An Analysis of Quality Improvement Education at US Colleges of Pharmacy

INTRODUCTION

Quality improvement (QI), as defined by the Health Resources and Services Administration (HRSA), “consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.”¹ The Institute of Medicine has indicated that each health care team member should be well versed in QI so that the quality and safety of care can be continuously improved.²

Advancing quality improvement concepts in pharmacy education has been a focus of the Accreditation Council for Pharmacy Education (ACPE) in recent years for all doctor of pharmacy (PharmD) programs across the United States (US).³ The American Association of Colleges of Pharmacy (AACP) and The Center for the Advancement of Pharmaceutical Education (CAPE) also formally endorse QI as one of their educational outcomes.⁴

The extent of QI education may vary among the PharmD programs, but there is no denying its importance and impact on a pharmacist’s career. Pharmacists and other health care professionals can expect increasing levels of accountability for performance on health care quality metrics in today’s health care environment.⁵ In fact, the ACPE standards state that “application of … quality metrics to advance patient care and service delivery within and between various practice settings” should be included as part of the required elements for didactic education in PharmD programs.⁴ Encouraging education in quality improvement begins with demonstrating its significance and relevance within a pharmacy student’s education and career.

The increased relevance of health care quality in the marketplace and pharmacy practice can be used to demonstrate its applicability and importance to pharmacy students. A 2004 study by Jackson shared self-reported data demonstrating that the application of QI concepts in PharmD programs improved students’ ability to identify errors, implement methods to decrease errors in their practice setting, and raise awareness of the impact these errors can have on the health of a patient.⁶ A study by Gilligan and colleagues assessed both instructors’ and students’ perceptions of implementing QI education in the curriculum.⁷ In this study, five colleges of pharmacy that utilized some portion of the EPIQ (“Educating Pharmacy Students and Pharmacists to Improve Quality” now called “Educating Pharmacists in Quality”; Alexandria, Virginia) educational program demonstrated a statistically significant improvement in students’ self-reported QI knowledge. The EPIQ program is a possible model that other colleges of pharmacy may adopt to improve both student QI knowledge and attitudes.^7-10 The EPIQ training program and additional resources are available through the Pharmacy Quality Alliance (PQA) website.¹¹ The PQA has developed multiple measures of safe and appropriate medication use that are currently utilized by federal and state quality programs. PQA “… collaboratively promotes appropriate medication use and develops strategies for measuring and reporting performance information related to medications.”¹² Measures developed and implemented by PQA are specifically designed to be sensitive to pharmacist intervention. PQA medication safety and management measures include metrics such as statin use in patients with diabetes, high risk medications in the elderly, comprehensive medication review completion rate, and adherence measures for statins, diabetes medications, and antihypertensives. The EPIQ modules refer to these measures and facilitate discussion about the importance of QI education so students and pharmacists are better prepared to discuss implications of these metrics in pharmacy practice.

While several studies have examined the application of specific QI concepts within pharmacy curricula, a review of the literature found that recently published studies did not delve into the extent and frequency to which QI concepts were covered nor offer a comparison between the PharmD programs in the US.^7-10 More than a decade ago, however, a descriptive study conducted by Johnson and Latif investigated the quality and quantity of medication error reduction, a component of QI education, in pharmacy curricula.¹³ The investigators found that the depth and frequency of medication error instruction within pharmacy curricula was highly variable, lacked standardization, and did not include key medication error instruction components. However with a great emphasis currently placed on QI education by the ACPE and CAPE Educational Outcomes and a shift in focus within pharmacy practice to quality and patient outcomes, it has become apparent that a measure of the current status of PharmD QI education is needed.^3,4 The main purpose of this study, therefore, was to explore the breadth and depth of QI education currently offered across accredited PharmD programs in the US. A secondary objective of this study was to propose a tentative QI curriculum that could be used as guideline for pharmacy programs.

DISCUSSION

Health care is rapidly shifting from a fee-for-service system to one that emphasizes value through various pay-for-performance models; thus, the importance of offering high quality of care to patients in an affordable way has never been greater, and pharmacists are an integral part of this shift.⁵ A shift in accountability necessitates that pharmacists are prepared to take on that accountability. Yet, as the results from this study demonstrate, QI education in schools of pharmacy has not yet become a priority.

