By Annette M. Boyle
BEDFORD, MA—A program launched in eight VA New England medical center anticoagulation clinics not only achieved its goals of improving delivery of anticoagulation care, it also continues to pay dividends in multiple other areas.
Within the VA, clinical pharmacy specialists provide direct patient care in clinics dedicated to the long-term management of anticoagulation, diabetes, hepatitis C, mental health, hypertension, hyperlipidemia and other conditions. While the VA has multiple quality improvement initiatives in traditional pharmacy areas such as dispensing and patient counseling, fewer quality programs have targeted the clinical pharmacy side of the house.
The VA’s New England region, Veterans Integrated Service Network (VISN) 1, decided in 2012 that improving the main measure of anticoagulation control for patients on warfarin, time in therapeutic range (TTR), warranted an implementation initiative that focused on introducing evidence-based clinical practices. The region’s anticoagulation clinics serve more than 5,000 veterans.
“Pharmacists are strongly data driven,” explained Megan McCullough, PhD, research health scientist at the Edith Nourse Rogers Memorial Veterans Hospital in Bedford, MA. “If there is strong evidence that any action will make a difference, that will enlist pharmacists’ support.”
The program aimed to speed adoption of a new algorithm for anticoagulation care that had a strong evidence base. “In a sense, we were updating clinical knowledge, but this algorithm really changed practice,” McCullough told U.S. Medicine. “One part of it specified that, if a patient was out of therapeutic range, they should be brought back to the clinic sooner. Initially, the pharmacists thought that they couldn’t manage that, but now all of them are doing it and we are seeing a real difference in how patients are doing.”
In addition to quickly seeing patients whose international normalized ratio (INR) were too high or too low, the critical processes of care associated with increasing TTR included not losing patients to follow up and using guideline-recommended target ranges.
The quality improvement program gave pharmacists access to a dashboard that allowed them to monitor the performance of individual patients and the clinic as a whole and to call patients who needed to come into the clinic. Clinical pharmacists and front-line staff also received feedback on their progress and how it compared to other sites, as well as suggestions for improvement.
According to a recent study published in the Annals of Pharmacotherapy, during the four years the project was active, TTR rose from 66.4% to 69.2% in VISN1 clinics. In clinics outside the region, average TTR also increased, but much more modestly, from 65.9% to 66.4%.1
The rate has continued to rise since the project officially ended and is now at 71%, said McCullough. “A year after the project stopped, internal facilitators are still having calls. They’ve put their hearts into the work and continue to check in with each other, talk about new challenges and new ways to improve their performance,” she noted.
Each clinic had one internal facilitator who participated on the project oversight committee and communicated goals and ideas to their local team. Internal facilitators did not have formal authority to make changes and frequently did not have time carved out of their schedules to permit participation.
External facilitators included experts in clinical pharmacy, implementation science, performance measurement, systems redesign and quality improvement. They coordinated education, ran journal clubs, drafted policies, provided feedback and assisted with specific challenges when requested, according to a second article on the process the project used published in Research in Social and Administrative Pharmacy.2
The structure and support of the program generated significant growth for the internal facilitators, which contributed to the success seen in the improvement in TTR, and promises to benefit other clinical pharmacy programs.
“Many clinical pharmacy specialists have extensive training and tons of skills but have never been leaders before, so we started with building their confidence in becoming informal leaders who were not afraid to make suggestions to their peers,” said McCullough. “Those skills feed on themselves, so the more confident you feel, the better you do as a leader.”
McCullough attributed the success of the program to five critical factors which could be applied to other initiatives as well:
- Have strong evidence to support change.
- Enlist pharmacy and medical center leadership.
- Get the strongest, most interested person to be the champion.
- Train the champions in leadership, quality methods and collaboration.
- Develop a mutually supportive team.
Coaching the facilitators and building a team took time, but the benefits continue to spread through the organization. “One pharmacy chief said to me that one of the things he found most impressive was how well trained the pharmacists were. He said that the investment of being occasionally short-staffed while the facilitator went to training more than paid for itself as the skills have spread to other frontline staff and the team can use their new skills on other projects. Now he knows exactly who to go to to discuss how to implement other changes,” McCollough said.
Some of the clinical pharmacy specialists who participated in the program are now working with the national hepatitis C innovation team collaborative, she noted, and the pharmacy practice is looking to see how the facilitators and the processes developed on this project can help the VA improve in other challenging areas such as mental health, pain, diabetes and HIV management.
“Four years for this project represents a substantial investment, particularly when time is of the essence as it is in the VA,” McCollough noted. “But it really does pay off in ways we didn’t anticipate—how much everyone learned, the skills the frontline staff developed, the ability to take skills to other areas. It’s been a real joy to see it spread.”
- McCullough MB, Gillespie C, Petrakis BA, Jones EA, Park AM, Lukas CV, Rose AJ. Forming and activating an internal facilitation group for successful implementation: A qualitative study. Res Social Adm Pharm. 2017 Sep-Oct;13(5):1014-1027.
- Rose AJ, Park A, Gillespie C, van Deusen Lukas C, Ozonoff A, Petrakis BA, Reisman JI, Borzecki AM, Benedict AJ, Lukesh WN, Schmoke TJ, Jones EA, Morreale AP, Ourth HL, Schlosser JE, Mayo-Smith MF, Allen AL, Witt DM, Helfrich CD, McCullough MB. Results of a Regional Effort to Improve Warfarin Management. Ann Pharmacother. 2017 May 1;51(5):373-379.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.