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Measurement of Clinical Pharmacy Key Performance Indicators to Focus and

Improve Your Hospital Pharmacy Practice

Article in The Canadian journal of hospital pharmacy · April 2016

DOI: 10.4212/cjhp.v69i2.1543

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INNOVATIONS IN PHARMACY PRACTICE: CLINICAL PRACTICE

Measurement of Clinical Pharmacy Key

Performance Indicators to Focus and Improve
Your Hospital Pharmacy Practice
Elaine Lo, Daniel Rainkie, William M Semchuk, Sean K Gorman, Kent Toombs, Richard S Slavik,
David Forbes, Andrea Meade, Olavo Fernandes, and Sean P Spina

INTRODUCTION WHAT ARE cpKPIs?

C linical pharmacy is defined as “a health science discipline

in which pharmacists provide patient care that optimizes
medication therapy and promotes health, wellness, and disease
Key performance indicators are quantifiable measures of
quality that can be used to track an organization’s progress toward
achieving intended goals related to process inputs, process
prevention” and “embraces the philosophy of pharmaceutical care.”1 outputs, or outcomes.8 These indicators are discrete events that,
The role of the clinical pharmacist is to promote safe, effective, and when they occur for an individual patient, have been proven to
cost-conscious drug therapy and improve patient outcomes.2 result in a positive outcome for that person. The US Agency for
Published evidence from observational studies, randomized Healthcare Research and Quality (AHRQ) defines a process
controlled trials, and systematic reviews has shown that clinical measure as “a health care-related activity performed for, on behalf
pharmacist activities improve patient, medication, and surrogate of, or by a patient” and assesses the activities carried out by health
outcomes; reduce health resource utilization and costs; reduce care professionals to deliver services.9 These types of measures are
morbidity and mortality; and improve patients’ quality of life.3-6 most useful when there is strong evidence associating processes
Despite published evidence supporting the benefits of clinical with clinically important outcomes. The AHRQ defines an
pharmacy services for health and economic outcomes, quantitative
outcome measure as “a health state of a patient resulting from
expressions that describe whether or how often a process of care
health care”, noting that such measures can encompass a
or outcome of care occurs, also known as performance indicators,
vast range of health states, including physiologic measurements,
must be monitored to ensure that these services are delivered
laboratory test results, or a patient’s symptoms, morbidity,
consistently. However, until recently, there was no established
functional state, and quality of life.10 Many “outcome measures”
consensus as to which activities are key indicators of clinical
actually employ processes of care or use of services (e.g., hospital
pharmacy performance. A grass-roots collaborative of Canadian
readmission rates) as “proxies” for patients’ health states. Key
hospital pharmacists recently addressed this unanswered question
by systematically establishing clinical pharmacy key performance performance indicators differ from workload measurement or
indicators (cpKPIs) using a Delphi technique.7 Some questions workload management because they are selected on the basis of
remain, including “What activities do pharmacists perform, and a proven association with a positive patient outcome, whereas
how consistently do they perform them?” To answer these workload measurement or management counts the frequency
questions, we first must understand what cpKPIs are; why of an activity that is not necessarily specifically known to affect
cpKPIs should be measured and reported; who will be affected outcomes for individual patients. Moreover, a cpKPI would be
by these measurements; where and how cpKPIs can be measured, selected only if the specific activity or event had been proven to
reported, and utilized: and when we should begin to capture have a positive effect on patient outcome.
cpKPIs. This article aims to address these questions about cpKPI Fernandes and others7 indicated that a cpKPI should fulfill
adoption and measurement from multiple perspectives (including the following criteria: reflect a desired quality of practice, link to
those of front-line pharmacists, leadership, external stakeholders, direct patient care, be supported by evidence of an impact on
and the public), supplemented by examples from the authors’ meaningful patient outcomes, be pharmacy- or pharmacist-
experience. sensitive, and be feasible to measure. The Delphi rounds resulted