The federal government is leading the effort in quality improvement standards in several settings. The Centers for Medicare and Medicaid Services (CMS) has launched quality improvement programs for physicians, nursing homes, hospice programs, and even Medicare Part D Prescription Drug plans, which provide senior beneficiaries coverage of their medicines.²⁰ The CMS Star Rating System assesses medication safety and appropriateness, among other things, and pharmacists drive improvement in these performance metrics and the ultimate optimization of patient care. In fact, payers are beginning to identify pharmacist intervention as a fundamental way in which to improve safety for beneficiaries and increase medication adherence, which has led to several pay for performance models in the marketplace.²¹ Yet, only 58% of our respondents reported teaching the Medicare Star measures and payment incentives. This represents just one example of the many QI topics that can help PharmD students succeed in the changing health care system and grow with the profession of pharmacy. The need for quality and safety training is not limited to pharmacy education. Similar results have been found in studies assessing quality and safety education in US and Canadian medical schools.^22,23

The primary findings of this study indicate that in pharmacy schools, the broadest topics are taught the least often, and more pharmacy-specific topics are covered more frequently in pharmacy QI courses. For example, six-sigma, pharmacy quality dashboards, and Medicare STAR ratings are discussed least often, while adverse event reporting, medication reconciliation, and drug-drug interactions are addressed most often. This may be because there has been a focus on adding adverse event reporting, medication reconciliation, and drug-drug interactions into education for some time whereas the other topics are “newer” and more reflective of recent changes in the US health care system.¹³ It may take colleges or schools of pharmacy time to adapt and to add these topics to the PharmD curricula. Additionally, the pharmacy specific topics may be seen as fitting into the traditional model of pharmacy practice, whereas the broader topics may be seen as “outside” of the traditional role of the pharmacist. Nonetheless, with the changing landscape of the US health care system, the broader and least covered topics of six-sigma, pharmacy quality dashboards and Medicare STAR ratings are becoming more of a necessity to demonstrate the value of pharmacist services in the larger context of the health care market.

Another concern is that there are some programs that do not teach students the concept of how to improve quality. Pharmacists must know at a most basic level how to improve quality, whether it is on a small scale (improving workplace and workflow quality) or on a large scale (improving outcomes and patient satisfaction).^2,3

Interestingly, requiring a QI class was more likely in private schools, while requiring a QI project was more often reported by public schools. These differences in curricula are difficult to explain and require further research. Studies have previously shown that students gain a greater understanding and appreciation of quality improvement principles when completing a project.^6-8,23 Gilligan and colleagues reported more change in knowledge and attitudes when the program included a QI project as part of the educational experience.⁷ Additionally both preceptor and faculty self-reported attitudes are improved with the use of the EPIQ program.^9,10

From the returned responses, about 27% of colleges or schools of pharmacy require a standalone class dedicated to QI. These results are similar to those reported by Smith and colleagues who found standalone QI classes in only 20% of nursing schools.²⁴ QI projects, which are required in about 12% of our study respondents’ institutions, may offer more opportunities for learning, professional development, and academic distinction. Furthermore, there are two reported colleges or schools of pharmacy nationwide (3% of respondents) that require a QI class, QI project, and a senior research project. Further research will shed light on the outcomes for students who participate in programs with this extensive emphasis on QI and research.

Future research will consist of further data collection to more completely describe the QI curricula being offered within ACPE accredited colleges or schools of pharmacy. To date, an all-encompassing nationwide survey of QI education/curricula has not yet been performed. However, with a 47% response rate, more data is needed to determine if any other differences exist. Additional research will be conducted to describe exemplary colleges or schools of pharmacy that have implemented QI curricula, and will focus on describing specific programs and their QI curricula more in-depth. The goal will be to highlight examples of best practices, such as an elective QI class, required class, interprofessional class, integrated class, and project.

The profession of pharmacy is constantly changing. In order for graduates to be practicing at the highest level, they must be ready to participate in a health care system that is driven by quality and outcomes. Schools and colleges of pharmacy can use the list of topics generated for this survey to start a conversation within their curriculum committees to decide how to best incorporate these important topics. Additionally, the EPIQ training program offered by PQA is a possible model that other colleges or schools of pharmacy may adopt to improve both QI knowledge and knowledge attitudes.^7-11 Table 4 depicts a proposed QI curriculum based on EPIQ training program offered by PQA.^11,12

This study assumed that the respondents were familiar with the respective college or school of pharmacy’s QI curriculum and were able to respond appropriately. This study was limited by the small sample size and the lower than anticipated response rate. Additionally, it was sometimes difficult to locate the individual at each college or school of pharmacy who was most familiar with that program’s QI curricula. In some cases, the QI specialist was no longer at that institution and another faculty member had to fill out the questionnaire to their best ability, which was sometimes not comprehensive and could be incorrect or incomplete.