# Defining Value and Quality in Pharmacy

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If you were to come to my office, you would find a binder I still keep on my shelf with materials from a Pharmacy Quality Alliance meeting that I attended more than a decade ago. Little did I know when I attended that meeting what impact it would have on my career.

During this 2008 meeting, the conversation centered on how we define quality in health care around appropriate medication use. One of the notes I took during this meeting was “Quality is value divided by cost.” Mathematically it looks something like this: quality = value/cost.

This little equation captured my imagination. As an amateur math nerd, I could see how quality could be improved by increasing value and/or decreasing costs.

Immediately, strategies that we had used in the pharmacy took a whole new meaning. Products and services that were considered “value adds” now factored into this quality equation. If we used these services (and at the time, the “IF” was in capital letters) we were directly impacting quality.

Believe it or not, even back then the conversation was around decreasing reimbursements, and I could also see how this action could impact the quality equation. When costs go down and the value remains the same, the quality would go up.

Ralph Waldo Emerson said that “a mind, once stretched by a new idea, never returns to its original dimensions.” I can tell you that I have found that quote to be so true. My mind was blown as I began to consider this new dimension of pharmacy and how quality could be measured.

Further down the road, I came across a similar equation involving quality. Only this time, it was structured differently. This equation was set up as value is equal to quality divided by cost (value = quality/cost).

Again, I could see the various levers and how they would relate to each other, though the amateur math nerd in me could not solve the mathematical proof of the equation in relation to the first one I encountered.

So, if you would look past this conundrum with me, we can find some common ground and come to an agreement that value, cost, and quality are related in direct and inverse relationships.

While the conversation can quickly (and understandably) focus on the cost aspect of quality and value, I will submit that an elevated emphasis on quality and value should have equal, if not greater, exploration. Why? Because that is where we have the most control, influence, and impact.

I will follow up with these 2 thoughts to consider:

1. We all have a definition of what pharmacists do. My definition is that pharmacists monitor drug safety and efficacy throughout the health care system. Our primary role is to make sure that the drugs patients get are safe and ultimately provide the desired effect. I will suggest that we, overall, do a fantastic job on the safety aspect; however, I would also suggest that we can improve in the efficacy aspect of this statement.
2. W. Edwards Demings proposed a framework of 14 principles for quality management. To be explicit, management would include improvement. One of these principles states, “Cease dependence on inspection to achieve quality.” On behalf of my colleagues who started to twitch reading this statement (and I am twitching with you), let me unpack this a bit more. Demings identified that inputs are the primary driver for quality. When you inspect an item for quality at the end of a process, the quality is either there or it isn’t. If it isn’t, it is because of something that happened beforehand—the input.

To improve quality and add value to the health care system, we need to focus on the inputs. When those inputs are aligned the right way, we can expect reliable consistent results.

To connect this back to the beginning when I was just learning about quality measures, there is some relationship between quality, value, and cost. Up to that point, the primary lever to improve the perception of quality and value was to reduce cost. There were occasional and random products and services that would attempt to add value and improve quality, but it was not focused or consistent.

There was a need to define and standardize how quality could be measured—it needed to be in some objective, repeatable, and standardized format. Once those definitions can be described, strategies can be employed to improve the score. This is a big topic to consider, but knowing how something is measured is a key ingredient in delivering value and improving quality.

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