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in identification of 8 cpKPIs (Table 1), which fell into 6 clinical opportunities for discharge medication reconciliation and
pharmacy critical activity areas: admission medication reconcili- creating a handover mechanism for pharmacists taking over care
ation, interprofessional patient care rounds, pharmaceutical care, of a service, to avoid duplication.
discharge medication reconciliation, patient education or Pharmacy leaders and hospital administrators are charged
discharge counselling, and bundled critical activity areas.7 with ensuring that pharmacists provide the best care for patients
within a given budget, thus supporting the effective use of health
WHY CAPTURE cpKPIs? care resources. In some organizations, cpKPI data have been
The Canadian consensus cpKPIs were developed to support presented to quality committees, senior management, and
improvement in the quality of patient care and to advance boards. For example, at the Regina Qu’Appelle Health Region
evidence-informed clinical pharmacy practice. They can help to and the Vancouver Island Health Authority, data are shared with
delineate the patient care expectations of a clinical pharmacist, senior management to demonstrate the value of pharmacists in
describe standards of practice, permit benchmarking within and diverse areas. Capturing the resolution of drug therapy problems
between organizations, and elevate professional accountability (DTPs) that involve high-alert drugs (as defined by the US
and transparency.7 The collaborative of Canadian hospital Institute for Safe Medication Practices) has helped to demon-
pharmacists (now becoming known as the Canadian National strate the impact of pharmacists on medication and patient safety.
cpKPI Collaborative), with its strong stake in clinical pharmacy At the University Health Network in Toronto, Ontario, cpKPIs
practice, overwhelmingly agreed that measuring the 8 consensus form part of the organization’s balanced scorecard.
cpKPIs would be useful in advancing clinical pharmacy practice Demonstrating the value of clinical pharmacy services
and improving the quality of patient care. Validation of the within business plans has become increasingly important as
importance of cpKPIs came from nonpharmacist stakeholders health authorities are required to make difficult choices about
who agreed or strongly agreed that measuring the 8 national resource allocation to optimize patient care. By capturing the
cpKPIs would be useful in advancing clinical pharmacy practice value of clinical pharmacy services through measurement of
and improving the quality of patient care.11 cpKPIs, administrators and managers have access to data that
Focusing on activities that have been shown to decrease may support maintaining or expanding clinical pharmacy services
morbidity and hospital readmission increases the likelihood that to provide appropriate evidence-based care. For example, at the
a pharmacist’s work will contribute to positive patient outcomes. Interior Health Authority in British Columbia, pharmacist
The cpKPIs can provide practical guidance to assist in prioritizing positions have been created on the basis of cpKPI data to justify
a pharmacist’s work and articulating patient care expectations. pharmacy services. In defending pharmacy resources during
Front-line pharmacists and pharmacy leaders can collaboratively periods of financial stress, cpKPI data can serve as a powerful tool
use cpKPIs as tools for self-reflection and for identifying improve- for maintaining pharmacy services. Recently, with support from
ment opportunities to advance practice. For example, at the Nova cpKPI data, leaders of the Regina Qu’Appelle Health Region
Scotia Health Authority—Central Zone, cpKPI data are shared were successful in protecting pharmacist positions against budget
among clinical pharmacy team members to generate discussion restraint measures.
and inspire creative solutions to prioritize tasks, streamline Pharmacy managers may use cpKPI data to evaluate and
workflow, and avoid redundancy. Examples of the successful use enhance patient care activities. Process measurement, such as
of cpKPIs include liaising with charge nurses to capture counting the number of patients who have received specific

Table 1. The 8 National Clinical Pharmacy Key Performance Indicators (cpKPIs)7

cpKPI Description
Medication reconciliation on admission Proportion of patients who receive documented admission medication reconciliation
(as well as resolution of identified discrepancies) performed by a pharmacist
Pharmaceutical care plan Proportion of patients for whom pharmacists have developed/initiated a pharmaceutical
care plan
Drug therapy problems Number of drug therapy problems addressed by a pharmacist per admission
Interprofessional patient care rounds Proportion of patients for whom pharmacists participate in interprofessional patient care
rounds to improve medication management
Patient education during hospital stay Proportion of patients who receive education from a pharmacist about their disease(s)
and medications(s) during their hospital stay
Patient education at discharge Proportion of patients who receive medication education by a pharmacist at discharge
Medication reconciliation at discharge Proportion of patients who receive documented discharge medication reconciliation and
resolution of identified discrepancies by a pharmacist
Bundled patient care interventions Proportion of patients who receive comprehensive direct patient care from a pharmacist
working in collaboration with the health care team

