Advancing Health Literacy Practices in Pharmacy through Quality Improvement – Part II

1. Advancing Health Literacy Practices in Pharmacy through Quality Improvement – Part II Curricular Modules for Pharmacy Faculty

2. Overview • Health literacy quality improvement • Exploring potential solutions • Studying the solutions and implementing effective strategies • Lessons from the field

3. HEALTH LITERACY QUALITY IMPROVEMENT (qi)

4. Health Literacy QI • There are several potential challenges that patients with limited health literacy may encounter at the pharmacy, or practices that may pose obstacles: • Limited staff awareness of health literacy • Poor signage • High-level written materials • Poor communication practices • Limited use of strategies to support patient comprehension

5. Health Literacy QI (cont’d) • There are several opportunities to improve the health literacy practices of pharmacists, staff and pharmacies: • Assess pharmacy health literacy practices • Identify potential problems • Explore and study potential solutions • Implement effective strategies

6. POTENTIAL SOLUTIONS TO COMMON HEALTH LITERACY ISSUES IN PHARMACY

7. Potential Solutions • Once a pharmacy has identified issues or problems, they can explore and study potential solutions. • Remove physical barriers • Increase knowledge and awareness • Improve written materials • Improve communication • Facilitate & confirm patient’s comprehension of their medications and how to take them • Resources for solutions • AHRQ’s Health Literacy Universal Precautions Toolkit

8. Potential Solutions (cont’d) • Increase pharmacy staff or students knowledge and awareness of health literacy: • Train staff on health literacy • Have staff watch a video on health literacy • Provide a continuing education (CE) article on health literacy to staff • Regularly post health literacy facts on a bulletin board or in a newsletter Potential Resource: AHRQ’s Health Literacy Universal Precautions Toolkit

9. Potential Solutions (cont’d). • Improve written materials • Assess and/or revise materials following existing guidelines • Use existing high-quality materials from credible sources • Offer materials in language of patients Potential Resource: AHRQ’s Health Literacy Universal Precautions Toolkit

10. Potential Solutions (cont’d). • Improve communication • Explain things using everyday words • Repeat key messages/actions • Encourage questions • Use teach-back • Teach-back can be an effective technique for health care professionals to use to check clarity and understanding. Potential Resource: AHRQ’s Health Literacy Universal Precautions Toolkit

11. Potential Solutions (con’t.).. • Facilitate patient’s comprehension and how to take their medications • Develop a list of the patient’s medication and the schedule for taking them • How to Create a Pill Card (Jacobson, 2007) • APhA’s MTM medication record tool • ASHP’s My Medicine List • Use a pill box for the patient’s medications • Help a patient understand, for example, that every 12 hours means 7am and 7pm Potential Resource: AHRQ’s Health Literacy Universal Precautions Toolkit

12. study the potential solutions and Implement effective strategies

13. Study Potential Solutions • Now, given the potential solutions to address the health literacy issues of the pharmacy, you need to study the effect. • Implement a quality improvement (QI) project, like the Plan – Do – Study – Act (PDSA) model described earlier.

14. In-Class Exercise • See Activity Guide #16. • Break into groups of 3-5; you have 30 mins • Complete a PDSA cycle worksheet for a pharmacy that wants to incorporate teach-back into counseling on new prescriptions • IHI PDSA Worksheet: http://www.ihi.org/knowledge/Pages/Tools/PlanDoStudyActWorksheet.aspx • Health Literacy Universal Precautions Toolkit PDSA worksheet http://www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf • Pick a person to present to the class

15. Lessons from the field

16. Pharmacy Case Studies • Lessons on QI from several pharmacies who used the assessment tool to assess their health literacy practices • The case study pharmacies included: • Supermarket chain pharmacy • Large retail chain pharmacy • Independent pharmacy • Clinic-based pharmacy • Hospital outpatient • 340B pharmacies

17. Pharmacy Case Studies (con’t.) SOURCE: Shoemaker SJ, Wasserman M, Staub-DeLong L. Understanding facilitators and barriers to quality improvement (QI) adoption and implementation in pharmacies: Results from an AHRQ health literacy QI study in pharmacies. American Pharmacists Association Annual Meeting, Seattle, WA. March 2011. Barriers to Implementation Fluctuating and unpredictable pharmacy workloads prevented consistent attention to tool implementation Lack of communication in pharmacies Overwhelming tool length Facilitators to Implementation • Available staff to implement (e.g., resident, student, faculty) • Ability to implement discrete parts of the Assessment Tool • Support from the pharmacy management

18. Pharmacy Case Studies (cont’d). • Key Lessons Learned • Interventions/tools should be adaptable. • Change champions are important. • Align and integrate QI initiatives with pharmacy’s priorities (e.g., MTM). • The Assessment Tool was used by residents’ /students’ to fulfill their project requirements (PharmD thesis and residency project). • Clinical faculty, residents, and students were key to implementation in pharmacies.

19. Summary • Quality improvement (QI) techniques can be effective strategies for advancing the health literacy practices of pharmacies and pharmacists. • The Plan-Do-Study-Act (PDSA) QI model can be an easy-to-use model for PharmD students and residents to use for their required projects.

20. References • American Society of Health-System Pharmacists. The Pharmacist’s Role in Quality Improvement. Accessed at: http://www.ashp.org/DocLibrary/Policy/QII/RoleinQI.aspx • DeWalt DA, Callahan LF, Hawk VH, Broucksou KA, Hink A, Rudd R, Brach C. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. April 2010. • Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: updating the cost-of-illness model. J Am Pharm Assoc (Wash). 2001 Mar-Apr;41(2):192-9. • Institute for Healthcare Improvement (IHI) PDSA Worksheet for Testing Change. Accessed at: http://www.ihi.org/knowledge/Pages/Tools/PlanDoStudyActWorksheet.aspx • Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academy Press, 2001).

21. References (cont’d) • Institute of Medicine, Preventing Medication Errors: Quality Chasm Series. (Washington: National Academy Press, 2006). • Jacobson KL, Gazmararian JA, Kripalanie S, McMorris KJ, Blake SC, Brach C. Is Our Pharmacy Meeting Patients’ Needs? A Pharmacy Health Literacy Assessment Tool User’s Guide. (Prepared under contract No. 290-00-0011 TO7.) AHRQ Publication No. 07-0051. Rockville, MD: Agency for Healthcare Research and Quality: October 2007 • Johnson JA, Bootman JL. Drug-related morbidity and mortality: a cost-of-illness model. Arch Int Med.1995;155:1949-56. • Kohn L T, Corrigan J M., Donaldson MS (Institute of Medicine) To err is human: building a safer health system. Washington, DC: National Academy Press, 2000. • Ogrinc G, Nierenberg and DW, Batalden PW. Building Experiential Learning about Quality Improvement Into A Medical School Curriculum: The Dartmouth Experience. Health Affairs, 30, no.4 (2011):716-722.Accessed at: http://content.healthaffairs.org/content/30/4/716.full.pdf+html

22. References (cont’d). • Pharmacy Quality Alliance . (2009). Educating Pharmacy Students and Pharmacists to Improve Quality (EPIQ). Accessed at: http://www.pqaalliance.org/files/EPIQ-Flyer_MAR2010.pdf • Shoemaker SJ, Wasserman M, Staub-DeLong L. Understanding facilitators and barriers to quality improvement (QI) adoption and implementation in pharmacies: Results from an AHRQ health literacy QI study in pharmacies. American Pharmacists Association Meeting in Seattle, WA. March 2011. • Warholak TL, Nau DP. (2010). Quality and safety in pharmacy practice. McGraw-Hill; New York, NY.