CHAPTER 28

COMMITTEE FUNCTIONS Committees in the Nursing Home

I. Continuous Quality Improvement Program - Medical Errors Committee Consultant Pharmacist participation Required by Florida Board of Pharmacy (see page 29.3)

II. Quality Assessment and Assurance Committee:

II. Pharmaceutical Service Committee:

III. Infection Committee:

IV. Patient Care Plan Committee:

V. Restraint Committee

VI. Psych Committee

VII. JCAHO Committee

VIII. Pharmacy & Therapeutics Committee

28.2 64B16-27.300 Standards of Practice - Continuous Quality Improvement Program. (1) “Continuous Quality Improvement Program” means a system of standards and procedures to identify and evaluate quality-related events and improve patient care. (2) “Quality-Related Event” means the inappropriate dispensing or administration of a prescribed medication including: (a) A variation from the prescriber’s prescription order, including, but not limited to: 1. Incorrect drug; 2. Incorrect drug strength; 3. Incorrect dosage form; 4. Incorrect patient; or 5. Inadequate or incorrect packaging, labeling, or directions.

(b) A failure to identify and manage: 1. Over-utilization or under-utilization; 2. Therapeutic duplication; 3. Drug-disease contraindications; 4. Drug-drug interactions; 5. Incorrect drug dosage or duration of drug treatment; 6. Drug-allergy interactions; or 7. Clinical abuse/misuse.

(3)(a) Each pharmacy shall establish a Continuous Quality Improvement Program which program shall be described in the pharmacy’s policy and procedure manual and, at a minimum shall contain: 1. Provisions for a Continuous Quality Improvement Committee that may be comprised of staff members of the pharmacy, including pharmacists, pharmacy interns, pharmacy technicians, clerical staff, and other personnel deemed necessary by the prescription department manager or the consultant pharmacist of record; 2. Provisions for the prescription department manager or the consultant pharmacist of record to ensure that the committee conducts a review of Quality Related Events at least every three months. 3. A planned process to record, measure, assess, and improve the quality of patient care; and 4. The procedure for reviewing Quality Related Events.

(b) As a component of its Continuous Quality Improvement Program, each pharmacy shall assure that, following a Quality-Related Event, all reasonably necessary steps have been taken to remedy any problem for the patient. (c) At a minimum, the review shall consider the effects on quality of the pharmacy system due to staffing levels, workflow, and technological support. (4) Each Quality-Related Event that occurs, or is alleged to have occurred, as the result of activities in a pharmacy, shall be documented in a written record or computer database created solely for that purpose. The Quality-Related Event shall be initially documented by the pharmacist to whom it is described, and it shall be recorded on the same day of its having been described to the pharmacist. Documentation of a Quality-Related Event shall include a description of the event that is sufficient to permit categorization and analysis of the event. Pharmacists shall maintain such records at least until the event has been considered by the committee and incorporated in the summary required in subsection (5) below. (5) Records maintained as a component of a pharmacy Continuous Quality Improvement Program are confidential under the provisions of Section 766.101, F.S. In order to determine compliance the Department may review the policy and procedures and a Summarization of Quality-Related Events. The summarization document shall analyze remedial measures undertaken following a Quality-Related Event. No patient name or employee name shall be included in this summarization. The summarization shall be maintained for two years. Records are considered peer-review documents and are not subject to discovery in civil litigation or administrative actions.

Specific Authority 465.0155 FS. Law Implemented 465.0155 FS. History–New 7-15-99, Amended 1-2-02, 6-16-03, 11- 18-07.

28.3 NURSING HOME

SAMPLE POLICY & METHODS

Consultant Pharmacist’s Quarterly Report

POLICY:

The consultant pharmacist is to submit to the Quality Assessment & Assurance Committee, at least quarterly, a written report on the status of the facility’s pharmaceutical service and staff performance.

METHOD:

1. The consultant pharmacist is to submit to the Quality Assessment & Assurance Committee by the next month following each calendar quarter, a written report on the status of the facility’s pharmaceutical service and staff performance.

2. The report is to include but not be limited to:

a. A review and assessment of compliance with any plan of action previously adopted by the Quality Assessment & Assurance Committee.

b. A review and ongoing assessment of compliance with all of the facility’s drug- related policies and procedures including but not limited to those pertaining to ordering and dispensing; prompt and timely provision; receipt, storage, control, distribution, record keeping, disposal, reconciliation and accountability of all drugs and biologicals.

c. Recommendations, if any, for improving the delivery of pharmaceutical service, with the goal of correcting or preventing instances of noncompliance and enhancing the level of patient care in the facility.

d. A proposed plan of action for assisting in the implementation of corrective and preventive strategies for enhancing the level of pharmaceutical service in the facility.

e. The administrator is responsible for maintaining these reports on file in the facility for at least one (1) year.