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cpKPI activities in relation to the total number of patients, can recent adopters include the Vancouver Island Health Authority
elevate the professional accountability of pharmacists and provide and the Interior Health Authority in British Columbia, as well
recognition for their work. Adopters of measurement programs as the Nova Scotia Health Authority—Central Zone. Along with
in health care have witnessed improvement in performance over site-specific data capture, the Canadian National cpKPI Collab-
time.12 At the Interior Health Authority, pharmacists capture orative has begun initial groundwork for the development of a
3 aspects of a resolved DTP: disease state, drug, and intervention. national registry of Canadian cpKPIs, to facilitate data collection
Feedback based on the captured aggregate data across the at individual sites and analysis at the local level and then more
organization is given to all clinical pharmacists, as a group, to broadly using a comparative national analysis.
encourage practice toward resolving DTPs that are predefined as At the University Health Network, for example, a clinical
reflecting the highest-quality evidence-based pharmacotherapy metrics “cross-walk” document was developed through live focus
interventions, such as adding an angiotensin-converting enzyme groups, during which front-line pharmacists summarized their
inhibitor for a patient with heart failure in the absence of opinions about desired attributes for a cpKPI-capture system.
contraindications. Nonetheless, cpKPIs represent only one type “Easy to use and intuitive” was voted by most sites as an impor-
of indicator on the performance dashboard, and there are many tant attribute for success in capturing these data. For example,
components of a pharmacist’s work that these indicators do not building tracking into existing electronic patient care systems,
capture. designing a data-entry interface with tick box predominance, and
The publicly funded health care system is increasingly auto-populating fields are features that achieve ease of use.
required to be accountable for the value it provides. Across The authors of the current article conducted semistructured
Canada, the provinces allocate, on average, about 38 cents of interviews with Canadian pharmacy leaders known to be
every budgeted dollar toward health care.13 A recent newspaper involved in cpKPI, which showed that various cpKPI collection
article stated that $3.6 billion was spent to fund 10 000 phys- strategies are currently in place, including paper-based collection,
icians in 2011/2012, with no mechanism on the government’s hospital-wide electronic health records, Microsoft Access
part to ensure that physician services are achieving value for databases (Microsoft; https://products.office.com/en-ca/access),
money.14 The same scrutiny should be imposed on pharmacists HanDBase software (DDH Software Inc; www.ddhsoftware.com/
in the future as budget pressures continue to escalate. Data for handbase.html), Emerald Health Information Systems
cpKPIs may be useful metrics to better inform taxpayers and (www.emeraldhis.com/), and Google Forms (https:// www.google.
external stakeholders on the value of pharmacists to patient care. ca/forms/about). Examples of cpKPIs that are tracked nationally
by these organizations are described in Table 2.
WHO IS AFFECTED BY cpKPIs? At sites with established clinical intervention tracking
programs, a shift to collecting cpKPI may be less of a challenge
The ultimate goal of cpKPI measurement and reporting is
than at sites that do not currently track pharmacist clinical
to advance clinical pharmacy practice and thus to improve the
interventions on a routine basis. Barriers and proposed solutions,
quality of patient care. Patients are affected by the care they
based on the current authors’ experiences, are summarized in
receive from pharmacists who deliver high-value activities proven
Table 3.
to optimize outcomes. Targeting a consistent suite of cpKPIs may
Front-line pharmacists may not routinely track clinical
result in the establishment of expectations of pharmacist services
metrics; therefore, an implementation challenge arises when these
for patients and the health care team. Front-line pharmacists are
pharmacists do not see the authentic, multidimensional value of
tasked with providing and documenting their care in collabora-
capturing cpKPIs and instead perceive their integration as a
tion with other care team members. Measuring and reporting
top–down mandate. Most pharmacists are inspired by influential
cpKPIs will also affect other stakeholders, including pharmacy
patient care enhancements. As such, reiterating how performing
leadership, interprofessional team members, and nonpharmacy cpKPI activities has been shown to positively influence morbidity
administrators. Pharmacy leadership analyzes and evaluates the and readmission is important. Harmonizing cpKPIs with local
cpKPI data generated to better understand the gaps in knowledge and health region priorities, Accreditation Canada, and CSHP
and skills of their pharmacists in order to support their profes- 2015 paints the “big picture” and helps to align priorities.
sional development. Rather than convincing front-line staff to “buy in” to
pre-set ideas, leaders can actively seek the support of pharmacists
WHERE ARE cpKPIs BEING CAPTURED? by instilling an authentic sense of “ownership” and involving staff
Some sites, such as the Regina Qu’Appelle Health Region members in meaningful cpKPI decision-making. Pharmacists
in Saskatchewan and the University Health Network in Toronto, value the efficiency of a system that captures data in a fashion
started capturing select cpKPIs over a decade ago, and other sites that minimizes time taken away from patient care. The University
are now beginning to collect designated indicators. These more Health Network and the Nova Scotia Health Authority—Central

