/publications/issue/2008/2008-10/2008-10-8710

Editor's Note: Never Events, Pay-for-Performance, and the Pharmacist's Role

Author: James C. McAllister III, MS, FASHP


Mr. McAllister is a health-systems consultant based in Chapel Hill, North Carolina.


In 2002, the National Quality Forum (NQF) endorsed a list of 27 adverse events "...that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability." The list of events includes such things as wrong-site surgery, an infant discharged to the wrong person, and patient death or serious disability associated with a medication error. At the time, NQF appeared to have been focused on encouraging self-reporting such incidents to organizations, like the Joint Commission, that hold provider organizations accountable for quality of care.

In an October 2006 press release, NQF added a new event and re-emphasized that the events were "...of concern to both the public and health care professionals and providers; clearly identifiable and measurable (and thus feasible to include in a reporting system); and of a nature such that the risk of occurrence is influenced by the policies and procedures of the health care organization." As one might expect, many states began to require public reporting of the events.

Initially driven by the 2001 Institute of Medicine report "Crossing the Quality Chasm: A New Health System for the 21st Century," discussions and debates occurred concurrently about the strategy of linking quality with reimbursement. The Centers for Medicare & Medicaid Services (CMS) leveraged its authority to create specific requirements to improve quality of care through financial incentives for hospitals (it should be noted that the incentive is the loss of about 4% of their typical reimbursement, rather than any additional reimbursement). Sharing the information collected with the public, as required by CMS, should assist patients in the selection of health care providers based on past performance. CMS also intends to withhold payment when patients develop certain preventable conditions resulting from selected "never events." Following quickly in the footsteps of the government, private insurers began to develop lists of errors that they would not pay for.

The implications for all pharmacists are considerable, because the majority of the pay-for-performance measures are related to the use of drugs, and our societal mission is to assume responsibility for helping patients make the best use of their medicines and improving drug therapy outcomes. It is abundantly clear that hospital executives understand the implications of these new requirements and are looking for support to achieve their goals. First, we need to learn about these changes and understand their implications. Two helpful resources include the American Society of Health-System Pharmacists' Quality Improvement Initiative resource center (www.ashp.org/qii), and a recent article, which I recommend as a comprehensive overview of the issue, by Bohanek and Grossbart ("Pharmacists' role in improving quality of care," published in the August 15, 2008, issue of the American Journal of HealthSystem Pharmacy).

Hospital pharmacy directors must ensure that the strategic plans and mission of the department are closely aligned with those of the hospital and that the staff understands and commits to meeting if not exceeding their quality improvement expectations. Participation of and leadership by pharmacy staff in multidisciplinary planning to ensure optimal reimbursement and quality improvement is critical, and the director of pharmacy should showcase his or her efforts at every opportunity. Similarly, we should request and substantiate additional resources to enhance quality and optimize reimbursement. Pharmacy practitioners should commit to ensuring compliance with established hospital guidelines to achieve hospital quality and reimbursement goals.

Bloggers (mostly physicians) on numerous Web sites are railing against these new expectations, and some valid points have been made. Pharmacists should promote the evidence-based development of standards that have quality and reimbursement implications. Some providers may lapse into a "defensive medicine" mode to ensure compliance with respect to lab studies ordered or drugs prescribed. This must be avoided. Similarly, these new expectations should not limit access to medical care due to an institutional fear of certain patient types, conditions, or medical history. Data collection will become increasingly important now and in the future to ensure that we can monitor progress or to challenge current expectations. Pharmacists can make a difference. What do you think?