28.4 NURSING HOME

SAMPLE REPORT QUARTERLY PHARMACY REVIEW OF SAMPLE FACILITY JULY 2009 THROUGH SEPTEMBER 2009

A total of 55 hours of consultant time was spent in the facility during this quarter. A total of 68 recommendations have been left this quarter. These recommendations can be broken down into the following categories:

0 - involved missing blood pressures when required 7 - involved missing pulses when lanoxin was in use 0 - involved missing or incomplete diagnosis 27 -involved charting omissions 2 - involved incomplete documentation on administered prn's. 2 - involved suggested changes in current therapy. 0 - involved suggested lab work 7 - involved missing information on prn order 15 -involved an antipsychotic order 8 - involved an anxiolytic order

I. PATIENT MEDICATIONS

The meds were found to be well organized with current labels. There were minimal duplications noted. All liquid containers and liquid cabinets were found clean. No outdated patient meds were found this quarter.

II. TREATMENT CARTS

Treatment cabinets and carts were found very neat throughout the quarter. There were no outdated products found. All treatments contained current labels. No discontinued products were noted.

III. REFRIGERATED MEDS

All three refrigerators were found to be in the safe zone throughout the quarter. There was no frost build-up and no food products were found this quarter. Puncture dates and expiration dates on insulin and miacalcin remained clean this quarter.

IV. MEDICATION RECORD SHEETS

Medication sheets were in general neat and orderly. Charting omissions were down this quarter. The reporting of episodes and side effects on antipsychotic and anxiolytic flow sheets remains good during the past quarter.

V. CONTROLLED SUBSTANCES

Controlled substances were destroyed during august.

VI. REFERENCE MATERIALS

All needed reference materials are present at each nursing station. The procedure manual was completely reviewed and updated during September.

28.5 VII. EMERGENCY BOXES

All 3 EDK's were found to be in good order throughout the quarter.

VIII. PRESCRIPTION USAGE

JULY AUGUST SEPTEMBER 1ST FLOOR 8.6 8.6 7.9 2ND FLOOR 6.7 6.3 6.5 3RD FLOOR 9.4 9.3 9.0

FACILITY AVERAGE 8.0 8.0 7.8

IX. PSYCHOACTIVE USE IN THE FACILITY

PATIENTS % OF POP AS OF 9/09

PATIENTS ON ANTIPSYCHOTICS 27 23% PATIENTS ON ANXIOLYTICS 42 35% PATIENTS ON ANTIDEPRESSANTS 41 34% PATIENTS W O.B.S. OR DEMENTIA 68 57%

AS OF 6/09

PATIENTS ON ANTIPSYCHOTICS 21 17.5% PATIENTS ON ANXIOLYTICS 40 33% PATIENTS ON ANTIDEPRESSANTS 34 28% PATIENTS W O.B.S. OR DEMENTIA 70 58%

AS OF 3/09

PATIENTS ON ANTIPSYCHOTICS 27 22.5% PATIENTS ON ANXIOLYTICS 35 29% PATIENTS ON ANTIDEPRESSANTS 36 30% PATIENTS W O.B.S. OR DEMENTIA 71 59%

AS OF 12/09

PATIENTS ON ANTIPSYCHOTICS 22 18% PATIENTS ON ANXIOLYTICS 28 23% PATIENTS ON ANTIDEPRESSANTS 30 25% PATIENTS W O.B.S. OR DEMENTIA 79 66%

SINCERELY,

CONSULTANT PHARMACIST

28.6 COMMITTEES IN THE HOSPITAL Function

 Enhance communication  Problem solve  Improve performance

PREPARATION, PREPARATION, PREPARATION

REQUIRED: CQI, functions of Pharmacy and Therapeutics Committee, and “pharmacy director should be involved in those committees responsible for establishing medication related policies and procedures” according to Medicare COP (482.25 (a)(1) and (b)).

Committee Type  Medical Staff  Hospital

EXAMPLES  Institution Review Board (IRB) ---- research  Management of Information (medical forms and abbreviations)  Performance Improvement Committee  Infection Control  Resuscitation Committee  Materials Use Standardization Team  Utilization review or resource Management  Patient Education  Pain Team  Pharmacy and Therapeutics Committee

28.7 PHARMACY AND THERAPEUTICS COMMITTEE

Primary purpose

 Advisory to medical staff on matters related to drug therapy

 Educational

Organization

 Medical Staff Committee – may need Medical Executive Committee and/or Board of Trustee approval on actions

 Membership: physicians, pharmacists, nurses, hospital administration, quality management, others

 At least 6 times per year recommended

 May use Sub-Committees o Formulary o Medication Use Analysis o Antibiotic Use, o Nutrition o Drug Safety

Functions

 Formulary management o Additions and deletions o Therapeutic/formulary interchange o Clinical practice guidelines o Restrict non-formulary medications

 Manages policies and procedures on selection, distribution, use and administration of medications o Purchasing procedures o Protocols that transfer authority for product selection and dosing from prescribers to pharmacy o Pharmacy consultation  Dosage adjustment  Drug information  Pharmacokinetics  Antimicrobial stewardship  Anticoagulation

28.8  Nutritional support  Patient education  Pain management  Compliance and medication history

 Cost effective therapy

 Medication safety

 Medication use indicators & performance improvement

 Adverse drug reaction reporting  Medication use evaluation  Medication variance reports

Pharmacists’ role on the committee – critical to success

Reference: ASHP Statement on the Pharmacy and Therapeutics Committee. http://www.ashp.org/bestpractices/formulary-mgmt/Form_St_PTComm.pdf

28.9