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Table 2. Sample of cpKPIs Currently Being Captured across Canada

cpKPI Captured Vancouver Island Interior Health Qu’Appelle University Health Nova Scotia
Health Authority Authority Health Region Network Health
(BC) (BC) (SK) (ON) Authority (NS)
Medication reconciliation √ √* √ √ √
on admission
Pharmaceutical care plan √* √† √
Drug therapy problem √ √ √ √
Disease √ √
Drug √ √ √
Type √ √ √
Significance and likelihood √
of future event
Interprofessional patient care rounds √ √* √ √† √
Patient education during hospital stay √ √* √ √† √
Patient education at discharge √ √* √† √
Medication reconciliation at discharge √ √* √ √
Bundled patient care interventions √* √† √
Data-capture software Microsoft HanDBase Google Forms Hospital-wide Emerald Health
Access database electronic Information
health record Systems
Users of data F, S F, S, E F, S F, S, E F, S
BC = British Columbia, cpKPI = clinical pharmacy key performance indicators, E = external stakeholders (patients/public),
F = front-line pharmacist, NS = Nova Scotia, ON = Ontario, S = senior management, SK = Saskatchewan.
*Completed as part of a research project; not continuously captured.
†Selected sites at this location.

Zone are examples of organizations where cpKPIs were rolled out Translating the cpKPI data into information that is useful
through a grass-roots movement championed by inspired (and to the public and external stakeholders is critical. For example,
inspiring) front-line pharmacists. Such active leadership by front- Mourao and others11 found in their stakeholder feedback study
line staff can enhance momentum and acceptance for cpKPI that discharge medication reconciliation was the cpKPI most
capture among peer pharmacists. likely to influence decisions to fund or use clinical pharmacist
services among nonpatient stakeholders. Several approaches have
WHAT ARE THE BENEFITS been taken by health authorities to assist external stakeholders in
OF CAPTURING cpKPIs? understanding cpKPI data:
• Evidence-based extrapolation: An extrapolation was
The Interior Health Authority has used trend analysis to
performed by the Interior Health Authority on the basis of
provide insight into processes over time. Unpublished data
RCT data5,6 (see Table 4). The organization’s press release
collected between 2009 and 2014 were used to define strategies
for Pharmacy Day 201416-18 presented cumulative data for
pertaining to pharmacists’ deployment to care areas. These data
resolved DTPs and explained how the data translated into
showed that pharmacists who were integrated into care teams reductions in emergency room visits, drug-related readmis-
were more effective than pharmacists who performed trouble- sions, and overall system costs.
shooting on multiple wards. Within the data, it was apparent • Real-life correlation: In an observational cohort study, the
that the majority of resolved DTPs had occurred at tertiary care University Health Network tracked outcomes for 8678
centres, rather than rural centres. These data are useful for patients who received a select cpKPI-based intervention on
ensuring that pharmacist resources are aligned to generate the one internal medicine ward over 5 years. With adjustment
greatest clinical impact. Finally, the data are useful in perform- through propensity analysis in this small pilot study, the
ance evaluation, as they allow discussion of personalized trends organization detected a nonsignificant trend (reduction in
in resolved DTPs over time, rather than an absolute number or 30-day hospital visits and readmissions by 2%) that can be
quota. explored more comprehensively in larger studies.19 Convert-
One of the goals of capturing cpKPIs, especially in a national ing abstract cpKPI data into tangible outcomes (such as
database, is to standardize, advance, and benchmark (internally hospital readmissions averted and monetary worth) helps
and externally) clinical pharmacy practice. By developing the public, as well as nonpharmacist senior management, to
comparison strategies, we can share and learn best practices and appreciate the value contributed by clinical pharmacists.
advance the profession. A challenge in setting benchmarks is • Heat matrix: For each resolved DTP, pharmacists at the
deciding on the appropriate denominator. Vancouver Island Health Authority estimate the clinical

