from nonreimbursable status under the health system’s pay-for-performance program (<75% compliance) to fully reimbursable (>90% compliance). The process developed and implemented through these huddles is still in place, resulting in successful rates of compliance.

Figure 1.

Physician/medical assistant best practice alert asthma action plan quality improvement process. Abbreviations used: AAP, Alert Asthma Action Plan; MA, medical assistant.

Practice implications

In both the CS registry and the AAP case reports presented, quality metrics for patient care significantly improved with process changes initiated by the implementation of clinical pharmacist–led QI huddles. Before these structured groups were established, many attempts to increase the quality metrics within the clinic were not as effective. Previous attempts included sharing quality metric numbers at clinic meetings with physician groups and other health professionals working more in their own silos to help increase the metrics.

The use of consistent pharmacist-led QI team huddles and the use of PDCA cycles provided the impetus to drive change in selected quality metrics. The clinical pharmacists involved were pivotal to organizing and helping incorporate new processes within their clinic sites. By serving as effective leaders, they were able to continue the huddle team on the overall path of success and work with all team members to keep them engaged. The PDCA cycles were a key part of the process because not every implemented change was successful the first time; many required fine-tuning and revisions to the plan.

Discussion

Although it has been shown that team huddles have a positive impact on patient outcomes, quality metrics, and safety, establishment of team huddles requires buy-in from clinic administration and care team members. Sharing data on the benefit of huddles to clinic flow, patient outcomes, and safety, as well as the impact on quality metrics, with team members aids in gaining support. Decisions about how the huddles will operate, from the time of the meetings to who is expected to attend, need to be established from the beginning. The goal of the huddles should be shared with all members, and a discussion of roles and how each team member can contribute should occur in the first huddle. In addition, setting team norms is vital. It is important that all members understand that all opinions matter, that these are “no judgement” meetings, and that all members need to contribute to make the huddles successful.

Once all members of the team have an understanding of how the huddle functions, the team should brainstorm on what their first task will be. Once this task is identified, the team will then assign “homework” to the members based on the PDCA cycle. At subsequent meetings, the members should review the previously assigned “homework” and evaluate what went well and what was identified as an area for improvement to focus on before the next meeting. The PDCA cycle method allows for the team to continuously evaluate the process change and quickly make adjustments until the desired outcome is met.

By implementing interdisciplinary QI team huddles, the PCMH clinics were able to generate additional revenue through performance measures. In the presented case studies, the interdisciplinary QI team huddles were led by PCMH clinical pharmacists. Although other health professionals can lead QI team huddles according to the processes outlined above, the infrastructure and clinical pharmacist’s dedicated time to lead the huddles were a definite advantage for consistency, communication, and feedback over several PDCA cycles.

In helping their clinics achieve more of the quality metrics set forth by health systems, clinical pharmacists can also increase the amount of metrics that qualify for this type of reimbursement. In our current situation, all incentive dollars coming into the institution from payers comes to the medical group. The medical group as a whole then decides on which metrics and goals to pay the clinics based on their performance. In addition, with more patients meeting their health goals, one might anticipate an associated reduction in health care resource utilization, including hospitalizations, emergency room visits, and overall health care costs. Thus, assigning clinical pharmacists as QI team huddle leads could fiscally benefit the health system and population health at large while improving patient care at the clinic level.

Clinical pharmacists in the ambulatory care setting focus on chronic care disease management and QI. As such, they are in an excellent position to lead team huddles focused on QI and registry management. In addition, pharmacists often interact with many different team members throughout the day, which allows them to serve as a strong facilitator for process changes within the health care team. At present, many ambulatory clinic sites across the country still do not have a clinical pharmacist as part of their care team. As clinical pharmacists are looking to establish practice within various ambulatory settings, examining how they can affect quality metrics will help to justify their role. Given that a majority of quality metrics can be affected by a clinical pharmacist, having pharmacists in these QI roles, such as leading QI team huddles, is beneficial for the clinic and for pharmacist practice.

Conclusion

Pharmacists can positively affect both patient care and reimbursement, the latter through improved ability to meet pay-for-performance metrics, when leading QI team huddles within the PCMH model. Using PDCA cycles in these huddles was an effective method to implement process changes.

Key Points.

Background:

• Clinical ambulatory care pharmacists are in key positions to improve clinic quality metrics.

Findings:

• Quality improvement team huddles led by clinical pharmacists improved outcomes and pay-for-performance measures.

• Using plan-do-check-act cycles was effective for implementing change within these patient-centered medical home–based clinics.

Appendix

Appendix 1.

Plan-do-check-act cycles for revision of the controlled substance prescription program

Step	Cycle 1	Cycle 2 changes	Final cycle
Step 1	RN/LPN prints prescriptions and has them signed by the physician.	No changes.	No changes.
Step 2	RN/LPN puts each prescription in a sealed envelope labeled with the patient name, registration number, pick-up date, who is authorized to pick up the prescription, and if the patient is due for any testing. If the patient is due for testing, the RN/LPN puts the necessary lab forms into the envelope with the prescription.	Lines for each pick-up date and signature of who is picking up the prescription were added to the envelope containing the prescription. If the patient is due for testing, a comment section was added to each pick-up date and testing information required line.	Lab order was now printed from the EMR.
Step 3	RN/LPN puts prescriptions for that week in a locked cabinet at the clerk work area.	No changes.	No changes.
Step 4	Patient comes to clerk window to pick up prescription.	No changes.	No changes.
Step 5	Prescriptions are given to patient after necessary testing, if any, is performed. (If urine drug screening is due, clerk will send patient to the lab before giving him/her the prescription. Lab slip will be included with the prescription.) If the patient him/herself did not pick up the prescription and testing is needed, clerk will inform the person that the patient will need to pick up the prescription the next month. Clerk will mark on the envelope that testing was not done and specify reason. If patient picks up the prescription and refuses testing, the clerk will send a note through the EMR to the physician.	Same as first cycle with the following changes: Person picking up the prescription signs the envelope on that date. Clerks added to the formal process that they could still provide the prescription to the patient even if he or she refuses testing.	No changes.
Step 6	If the patient is late picking up the prescription, the clerk will note this on the envelope and return to the RN/LPN to update the patient’s folder regarding new pick-up dates.	No changes.	No changes.
Step 7	Pick-up times will be from 7 AM to 7 PM Monday through Thursday and from 7 AMto 5 PM on Friday.	Pick-up times will be during normal business hours (wording changed instead of giving specific hours).	Pick-up times will be during normal business hours Monday through Friday but not Saturday.
Step 8		At the end of the day, the clerk takes all of the envelopes of the prescriptions that have been picked up and places them on the RN/LPN desk.	No changes.
Step 9			Clerks keep the key to the locked cabinet in the clerk’s desk labeled Clerk Key.

Abbreviations used: EMR, electronic medical record; LPN, licensed practical nurse; RN, registered nurse.

Appendix 2.

Outpatient office assistant scripts

Obtaining drug-comp urine:

Today you are due for a random drug screendthis is required by the University of Michigan for patients on certain medications.

If a patient refuses to go to the lab: Give the patient his or her script and send a note to the prescribing physician.

If an “authorized” person picks up medication:

Kindly explain that the patient is required to pick up next monthdwe have extended pick-up hours to our normal business hours Monday to Friday.