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Table 3. Purposes, Challenges, and Solutions of Implementing Clinical Pharmacy Key Performance
Indicators (cpKPIs)
Rationale and Utility of cpKPIs Barriers and Challenges Authors’ Proposed Solutions
Front-line pharmacists
Provide reference summary of: Time required to • Automate data collection where possible (e.g.,
• Activities proven to improve outcomes document cpKPIs self-populated patient name and medical record
• Priority of patient care activities to optimize number)
impact on outcomes • Enable pull-down data entry at point of care
• Pharmacists’ role that can be promoted to other • Incorporate into electronic health care system
members of interdisciplinary team Complexity of indicator • Simplify platform for documentation;
• Performance expectations with the employer documentation e.g., check boxes
• Collect minimal amount of required information
Cost • Use existing or least expensive hardware and
software data platforms
Daily tracking and • Make it a daily routine for all pharmacists
reporting consistency • Pharmacist-to-pharmacist accountability
• Live capture or end-of-day input
Practice leaders and pharmacy managers
Provide reference summary for: Front-line staff ownership • Access and use cpKPI knowledge mobilization kit*
• Justifying prioritization of scarce clinical and uptake • Regularly present collected data to staff
pharmacy services • Engage front-line staff in change management
• Justifying expansion of clinical pharmacy services and leadership processes
• Explaining value and estimating return on Lack of accuracy • Provide training during orientation and
investment in clinical pharmacy services and precision interim audits
• Determining effectiveness and efficiency of • Facilitate understanding to resolve local
clinical pharmacy services apprehension
• Setting benchmarks Effective change management • Change management strategies
• Performance management to implement and sustain
cpKPIs with everyday practice
Trend analysis • Set benchmarks through comparison between
clinical wards, hospitals, or health regions
• Be cautious in analyzing trends
Patient, taxpayers, external stakeholders
Provide reference summary of: Comprehension and • Correlate with and extrapolate to meaningful
• Clinical pharmacists’ role interpretation of cpKPI data patient outcomes (e.g., hospital readmissions),
• Activities proven to improve patient outcomes with recognized limitations
• Patient expectations • Explain the clinical significance of cpKPIs
• Activities to ensure pharmacist accountability • Tailor presentation according to the interest
• Appropriate use of resources to promote a more of audience
sustainable health care system • Acknowledge limitations of reporting isolated
indicators versus a dashboard of indicators
• Acknowledge differences in systems and human
resources across heterogeneous sites
*This kit is now available at www.cshp.ca/productsServices/cpKPI/index_e.asp

Table 4. Evidence-Based Extrapolation Performed by the Interior Health Authority,

British Columbia15
Outcome Relative Reduction* Annual Event
Reduction Rate†
Reduction in visits to emergency department 47% 19 177/year
Reduction in hospital visits 16% 21 804/year
Reduction in drug-related readmissions 80% 15 689/year
Reduction in readmissions 20% 2 506/year
Estimated cost saving $230/patient $19 million
*Based on data from randomized controlled trials.5,6
†Based on 15 5701 drug therapy problems resolved from January 1, 2009, to December 31, 2014.
The ratio extrapolation assumes a similar number of drug therapy problems resolved per patient,
and similar direct and indirect costs from original trials.

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significance of the potential adverse outcome associated with CONCLUSION

the problem and the likelihood of that outcome occurring
had there not been an intervention. This “heat map” With the recent publication of systematically developed
provides a visual representation of the risk to patients that consensus cpKPIs, a nationwide database capturing cpKPIs from
has been averted as a consequence of clinical pharmacy multiple institutions may be feasible in the foreseeable future.
services (Figure 1). This approach was adapted from the Implementing, measuring, and reporting cpKPIs will have many
Hazard Scoring Matrix promoted by the Institute for Safe advantages. For pharmacists, a defined list of cpKPIs can serve
Medication Practices.22 as a basis for prioritizing patient care activities. For leadership,
• Tailor to your audience: Pharmacists may more effectively
cpKPI data can be used to demonstrate practitioner value, can
deliver their message by tailoring key information in their
provide metrics for evaluating improvement initiatives, and can
presentations to the interest most valued by their specific
audience. inform performance evaluation. For patients, information
on cpKPI measurements can demonstrate accountability and
WHEN SHOULD WE START CAPTURING illustrate the impact of pharmacists on patient care. As a whole,
cpKPIs? cpKPIs contribute to improved patient care and advance the
With the publication of a nationally agreed upon group of profession of hospital pharmacy. In time, consensus cpKPIs can
cpKPIs, it is appropriate to start capturing these indicators across be developed for primary care and community-based practices.
Canada now. The time to capture cpKPIs is now!

Figure 1. “Heat matrix” from the Vancouver Island Health Authority for the period April 1 to October 1, 2015. Data values
represent numbers of resolved drug therapy problems (DTPs) in each risk category, where the risk categories are defined by
estimates of the clinical significance of the potential adverse outcomes and the likelihood of those outcomes occurring had
there not been an intervention. “No significance” means that the DTP had no clinical importance for the patient. “Minor
significance” means that the DTP was of little clinical importance for the patient; small adjustments to therapy were required
but were not expected to significantly alter hospital stay, resource utilization, or clinical outcome. “Moderate significance”
means that the DTP required intervention leading to moderate benefit for the patient; adjustments to therapy were expected
to enhance the effectiveness of drug therapy, producing minor reductions in patient morbidity or treatment costs. “Major
significance” means that the DTP required an intervention to prevent a moderate to major or reversible detrimental effect or
the DTP required an adjustment of therapy on the basis of accepted evidence-based guidelines. “Extremely significant”
means that the DTP required an intervention to save the patient’s life or to prevent severe or irreversible detrimental effects.
The aforementioned significance criteria were adapted from Kumar and others20 and Blix.21

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15. Slavik RS. Pharmacy: trusted care when and where you need it [oral indicators for hospital pharmacists. No other competing interests were
presentation]. Interior Health Pharmacy Awareness Month Campaign; 2015 declared.
Mar 25; Kelowna (BC). Address correspondence to:
16. Pharmacy Day highlights vital role of teams throughout Interior Health Dr Sean P Spina
[news release]. Kelowna (BC): Interior Health Authority; 2014 Mar 14. Vancouver Island Health Authority Pharmacy Services
17. Pharmacy Day in B.C. Interior Daily News [Penticton (BC)]. 2014 Mar 24. Royal Jubilee Hospital
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interprofessional medication reconciliation from admission to discharge
e-mail: [email protected]
reduce post-discharge patient emergency department visits and hospital
readmissions [abstract]. Pharmacotherapy. 2012;32(10):e219. Funding: None received.

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